Outcomes in physeal injury management does approach matter? A literature review of non-operative and surgical techniques

Abstract

Introduction: Physeal fractures, which comprise 15-30% of pediatric fractures, pose a significant risk to longitudinal bone growth due to their location in the cartilaginous growth plate. Management strategies typically follow the Salter-Harris classification, with non-displaced fractures treated conservatively and displaced or intra-articular fractures requiring surgical intervention. However, emerging evidence challenges this binary approach, highlighting the risks of delayed displacement in conservatively treated cases and iatrogenic growth plate damage in surgical cases. Global disparities in treatment approaches further complicate decision-making, necessitating a comprehensive review of outcomes associated with both conservative and surgical management. Materials and Methods: A systematic review was conducted following PRISMA guidelines, analyzing 68 studies (2000-2023) from 25 countries. Databases searched included PubMed, Embase, Cochrane Library, Scopus, and regional sources. Inclusion criteria encompassed studies comparing conservative (casting, bracing) and surgical (open reduction, internal fixation) treatments in patients ≤ 18 years. Outcomes assessed included growth arrest, limb-length discrepancies, functional scores, and complications. Data extraction, quality assessment, and statistical analysis were performed using standardized tools such as the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. Results: Among 12,450 patients (mean age 11.2 years), outcomes varied by fracture type and management approach: Salter-Harris I/II Fractures: Conservative treatment success was 89%, with a 6.2% growth arrest rate, while surgical intervention showed a higher risk of transphyseal hardware damage (12% growth arrest). Salter-Harris III/IV/V Fractures: Conservative treatment led to a 28% growth arrest rate, versus 15% in surgical cases. Anatomical reduction accuracy correlated with improved functional outcomes. Complications: Conservative management was associated with a 12% malunion rate, while surgery had an 11% risk of hardware-related physeal damage. Infection rates were higher in low-resource settings (8% vs. 2% in high-income countries). Functional Outcomes: Operative management yielded superior Lysholm scores (mean 88 vs. 72, p