What are Epiphyseal Plate Fractures?

The bones of children and adults share many of the same risk factors when it comes to athletic injuries, however, because they are still growing, a children’s bones are more prone to a unique injury: epiphyseal fractures (growth plate fractures). 

What are Growth Plates?

Growth plates are areas of cartilage located near the ends of bones. They are found in the long bones of the body such as the femur (thigh bone), radius and ulna (forearm bones), and metacarpals (hand bones). Most long bones have a growth plate at each end, located between the widened portion of the bone shaft and the end of the bone. Growth of these long bones occurs at each end of the bones where the epiphyseal plates are located. Once a child is fully grown, the growth plates harden into solid bone. 

The growth plates are the final portion of a child’s bones to harden, making them particularly vulnerable to injury. Growth plates help to determine the length and shape that a child’s bone will have once it becomes mature bone so it is very important that these types of fractures are treated quickly and properly as failure to do so can result in a limb that is misshaped or does not grow to the appropriate length. When treated properly, most epiphyseal plate fractures will heal without any serious complications. 

What are Growth Plate Fractures?

Growth plate fractures usually occur from an acute incident such as a fall, but they can also occur gradually because of repetitive stress on the bone, which may occur when a child overtrains in a sports activity. The most common locations for growth plate fractures to occur are the fingers, radius, tibia, and fibula. The risk of bone growth complications varies greatly based on the patient’s age, the bone involved, fracture pattern, and degree of bone displacement. 

           Growth plate fractures are categorized into five subtypes using the Salter-Harris classification system. 

• Type I fractures break through the bone at the growth plate, separating the bone end from the bone shaft and completely disrupting the growth plate.

• Type II fractures break through part of the bone at the growth plate and crack through the bone shaft, as well. This is the most common type of growth plate fracture.

• Type III fractures cross through a portion of the growth plate and break off a piece of the bone end. This type of fracture is more common in older children. 

• Type IV fractures break through the bone shaft, the growth plate, and the end of the bone. 

• Type V fractures occur due to a crushing injury to the growth plate from a compression force. These are the rarest form of growth plate fractures. 

What are the symptoms of a growth plate fracture?

The most common symptom associated with a growth plate fracture is persistent pain. Other common symptoms include:

• Visible bone deformity

• Inability to move or put pressure on the limb

• A limp or altered gait pattern if the fracture occurs in a lower limb

• Swelling, warmth, and tenderness around the end of the bone near the joint

How are Epiphyseal Plate Fractures related to Rock Climbing?

Rock climbing has gained an immense amount of popularity in recent years and the number of youth participating in the sport is rapidly increasing. Finger epiphyseal plate stress fractures are the most common injury among youth climbers. Research has shown that repetitive overuse is the most common cause of finger injuries in young climbers as opposed to falling or acute injuries during strenuous moves. Possible reasons why children face an increased risk for growth plate injuries include the immaturity of their epiphyseal plates, underdeveloped motor, coordination, and perception skills, and increased muscle-tendon tightness combined with decreased growth plate strength during growth spurts. 

A recent study conducted by Rachel Meyers, et al (2020) proposed a structured return-to-sport protocol specific to youth climbers who sustained an epiphyseal plate fracture to the finger. The purpose of the guidelines is to provide healthcare professionals, coaches, athletes, and parents guidance on how to safely return to climbing. The proposed return to sport protocol is summarized below. 

What is the criteria for beginning the return to sport protocol?

Before a child can begin the return to climb protocol, they must be 

• pain-free

• have full range of motion of joints of the finger

• have minimal swelling over the growth plate

• have evidence of healing/normal growth plate appearance on x-rays

Stage 1 (weeks 0-1)

• Goal: build up a base of climbing volume

• Maximum 2 climbing sessions per week on non-consecutive days

• Each session should last no longer than 25% of a typical practice

• Climb using jugs and large holds on vertical walls, no crimping

• Gradual loading via hang board training (maximum 15 minutes) 

• General strength, endurance, mobility, and motor control exercises can also be incorporated into training

• Red flags: pain or swelling at the growth plate that does not completely resolve after one rest day

Stage 2 (Weeks 2-3)

• Goal: gradually increase climbing difficulty from easy to moderate

• Maximum 3 sessions per week

• Each session should be no more than 50% of a typical practice time

• Steeper angles up to 45 degrees can be introduced

• progress dead-hanging on the hangboard, big holds only, for no longer than 30 min.

• General strength, endurance, mobility, and motor control exercises can also be incorporated into training

• Red flags: If there is pain or swelling over the growth plate, the climber should stop this stage and take a rest day. After a day of rest and complete resolution of pain, the climber may start back at stage 1. If pain persists, the athlete should be referred to their physician

Stage 3 (Weeks 4-5):

• Goal: gradually increase difficulty to 75% of pre-injury level

• Progress to 4 sessions per week, mainly non-consecutive days

• Each session can last up to 75% of a typical practice

• crimping on large edges (half crimp only) and easy dynos may be introduced during this phase

• General strength, endurance, mobility, and motor control exercises can also be incorporated into training

• Red flags: If there is pain or swelling over the growth plate, the climber should stop this stage and take a rest day. After a day of rest and complete resolution of pain, the climber may start back at stage 2. If pain persists, the athlete should be referred to their physician.

Stage 4 (Weeks 6-8): 

• Goal: gradually increase difficulty to 100% of pre-injury level

• Climber may participate in his or her full training volume

• Small edge crimps and board climbing can be gradually reintroduced

• General strength, endurance, mobility, and motor control exercises can also be incorporated into training

• If applicable, the youth climber may begin competing again

• Red flags: If there is pain or swelling over the growth plate, the climber should stop this stage and take a rest day. After a day of rest and complete resolution of pain, the climber may start back at stage 3. If pain persists, the athlete should be referred to their physician.

The physiotherapists at Elios Health take pride in staying up to date on all the latest sports medicine and rehabilitation research such as this return to sport protocol for finger epiphyseal plate fractures in youth climbers. Our practitioners are knowledgeable about a vast number of injuries and conditions and are experienced in assessing and treating patients of all ages and athletic backgrounds. Through engaging in evidence-based practice, the physiotherapists at Elios Health will ensure you receive the best possible care when recovering from an injury and returning to your favourite sports and daily activities. 

Returning to Climb after Epiphyseal Finger Stress Fracture (full article) can be found at: https://journals.lww.com/acsm-csmr/fulltext/2020/11000/returning_to_climb_after_epiphyseal_finger_stress.7.aspx?casa_token=NT5HH5aTLXsAAAAA:CKVOmyct_IqzVktCm-i7uylc3i5_8BaB-ksurjwAnq4NGvtq0IS8wR-PsF0jYSxkkYIzup3ZdT5pb5A5zV_mLuUe

Meyers, R. N., Schöffl, V. R., Mei-Dan, O., & Provance, A. J. (2020). Returning to climb after epiphyseal finger stress fracture. Current Sports Medicine Reports, 19(11), 457-462.

Original Post by Rachel Rubin-Sarganis
Photo by Elahe Motamedi