Effectiveness of surgical versus conservative treatment for distal femoral growth plate fractures: a systematic review

Abstract

Injury to the distal femoral growth plate in children is typically due to a high-energy trauma such as contact sports or motor vehicle accidents. There is no clear evidence as to whether surgery or application of a plaster or splint is the best option for these injuries in terms of growth arrest and growth deformity. Different graded distal femur physeal fractures are known to be associated with poorer outcomes. The objective of this review was to determine whether surgery, in comparison to conservative treatment, is a safe and effective intervention for the management of distal femoral growth plate fractures. Methods This study included children 18 years of age or younger with a traumatic injury to a previously normal distal femoral physis. Primary outcomes of interest were rates of growth arrest and angular deformity. Secondary outcomes included patient factors such as knee range of motion, treatment factors such as loss of position of the fracture and hospital factors such as length of inpatient stay. A three-step search strategy for PubMed, Embase and Scopus databases was utilized to identify current studies from 1 January 1990 to 8 January 2017. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Results Of the 7740 studies identified with the search, 15 case studies with data inclusive of outcomes of interest were selected for inclusion. A total of 466 patients were included. The rate of complication in the surgical population was 37.8%. In the conservative population the rate of complication was 34.0%. Five of the 15 papers showed Salter-Harris (SH) classification to correlate with prognosis, three papers showed presence of displacement to correlate with prognosis which would have had an influence on the results of these higher graded injuries likely to have been managed operatively. A high rate of position loss and subsequent growth abnormalities was observed when conservative management was instituted. Follow-up for three months detected complications at a rate of 19.3%, compared to a complication rate of 71.4% for follow-up of 12 years or more. Secondary outcomes such as return of function, pain levels, non-union, specific complications of surgery and length of hospital stay were not provided in sufficient detail for judgements to be made. This review was conducted according to the a priori with additional results from particular studies described. One study suggested that the presence of displacement as well as the SH classification influenced the outcome of the patient in terms of growth and angular deformity. Other studies noted a high complication rate of growth deformity in SH II fractures. Rang Type VI injuries were observed in this review, with predominately conservative management associating with satisfactory outcomes. Conclusions Due to the nature of the studies located and included, it is unclear whether surgical intervention is more effective than conservative intervention and which modalities of each are most beneficial in terms of growth arrest, leg length discrepancy and angular deformity. The rate of complication is marginally higher in the surgical population than that in the conservative population. The diversity of paediatric injuries and clinician training suggests that each case must be assessed and treated on an individual basis with available resources in mind.