Addressing Growth Plate Injuries in Children: Treatment Options and Concerns

Growth plate injury

Dear Dr.
Chen,
My five-year-old niece recently suffered an injury when a large concrete pillar fell on her, resulting in a comminuted fracture of her right foot.
The skin and soft tissue on the sole of her foot were torn open, and the ligaments in her foot were ruptured.
After treatment, the doctor indicated that because the growth plates in her foot and heel were affected, it would lead to slower development, causing her affected limb to be shorter and resulting in a leg length discrepancy.
Since the injury involved the sole and heel of her foot as well as the lower leg, bone lengthening surgery is not an option, and due to the discrepancy being greater than three centimeters, she cannot wear corrective shoes.

Are there any other viable options (remedial measures) available? Regarding the ligaments, is it true that they cannot be repaired, or is it simply that they don't need to be? Please provide a detailed explanation.
I would be very grateful for your assistance.
Thank you.

Joanne, 20~29 year old female. Ask Date: 2002/09/30

Dr. Chen Xingyuan reply Orthopedics

Regarding the question raised by this young lady, without X-rays or a physical examination, it is difficult to assess the extent of her niece's injury.
Based on your description, I will analyze the situation involved.
To my knowledge, "leg length discrepancy" is most severely affected by injuries to the distal femur and proximal tibia, particularly near the knee.
Therefore, bone lengthening procedures are generally performed on the femur and tibia.
There can also be growth retardation at the distal tibia near the ankle; however, to estimate the difference in leg length after growth, long-term observation over several years is necessary for an accurate assessment.
Your niece is still quite young and requires further observation.

However, based on your description, if the growth plate in the foot has already been injured, a "size discrepancy" may be unavoidable.
Since there are many growth plates in that area, understanding the severity and subsequent effects still requires reviewing X-rays.
The ligaments on the dorsum of the foot can help raise the toes or flex the ankle, but the primary function of the foot is for walking, unlike the hand where every effort is made to repair ligaments.
From your description, I cannot determine the current functionality of the ankle and toes, making it difficult to decide whether surgical intervention is necessary.
Additionally, if the ligaments have been severely compressed and torn, whether the torn ends can be reattached is also a concern.

In conclusion, while my response may seem somewhat rigid, I believe the best course of action is to have a qualified orthopedic surgeon, particularly a pediatric orthopedic specialist, conduct a physical examination and then determine the future treatment plan.

Reply Date: 2002/09/30

More Info

Injuries to the growth plates in children can have significant implications for their growth and development, particularly when it comes to fractures or trauma that affect the bones in the lower extremities. In the case of your niece, who suffered a severe injury to her foot resulting in a comminuted fracture and damage to the ligaments, there are several important considerations and potential treatment options to discuss.

Understanding Growth Plate Injuries
Growth plates, or epiphyseal plates, are areas of developing cartilage tissue located near the ends of long bones in children and adolescents. These plates are crucial for bone growth, and any injury to them can lead to complications such as growth arrest or discrepancies in limb length. In your niece's case, the injury to the growth plates in her foot could indeed lead to slower growth in that limb, potentially resulting in a noticeable difference in length compared to the other leg.

Treatment Options
1. Monitoring and Follow-Up: After a significant injury, regular follow-up with a pediatric orthopedic specialist is essential. They can monitor the growth of the affected limb through periodic X-rays to assess the status of the growth plates and determine if any growth disturbances are occurring.

2. Physical Therapy: Engaging in physical therapy can help improve function and strength in the affected limb. While it may not directly influence the growth of the bone, it can aid in rehabilitation and help the child adapt to any functional limitations.

3. Surgical Options: In cases where there is a significant discrepancy in limb length that is expected to worsen, surgical intervention may be considered. This could involve procedures such as limb lengthening or corrective osteotomy, depending on the specific circumstances and the age of the child. However, these options are typically reserved for cases where the discrepancy is substantial and is expected to impact the child's quality of life.

4. Use of Orthotics: While you mentioned that corrective shoes may not be an option due to the expected length discrepancy, custom orthotics or shoe lifts might still be beneficial. These can help balance the child's gait and reduce discomfort while walking.

5. Addressing Ligament Damage: Regarding the ligament injury, whether or not surgical intervention is necessary depends on the extent of the damage. In some cases, if the ligament is completely torn and causing instability, surgical repair may be warranted. However, if the injury is not causing significant functional impairment, conservative management with physical therapy may be sufficient.

Long-Term Considerations
It is crucial to keep in mind that children are remarkably resilient, and their bodies have a great capacity for healing and adaptation. However, growth plate injuries can lead to complications such as:
- Growth Arrest: If the growth plate is severely damaged, it may stop growing altogether, leading to a permanent difference in limb length.

- Deformities: Depending on the nature of the injury, there may be a risk of developing deformities in the affected limb, which could affect mobility and function.

- Osteoarthritis: Injuries to the growth plate can also predispose the child to early-onset osteoarthritis in the affected joint later in life.

Conclusion
In summary, while your niece's injury is serious and may lead to complications with growth and development, there are several avenues for treatment and management. Regular follow-up with a pediatric orthopedic specialist is critical to monitor her progress and address any emerging issues. Physical therapy, potential surgical options, and the use of orthotics can all play a role in her recovery and adaptation to any changes in her limb length. It is essential to maintain open communication with her healthcare team to ensure the best possible outcomes.

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