Distal Femur Physeal Fracture

Aka: Distal Femur Physeal Fracture, Epiphyseal Fracture of the Distal Femur, Distal Femur Fracture in Children

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II. Epidemiology

  1. Incidence: 1% of Pediatric Fractures

III. Mechanism

  1. Knee hyperextension injury is most common mechanism
    1. Physis is weaker than the surrounding ligaments
  2. Valgus or varus stress may also have been present

IV. Findings

  1. Acute Knee Pain and tenderness over the distal femur
  2. Local swelling
  3. Knee Deformity
  4. Limited range of motion due to pain
  5. Non-ambulatory

V. Exam

  1. See Knee Exam
  2. Distal Neurovascular Exam
  3. Examine the proximal and distal joints, as well as the contralateral side
    1. Associated injuries may be missed due to distracting injury
    2. See Secondary Trauma Evaluation

VI. Imaging

  1. Knee XRay (AP and Lateral)
    1. Salter Harris 2 Fracture is most common Distal Femur Physeal Fracture
    2. Initial XRay may be negative for physeal Fracture
      1. Consider non-weight bearing and Splinting if high index of suspicion
      2. Repeat XRay in 5 days
  2. MRI (or CT)
    1. Consider in non-diagnostic XRay on serial imaging

VII. Differential Diagnosis

  1. See Knee Injury

VIII. Management

  1. Serial neurovascular exams
  2. Analgesia
    1. See Pediatric Analgesic
  3. Immobilization (with Crutches for non-weight bearing)
    1. Long Leg Posterior Splint OR
    2. Knee Immobilizer
  4. Initial Closed Reduction Indications (Emergency Department)
    1. Neurovascular compromise
    2. Severe deformities
  5. Orthopedic Consultation
    1. ORIF often needed in Salter 2 and worse Fractures to prevent growth problems
  6. Monitoring
    1. Continued monitoring of healing and growth for at least 6-12 months
    2. Ideally observe until skeletal maturity

IX. Complications

  1. Common
    1. Premature epiphyseal closure (physeal growth arrest, 58% of cases)
    2. Angular deformity
    3. Limb Length Discrepancy >1.5 cm (22% of cases)
  2. Other complications
    1. Vascular injury
    2. Knee ligament laxity
    3. Compartment Syndrome

X. Prognosis

  1. High risk for growth complications

XI. Resources

  1. Distal Femoral Physeal Fractures - Pediatric (OrthoBullets)
    1. https://www.orthobullets.com/pediatrics/4020/distal-femoral-physeal-fractures--pediatric
  2. Distal Femur Fractures (POSNA)
    1. https://posna.org/physician-education/study-guide/distal-femur-fractures

XII. References

  1. Thokalath (2025) Crit Dec Emerg Med 39(12): 22-3
  2. Sepúlveda (2022) EFORT Open Rev 7(4):264-73 +PMID: 37931413 [PubMed]

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