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Do you think it's the right thing to do surgery after casting a leg for four weeks? Our nine-year-old son got tackled from the left while playing football. They weren't sure if he had a fracture of the growth plate so they put him in a cast. Four weeks later, now they say he has a problem that requires surgery. I'm like 'whoa' -- first there's almost nothing there, now we need surgery?

Any fracture affecting the growth plate of bones in children can result in stopping growth. Disturbance of growth after fracture of the distal femur (bottom end of the thigh bone just above the knee) is a particularly vexing problem. That's because this is where the fastest growth plate in the body is located. Young children can experience as much as a three-inch difference in leg length from a fracture of this type. Assessment isn't always easy. There can be more damage present than is visible with standard X-rays. If the radiologist sees a slight fleck of bone next to the growth plate or a little bit of widening or other irregularity of the growth plate, a CT scan may be ordered. As a precaution, any suspicion of growth plate disruption is treated with a full leg cast (up to the groin) for four weeks. Obese or young patients may need a full hip-to-foot (spica) cast to hold the leg still during the healing phase. Growth plate fractures are diagnosed and classified using a standard model called the Salter-Harris (SH) classification. Fractures in this area are divided into four groups (SH I, II, III, and IV) depending on severity. Severity is determined by the number of bone fragments, presence of displacement (separation), and size of displacement. As you might imagine, more severe fractures (SH III and IV) are the most likely to develop growth arrest, arthritis, and other complications. Surgery is advised whenever the fracture is displaced. For a child who was put in a cast now needing surgery, there must be a reason for this decision. Has the fracture separated or failed to heal? Perhaps the bone is healing with poor alignment putting your child at increased risk for posttraumatic arthritis. The procedure may be needed to put any pieces of nonhealing or poorly aligned bone back in place. Everything will be held together with wires, pins, or screws until healing has occurred. Wires are used for small fragments. Pins and screws are used for large bone fragments. The surgeon can place the hardware through the growth plate but must try and avoid going through the knee joint itself. The child is then put back in a cast for at least a month (up to six weeks). With this information in mind, you should be able to ask the surgeon to explain (maybe for a second time -- that's okay, too) the need for a change in treatment from nonoperative to operative care. Don't hesitate to ask additional questions until you understand fully what's going on and why.

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