Review Article

Physeal Arrest of the Distal Radius

Abstract
Joshua M. Abzug, MD Fractures of the distal radius are among the most common pediatric
Kevin Little, MD fractures. Although most of these fractures heal without complication,
some result in partial or complete physeal arrest. The risk of physeal
Scott H. Kozin, MD
arrest can be reduced by avoiding known risk factors during fracture
management, including multiple attempts at fracture reduction.
Athletes may place substantial compressive and shear forces across
the distal radial physes, making them prone to growth arrest. Timely
recognition of physeal arrest can allow for more predictable
procedures to be performed, such as distal ulnar epiphysiodesis. In
cases of partial arrest, physeal bar excision with interposition grafting
can be performed. Once ulnar abutment is present, more invasive
procedures may be required, including ulnar shortening osteotomy or
radial lengthening.

From the Department of

Orthopaedics, University of Maryland
School of Medicine, Baltimore, MD
(Dr. Abzug), the Department of
Orthopaedic Surgery, University of
Cincinnati College of Medicine,
Cincinnati, OH (Dr. Little), and the
Department of Orthopaedic Surgery,
Temple University School of
Medicine, Philadelphia, PA
(Dr. Kozin).
Dr. Abzug or an immediate family
member serves as a paid consultant
to AxoGen. Dr. Kozin or an immediate
family member serves as a paid
consultant to Checkpoint Surgical and
serves as a board member, owner,
officer, or committee member of the
American Society for Surgery of the
Hand. Neither Dr. Little nor any
immediate family member has
received anything of value from or has
stock or stock options held in
a commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop
Surg 2014;22:381-389
http://dx.doi.org/10.5435/
JAAOS-22-06-381
Copyright 2014 by the American
Academy of Orthopaedic Surgeons.
T he physes of long bones are rela-
tively prone to injury. Fractures of
the distal aspect of the forearm are one
of the most common injuries in chil-
dren, and a substantial number of these
injuries involve the growth plate of
the distal radius. Despite the frequency
of physeal fractures, growth arrest is
rare, with rates as low as 1% to 7%.1,2
Although fractures account for most
of the damage to the growth plate,
ischemia, infection, irradiation, tu-
mors, and repetitive stress can all
inflict irreparable damage. As a result,
the growth of the distal radius can
be altered, impaired, or completely
stopped. If the ulnar physis is unin-
jured, a growth discrepancy between
the radius and ulna can become
readily apparent.
Anatomy
The epiphysis of the distal radius be-
gins to ossify between ages 8 and 18
months. Typically, the physis is ori-
ented transversely and progresses
toward a shallow dome during skeletal
maturation, with the distal aspect
centrally located in the AP and lateral
planes. Except for the distal radioulnar
joint (DRUJ), the physis of the distal
radius is entirely extracapsular.3 The
distal radial and ulnar physes con-
tribute approximately 75% and 80%
of longitudinal growth, respectively.4
The physis derives its blood supply
from the epiphysis and, as a result,
vascularity is rarely compromised by
a physeal fracture, even with consid-
erable displacement. Complete phys-
eal closure occurs at approximately
age 17 years, occurring sooner in
girls than in boys. During upper
extremity use, the distal radius typi-
cally receives approximately 80%
of the stress placed across the wrist
joint with neutral ulnar variance.
However, as positive ulnar variance
increases, increased stress is placed
across the distal ulna, leading to
impaction of the ulna against the
lunate and triquetrum, wrist pain and,
ultimately, degenerative changes in the
carpus and triangular fibrocartilage
complex (TFCC).5
The physis is arranged in distinct
zones that have different mechanical
and biologic properties.4 The resting,

June 2014, Vol 22, No 6 381

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Physeal Arrest of the Distal Radius
or reserve, zone of the physis is
immediately adjacent to the epiphysis;
pluripotent chondrocytes reside here in
preparation for proliferation. Injuries
at this level lead to complete cessation
of longitudinal bone growth. The
physeal vasculature passes through this
layer and branches out at the junction
between the reserve and proliferative
zones. The hypertrophic zone is adja-
cent to the proliferative zone and is
divided into three separate layers:
maturation, degeneration, and pro-
visional calcification. In the provisional
calcification layer, chondrocyte apo-
ptosis occurs, leaving a relatively weak
extracellular matrix. The weak extra-
cellular matrix leads to increased injury
through this zone, and most growth
plate fractures occur in this area. This
layer is far from the reserve zone,
which is the main reason why most
growth plate injuries do not cause
permanent growth arrest.
Etiology
Injury to the reserve or proliferative
zones of the physis can result in per-
manent damage to the physis. Frac-
tures through the physis account for
most cases of physeal arrest in the
distal radius. Salter and Harris4 ini-
tially described fractures through the
growth plate in 1963. Type I frac-
tures extend through the hypertro-
phic zone of the physis, and type II
fractures extend through both the
hypertrophic zone and the metaph-
ysis. Following these types of frac-
tures, the rate of growth arrest is
approximately 1% to 7%1,2 and has
been linked to repeated, forceful
fracture manipulation as well as re-
manipulation .10 days after the
original injury.6 Type III and type IV
fractures traverse the reserve zone
and have an increased risk of per-
manent growth arrest, especially in
the setting of malunion and bridging
from the epiphysis of one fragment
to the metaphysis of another. Type V
382
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
injuries involve a substantial com- Figure 1
pression injury to the physis and
have a high rate of posttraumatic
growth arrest;6,7 however, these in-
juries are typically found only at
follow-up after altered growth has
been detected. Growth arrest of the
distal radius has also been noted
after pure metaphyseal fracture8 and
has been attributed to concomitant
physeal crush injury (Salter-Harris
type V) that was not noted on initial
radiographic assessment.
Other causes of physeal arrest
include vascular ischemia associated
with compartment syndrome and
frostbite; these conditions can result
in tissue necrosis that may lead to
loss of the reserve layer of the
physis.9 Sickle-cell disease, thalas-
semia, or purpura fulminans can
lead to local arterial occlusion
and subsequent growth arrest. In
younger children, infections com-
monly occur at the physis as a result
of the low blood flow in the vas-
PA radiograph of the distal radius
cular loops of the primary spon- demonstrating physeal growth arrest
giosa, where bacterial cells can in a 6-year-old boy following an
accumulate. In general, the infec- infection years earlier. (Courtesy of
tion remains in the metaphysis and Shriners Hospital for Children,
Philadelphia, PA.)
hypertophic zone and does not
cause permanent growth arrest;
however, if the infection progresses Repetitive stress to the physis can
toward the reserve zone, destruction lead to growth disturbance and is fre-
of cells in the reserve zone can occur quently seen in gymnasts who bear the
(Figure 1). A subperiosteal abscess full weight of their bodies through
or septic arthritis in the adjacent their upper extremities (gymnast
joint can lead to compression or wrist). The Heuter-Volkman principle
destruction of the epiphyseal blood states that compression across the
supply, leading to growth arrest.10 physis will impair growth, whereas
External beam irradiation also can tension across the physis will increase
lead to growth arrest secondary growth.11,12 In gymnastics, weight
to direct damage to the rapidly bearing can impart up to 10 times
proliferating cells of chondrocytes body weight through the wrist, which
and small arterioles or from ische- likely explains why female gymnasts
mia caused by vascular compro- tend to have increased ulnar variance
mise. Tumors, especially malignant compared with non-gymnasts.13 The
lesions, can invade physeal struc- plausibility of this relationship was
tures and cause direct damage to confirmed in a large meta-analysis of
proliferative chondrocytes. Surgical the literature that included animal
resection of periphyseal benign studies; however, there was insuffi-
tumors may result in growth arrest cient evidence to completely confirm
if aggressive curettage is used. the causality.14
Journal of the American Academy of Orthopaedic Surgeons

Presentation and
Evaluation
The presentation of growth arrest of
the distal radius can vary. Physeal
arrest may be discovered on routine
radiography performed at follow-
up for previous trauma. Alterna-
tively, the patient may present
with ulnar-sided wrist pain and/or
deformity such as prominence of the
ulnar head. The patient should be
queried regarding previous history
of trauma to the affected extremity
and previous treatment for infec-
tion, tumor excision, radiation
therapy, or thermal injury. Previous
surgery on the extremity should be
noted, as well. Physical examination
of the affected extremity often
demonstrates a prominent ulnar
head and angular deformity of the
wrist, with occasional loss of fore-
arm pronation/supination and
radial/ulnar deviation of the wrist
(Figure 2). DRUJ stability should be
assessed in full supination, full pro-
nation, and neutral rotation as well as
through compression of the DRUJ
though the entire range of motion.
The contralateral limb should be used
as a base for comparison.
Plain radiography is the preferred
method of evaluating physeal in-
juries.15 Traditional PA and lateral
views obtained with the forearm in
neutral rotation will demonstrate
most physeal abnormalities and allow
adequate assessment of ulnar vari-
ance.16,17 Following physeal injury,
repeat radiography is recommended
every 3 months until normal growth
resumes, as demonstrated by evidence
of a parallel Park-Harris line through
the metaphysis of the distal radius,
the presence of a physeal bar, or
noticeable changes in ulnar vari-
ance. Because discerning the pres-
ence of a physeal injury or the
size and location of the physeal
bar on plain radiography is often
difficult, advanced imaging can be
June 2014, Vol 22, No 6
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 2
Clinical photograph of the hand and
wrist demonstrating a prominent
ulnar head following physeal arrest
of the distal radius. (Courtesy of
Shriners Hospital for Children,
Philadelphia, PA.)
useful. CT has been used success-
fully to discern the nature of the
bony bar;18 however, this modality
is not a first-line tool for diagnosis
of physeal injury because of con-
cerns regarding radiation exposure
and limited usefulness for evalua-
tion of soft tissues (Figure 3). The
use of MRI has been advocated
because of its ability to delineate
concomitant soft-tissue injury to
the wrist (eg, TFCC injury) or
a nonossified cartilage bar that may
require further intervention.19,20
Three-dimensional MRI also has
been used to assess the physis
and allows for an accurate deter-
mination of the size of the physeal
bar.21 MRI and CT findings have
been shown to correlate with the
histology of physeal injury in ani-
mal models, but no direct correla-
tion between these two imaging
techniques has been published to
date.22
Joshua M. Abzug, MD, et al
Figure 3
Coronal CT scan of the wrist
demonstrating physeal arrest of the
ulnar half of the distal radius. Note
the early arthritic changes
demonstrated by the cystic lesion
(arrow) on the lunate caused by ulnar
abutment. (Courtesy of Joshua
M. Abzug, MD, Baltimore, MD.)
Classification
Once growth arrest is identified, it
can be classified based on the location
and size of the physeal bar. The most
common classification is based on
anatomic location. Central growth
arrest with a bony bridge surrounded
by normal physeal cartilage is the
most common type (Figure 4). Based
on the size and location of the
physeal bar, growth may be halted
completely or an angular deformity
may develop at eccentric locations.
When growth stops completely on
one side of the physis (peripheral
arrest), angular deformity often
develops as a result of continued
growth on the opposite side of the
physeal bar. A linear physeal bar,
which is most often seen in Salter-
Harris III and IV injuries, traverses
the physis along the line of the pre-
vious fracture, with normal cartilage
found on either side.
Four distinct radiographic grades
have been identified for gymnast
wrist. In grade 0, wrist pain is reported
383
 Physeal Arrest of the Distal Radius
Figure 4
Coronal (A) and sagittal (B) T1-weighted magnetic resonance images of the
wrist showing a central bar (arrows) traversing the distal radius physis. (Courtesy
of Shriners Hospital for Children, Philadelphia, PA.)
during activity but no abnormality is
detected on radiography, whereas
grade 1 is characterized by mild
irregularity or the loss of definition of
the physis on radiography. Grade 2 is
characterized by at least one of the
following findings: cystic changes,
metaphyseal sclerosis, striations, or
beaking of the metaphysis. Grade 3 is
characterized by widening of the
physis12,13 (Figure 5).
Management
Nonsurgical
Asymptomatic patients with physeal
arrest of the distal radius are treated
based on the amount of growth re-
maining in the physis. Paley et al23
described a multiplier method for
predicting length discrepancy in the
upper extremity. This tool can be
used to predict ultimate limb-length
discrepancy, timing for epiphysiod-
esis, and the amount of growth re-
maining in the radius and ulna.
Predicting the amount of remaining
growth and assessing the child’s ulnar
variance are crucial for determining
384
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
whether surgical intervention is
warranted. If minimal growth re-
mains, then observation is warranted.
If .2 mm of growth remains, we
typically recommend surgical inter-
vention because relative shortening
of the distal radius by as little as
2.5 mm substantially increases the
load transmitted across the distal
ulna. This increased load can lead to
wrist pain, disordered kinematics,
and early arthritis24 (Figure 3). Sur-
gery is also warranted in patients with
progressive deformity or in those with
symptoms such as ulnar-sided wrist
pain or limited motion.
Surgical
Physeal Bar Resection and
Interposition
Management of a physeal bar is
easier when it is identified early,
before deformity develops. The goal
of early surgical intervention is to
remove the fibrous or bony bar and
place interposition material into the
void to permit the remaining
growth. Typically, local fat is placed
into the void after the bar is re-
Journal of the American Academy of Orthopaedic Surgeons
Figure 5
PA radiograph demonstrating
widening of the physis in a 10-year-
old gymnast. (Courtesy of Shriners
Hospital for Children, Philadelphia,
PA.)
sected; however, alternatives such
as methylmethacrylate have been
used. Identification of the exact
location of the bar is key to resec-
tion. This typically requires the use
of advanced imaging such as CT or
MRI. Kang et al25 recommended
the use of intraoperative computer-
assisted navigation to appropri-
ately identify the bar.
Physeal bar resection is a relatively
demanding surgical procedure. Ob-
taining access to the bar and gauging
complete resection can be challeng-
ing. In addition, the surrounding
physis may be unhealthy and unre-
sponsive to untethering following bar
resection. All of these factors prohibit
predictable results following resec-
tion; therefore, we do not routinely
perform this procedure in older chil-
dren. However, in the young child
with substantial physeal growth
remaining, bar resection can be
attempted.

Epiphysiodesis
In cases of partial physeal arrest of the
distal radius, epiphysiodesis of the
distal radial physis can be performed
to arrest the remaining growth and
prevent angular deformity. In cases of
complete physeal arrest of the distal
radius, ulnar epiphysiodesis should
be performed simultaneously to pre-
vent a difference in length between the
radius and ulna (positive ulnar vari-
ance). Based on the patient’s age and
the type of deformity, these proce-
dures may be performed in isolation
or in combination with a radial and/or
ulnar osteotomy.
Epiphysiodesis is a straightforward
procedure that can reliably arrest the
growth of either the distal radius or
distal ulna. Multiple techniques can be
used to accomplish physeal arrest,
including percutaneous drilling, open
curettage, and open burr resection with
or without the use of supplemental
bone graft.
We perform epiphysiodesis with
the aid of a cannulated drill system. A
direct radial or ulnar approach is
used to gain access to the physis of the
distal radius or ulna, respectively. A
small longitudinal incision is made
and blunt dissection to bone is per-
formed. Under fluoroscopic guid-
ance, a guidewire is then placed
manually into the physis, and place-
ment is confirmed. Subsequently, the
cannulated drill is placed over the
guidewire to create a tract, with care
taken to ensure that no significant
torquing occurs to break the wire.
The wire is then removed and the drill
is advanced along the tract across the
entire physis (Figure 6). While the drill
is on, it is moved in a dorsal-to-volar
direction and a proximal-to-distal
direction. Fluoroscopy is used inter-
mittently to ensure accurate drilling.
A small burr can be inserted into the
drilled tract to ensure complete
epiphysiodesis.
In a retrospective review of 30 ado-
lescents with deformity following
June 2014, Vol 22, No 6
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
posttraumatic growth arrest of the
distal radius, Waters et al26 performed
an ulnar epiphysiodesis in 14 pa-
tients, including 3 who underwent
concurrent radial epiphysiodesis. Of
this group, two patients had persis-
tent ulnar growth that required
a repeat epiphysiodesis in one patient
and an ulnar shortening osteotomy
(USO) in the other.
Ulnar Shortening Osteotomy
Ulnar shortening can provide sub-
stantial pain relief when the ulna is
impacting upon the lunate or trique-
trum. Shortening can also restore
DRUJ alignment and stability, nor-
malize wrist mechanics, and alleviate
pain caused by a tear of the TFCC. In
the adult population, Kim and Song27
showed that USO alone or combined
with arthroscopic débridement of
the TFCC resulted in substantial
improvement of wrist function and
reduced pain compared with arthro-
scopic débridement of the TFCC
alone. Furthermore, no significant
differences in function and pain were
noted with the addition of arthro-
scopic débridement as long as the
TFCC flap was stable. USO alone is
the preferred treatment method for
ulnar impaction syndrome in skele-
tally mature patients.27 If a sub-
stantial amount of physeal growth
remains, we perform a USO with
a distal ulnar epiphysiodesis.
USO is performed via a direct
approach to the ulna between the
extensor carpi ulnaris and flexor
carpi ulnaris. The osteotomy is per-
formed as distal as possible to limit
the risk of nonunion and to ensure
that the osteotomy is distal to the
central band of the interosseous
membrane; however, the location of
the osteotomy is limited by the need
to obtain fixation of the distal frag-
ment.28 We prefer to place the plate
on the volar aspect of the ulna to
decrease the likelihood of hardware
irritation (Figure 7). The periosteum
is incised only at the level of the
Joshua M. Abzug, MD, et al
Figure 6
Intraoperative fluoroscopic image of
the wrist demonstrating the use of
a cannulated drill to perform an ulnar
epiphysiodesis. (Courtesy of Joshua
M. Abzug, MD, Baltimore, MD.)
osteotomy to preserve the osseous
blood supply and to enhance the
likelihood of union. Once the area is
exposed, the desired amount of bone
is removed. We prefer to use a USO
system that maintains rotational
control, allows the osteotomy to be
performed obliquely, and permits an
accurate amount of bone removal.
Alternatively, a transverse, step-cut,
or Z-osteotomy can be performed.
Once the bone is removed, the os-
teotomy site is compressed and
fluoroscopy is used to assess the
wrist, ensuring that the desired
amount of correction is achieved. If
any potential for growth remains, we
supplement the USO with a distal
ulnar epiphysiodesis.
In their retrospective series, Waters
et al26 performed 18 USOs, with no
nonunion reported. Two patients had
irritation that necessitated removal of
instrumentation. Ulnar length was
shortened an average of 6 mm (range,
3 to 12 mm). Preoperatively, ulnar
variance was an average of 4.5 mm
positive (range, 9 mm negative to
12.5 mm positive) and decreased
postoperatively to an average of zero
(range, 6 mm negative to 3 mm pos-
itive).26 In our experience, attempting
385
 Physeal Arrest of the Distal Radius

Figure 7

A, Preoperative fluoroscopic image of the distal radius demonstrating physeal growth arrest and ulnar abutment.
B, Intraoperative photograph showing the volar placement of the ulnar shortening osteotomy plate. C, Postoperative
fluoroscopic image of the radius and ulna demonstrating placement of the osteotomy plate following an ulnar shortening of
15 mm. Note the oblique cut and placement of the lag screw. (Courtesy of Joshua M. Abzug, MD, Baltimore, MD.)

to shorten the ulna .12 to 15 mm is to hardware irritation. However, Distraction Osteogenesis

technically challenging and can yield
a higher rate of nonunion.
Radial Osteotomy
Radial osteotomy can be performed
to correct any angular deformity that
occurs following partial growth
arrest. Acute lengthening of the
radius also can be performed, if
necessary. Radial osteotomy with or
without acute lengthening can be
performed alone or in combination
with any of the previously described
techniques. Sagittal and coronal
alignment should be corrected. Wa-
ters et al26 recommended the use of
radial opening wedge osteotomy to
correct angular deformity of the
wrist in any patient with ,10° of
radial inclination.
A standard volar or dorsal
approach to the radius can be used
based on the deformity present. We
prefer to use a volar approach
whenever possible because dorsal
placement of the plate may lead
several osteotomy procedures (eg,
opening wedge, closing wedge,
dome) can be performed based on
the type of deformity. Typically, the
osteotomy is fixed with a plate and
screw construct, with care taken to
ensure that volar tilt, radial inclina-
tion, radial length, and DRUJ align-
ment are restored (Figure 8).
In a series of 30 patients with
progressive deformity following
radial growth arrest, Waters et al26
performed 7 radial osteotomies,
including opening wedge, closing
wedge, and Z-lengthening osteoto-
mies. Complications included one
refracture through the osteotomy
site that was initially fixed with pins
but eventually required revision to
a plate and screw construct. One
patient required removal of instru-
mentation secondary to hardware
irritation. All patients healed and
radial inclination improved from an
average of 8.5° preoperatively to
15.5° postoperatively.
Distraction osteogenesis with the
use of a circular external fixator permits
simultaneous bone lengthening and
three-dimensional correction of defor-
mity. The benefits of this technique are
the ability to correct large limb-length
discrepancies, the opportunity to per-
form an osteotomy of either the radius
or ulna (typically the radius) without
the need for an osteotomy of the other
bone, and the capability to fine-tune the
correction of the deformity during the
lengthening process.29,30 However,
this technique is technically challeng-
ing and requires that the surgeon
be familiar with the anatomy and
nuances of the procedure.
Page and Szabo29 and Gündeş et al30
described the use of distraction osteo-
genesis in a total of eight patients
with physeal arrest of the distal radius.
Page and Szabo29 reported complica-
tions in three of four patients, includ-
ing unplanned returns to the operating
room in two patients. Additional
complications included multiple pin

386 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Joshua M. Abzug, MD, et al

Figure 8

Preoperative PA (A) and lateral (B) radiographs of the

distal radius demonstrating physeal arrest in an 11-year-
old boy following a fracture. C, Intraoperative photograph
showing a corticocancellous iliac crest autograft used to
perform an acute radius lengthening. Postoperative PA (D)
and lateral (E) radiographs demonstrating the plate and
screw construct. (Courtesy of Shriners Hospital for
Children, Philadelphia, PA.)

tract infections, skin tenting around
a pin that necessitated release, and
dermatitis around a pin. Gündeş et al30
also reported complications associated
with distraction osteogenesis. One
patient developed a superficial pin
tract infection and all four patients
experienced pain during the first 3
weeks of lengthening, which required
1- to 3-day breaks from distraction.
Outcomes
Little evidence exists in the literature
with regard to the success of physeal bar
resection and interposition for physeal
arrest of the distal radius. One patient
treated with excision of a physeal bar
and ulnar epiphysiodesis was reported
to have an excellent outcome, including
a postoperative modified Mayo wrist
score of 100.26 In a series by Waters
et al,26 18 of 30 patients underwent
multiple concomitant procedures to
achieve correction. In 24 symptomatic
patients, the average Mayo wrist score
improved from 82 preoperatively to
98 postoperatively (maximum score:
100). All patients had good or excel-
lent results, with decreased pain and
increased activity level.
Prevention and Monitoring
Prevention of physeal arrest of the
distal radius is difficult in most cases;
however, certain factors increase the
risk of growth arrest. We recommend
one or two gentle attempts in the
emergency department, followed by
one or two gentle attempts in the
operating room. If closed reduction is
unsuccessful, open reduction should

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Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Physeal Arrest of the Distal Radius
be performed.6 Acceptance of a slight
angular deformity that can remodel
with growth is favored over ongoing,
aggressive reductions that increase
the risk of physeal arrest. Late at-
tempts at reduction should be
avoided, as well. Once the fracture is
7 to 10 days old, no further attempt
at reduction should be made.31
Rather, fracture healing and remod-
eling should be allowed to occur. If
noteworthy deformity exists follow-
ing this process, an osteotomy can be
performed with or without other
procedures to correct the deformity
and/or limb-length discrepancy.
Displaced fractures of the distal
radius should be followed until
growth is detected. Typically, after
the acute injury heals, radiography is
performed 3 to 6 months later to
assess continued growth. The radio-
graphs should be evaluated for any
sign of a physeal bar or evidence of
growth such as a Park-Harris line
through the metaphysis of the distal
radius. In addition, ulnar variance
detected at the initial evaluation can
be compared with that present at the
follow-up examination.
Summary
Physeal arrest of the distal radius
following a fracture through the
growth plate is a documented, but
rare, complication. Avoiding
known risk factors during fracture
management is crucial to reduce the
risk of physeal arrest. Furthermore,
close follow-up until new growth is
demonstrated is required. Early
recognition of a physeal arrest al-
lows for more surgical options,
which may be less invasive. Once
physeal arrest is detected, a combi-
nation of procedures is typically
required to correct the deformity and
limb-length discrepancy. Results of
these procedures have been reported
infrequently in the literature; however,
the outcomes are promising with re-
388
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
gard to restoration of radiographic
parameters and improvement in pain
and function.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, reference 23
is a level II study. Reference 29 is
a level IV study.
References printed in bold type are
those published within the past 5
years.
1. Buterbaugh GA, Palmer AK: Fractures and
dislocations of the distal radioulnar joint.
Hand Clin 1988;4(3):361-375.
2. Lee BS, Esterhai JL Jr, Das M: Fracture of
the distal radial epiphysis: Characteristics
and surgical treatment of premature, post-
traumatic epiphyseal closure. Clin Orthop
Relat Res 1984;185:90-96.
3. Birch JG, Herring JA, Wenger DR: Surgical
anatomy of selected physes. J Pediatr
Orthop 1984;4(2):224-231.
4. Salter R, Harris WR: Injuries involving the
epiphyseal plate: AAOS instructional
course lecture. J Bone and Joint Surg Am
1963;45:587-662.
5. Palmer AK, Werner FW: Biomechanics of
the distal radioulnar joint. Clin Orthop
Relat Res 1984;187:26-35.
6. Valverde JA, Albiñana J, Certucha JA:
Early posttraumatic physeal arrest in distal
radius after a compression injury. J Pediatr
Orthop B 1996;5(1):57-60.
7. Aminian A, Schoenecker PL: Premature
closure of the distal radial physis after
fracture of the distal radial metaphysis.
J Pediatr Orthop 1995;15(4):495-498.
8. Tang CW, Kay RM, Skaggs DL: Growth
arrest of the distal radius following
a metaphyseal fracture: Case report and
review of the literature. J Pediatr Orthop B
2002;11(1):89-92.
9. Hernandez J Jr, Peterson HA: Fracture of
the distal radial physis complicated by
compartment syndrome and premature
physeal closure. J Pediatr Orthop 1986;6
(5):627-630.
10. Fitoussi F, Litzelmann E, Ilharreborde B,
Morel E, Mazda K, Penneçot GF:
Hematogenous osteomyelitis of the wrist in
children. J Pediatr Orthop 2007;27(7):
810-813.
11. Read MT: Stress fractures of the distal
radius in adolescent gymnasts. Br J Sports
Med 1981;15(4):272-276.
Journal of the American Academy of Orthopaedic Surgeons
12. Roy S, Caine D, Singer KM: Stress changes
of the distal radial epiphysis in young
gymnasts: A report of twenty-one cases and
a review of the literature. Am J Sports Med
1985;13(5):301-308.
13. DiFiori JP, Caine DJ, Malina RM: Wrist
pain, distal radial physeal injury, and ulnar
variance in the young gymnast. Am J Sports
Med 2006;34(5):840-849.
14. Caine D, Howe W, Ross W, Bergman G:
Does repetitive physical loading inhibit
radial growth in female gymnasts? Clin J
Sport Med 1997;7(4):302-308.
15. Ecklund K, Jaramillo D: Imaging of growth
disturbance in children. Radiol Clin North
Am 2001;39(4):823-841.
16. Epner RA, Bowers WH, Guilford WB:
Ulnar variance: The effect of wrist
positioning and roentgen filming technique.
J Hand Surg Am 1982;7(3):298-305.
17. Jung JM, Baek GH, Kim JH, Lee YH,
Chung MS: Changes in ulnar variance in
relation to forearm rotation and grip.
J Bone Joint Surg Br 2001;83(7):
1029-1033.
18. Young JW, Bright RW, Whitley NO:
Computed tomography in the evaluation of
partial growth plate arrest in children.
Skeletal Radiol 1986;15(7):530-535.
19. Dwek JR, Cardoso F, Chung CB: MR
imaging of overuse injuries in the
skeletally immature gymnast: Spectrum of
soft-tissue and osseous lesions in the hand
and wrist. Pediatr Radiol 2009;39(12):
1310-1316.
20. Havránek P, Lízler J: Magnetic resonance
imaging in the evaluation of partial growth
arrest after physeal injuries in children.
J Bone Joint Surg Am 1991;73(8):
1234-1241.
21. Sailhan F, Chotel F, Guibal AL, et al: Three-
dimensional MR imaging in the assessment
of physeal growth arrest. Eur Radiol 2004;
14(9):1600-1608.
22. Koff MF, Chong R, Virtue P, et al:
Correlation of magnetic resonance imaging
and histologic examination of physeal bars
in a rabbit model. J Pediatr Orthop 2010;
30(8):928-935.
23. Paley D, Gelman A, Shualy MB,
Herzenberg JE: Multiplier method for
limb-length prediction in the upper
extremity. J Hand Surg Am 2008;33(3):
385-391.
24. Graham TJ: Surgical correction of malunited
fractures of the distal radius. J Am Acad
Orthop Surg 1997;5(5):270-281.
25. Kang HG, Yoon SJ, Kim JR: Resection of
a physeal bar under computer-assisted
guidance. J Bone Joint Surg Br 2010;92
(10):1452-1455.
26. Waters PM, Bae DS, Montgomery KD:
Surgical management of posttraumatic
distal radial growth arrest in

adolescents. J Pediatr Orthop 2002;22
(6):717-724.
27. Kim BS, Song HS: A comparison of ulnar
shortening osteotomy alone versus
combined arthroscopic triangular
fibrocartilage complex debridement and
ulnar shortening osteotomy for ulnar
impaction syndrome. Clin Orthop Surg
2011;3(3):184-190.
June 2014, Vol 22, No 6
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
28. Giebel GD, Meyer C, Koebke J, Giebel G:
Arterial supply of forearm bones and its
importance for the operative treatment of
fractures. Surg Radiol Anat 1997;19(3):
149-153.
29. Page WT, Szabo RM: Distraction
osteogenesis for correction of distal radius
deformity after physeal arrest. J Hand Surg
Am 2009;34(4):617-626.
Joshua M. Abzug, MD, et al
30. Gündeş H, Buluç L, Sahin M, Alici T:
Deformity correction by Ilizarov
distraction osteogenesis after
distal radius physeal arrest. Acta
Orthop Traumatol Turc 2011;45(6):
406-411.
31. Bae DS: Pediatric distal radius and forearm
fractures. J Hand Surg Am 2008;33(10):
1911-1923.
389