November 1996 Vol.18, No.
11
Continuing Education Article
FOCAL POINT
★Interfragmentary compression
for physeal fractures in dogs is
the surgical treatment of choice,
although good results have
been achieved with multiple-pin
fixation.
KEY FACTS
■ Proximal femoral physeal
fractures only occur in immature
animals because the physis must
be open for trauma to occur.
■ Physical examination following
proximal femoral physeal fracture
should evaluate all body systems
because of the correlation of
these fractures with physical
trauma.
■ Because some dogs have
minimal fragment displacement
following a fracture, radiography
and careful evaluation of the
physis are important for accurate
diagnosis.
■ Age at the time of injury is critical
for prognosis; younger dogs have
a greater chance of developing
degenerative joint disease.
Fractures of the
Proximal Femoral
Physis in Dogs
Auburn University Kansas State University
D. M. Tillson, DVM, MS R. M. McLaughlin, DVM, DVSc
J. K. Roush, DVM, MS
T he proximal femoral physis is a common site of fractures in immature
dogs. Synonyms for fractures of the proximal femoral physis include
capital physeal fracture, capital epiphyseal fracture, slipped capital
epiphysis, and proximal femoral epiphyseal separation.1–7 Fractures of the prox-
imal femoral physis are most commonly Salter-Harris type I or II fractures,
which account for 16% of all physeal fractures.1,2,8–10 Complications of proxi-
mal femoral physeal fracture and its repair include degenerative joint disease,
deformity and osteonecrosis of the femoral head and neck, subluxation or luxa-
tion of the coxofemoral joint, fracture nonunion, fixation failure, infection,
and sciatic nerve impingement.1,4,6,11–13
This article reviews information pertinent to fractures of the proximal
femoral physis in dogs. The anatomy and blood supply of the coxofemoral
joint and the anatomy of the normal physis are reviewed. Treatment and repair
options are presented, and complications associated with fracture repair and
healing are discussed.
ANATOMY OF THE CANINE COXOFEMORAL JOINT
The joint between the os coxae and the proximal femur is a synovial or di-
arthrodial joint with a ball-and-socket configuration.14 The joint consists of a
joint cavity, joint capsule, synovial fluid, articular cartilage, and underlying
bone.14 The os coxae is formed by fusion of the ilium, ischium, pubis, and ac-
etabular bones at 12 weeks of age.14,15 The femoral head is anchored into the
acetabulum by the round ligament (ligament of the head of the femur), sur-
rounding joint capsule, and transacetabular ligament.14 In immature dogs, the
coxofemoral joint develops in a normal manner as long as all forces acting on
the hip are balanced and neutral to accommodate congruency between the ac-
etabulum and femoral head.15 Instability between the femoral head and acetab-
ulum leads to incongruency and degenerative joint disease.15,16
BLOOD SUPPLY TO THE CANINE FEMORAL HEAD
The arterial supply to the coxofemoral joint and proximal femur has been
The Compendium November 1996 Small Animal

Figure 1— The vascular supply of

the proximal femur comes primarily
from the lateral (Lat) and medial
(Med ) circumflex femoral arteries.
The cranial and caudal gluteal (CG )
arteries also contribute to the blood
supply. (A) Lateral view of the
blood supply to the proximal fe-
mur. (B) Ventrodorsal view of the
blood supply to the proximal fe-
mur. Note how the fine branches of
the vessels anastomose and form a
comprehensive vascular network.
Care should be taken during surgi-
cal repair to minimize iatrogenic
trauma to the blood supply. a =
artery, Asc = ascending, br =
branch, Des = descending, Ext = ex-
ternal, LCF = lateral circumflex. (Il-
lustrated by Lisa Makarchuk,
Auburn University.)

studied extensively because of

the high frequency of traumatic
and degenerative diseases affect-
ing the canine coxofemoral joint
and the importance of the ca-
Figure 1A
nine coxofemoral joint as a mo-
del for human studies. Know-
ledge of the blood supply to
both an immature and a mature
canine coxofemoral joint is im-
portant for these studies and for
surgical repair of proximal
femoral physeal fractures.
The proximal femoral blood
supply has been studied by evalu-
ating the extraosseous, intracap-
sular, and intraosseous compo-
nents.17–20 The medial and lateral
circumflex femoral arteries
(branches of the deep femoral
and femoral arteries, respectively)
provide a majority (about 70%)
of the extraosseous blood supply
to the proximal femur and the
coxofemoral joint.11,14, 17–22 The
caudal gluteal, cranial gluteal,
and iliolumbar arteries also con-
tribute to the proximal femoral
blood supply18,20 (Figure 1).
The intracapsular blood sup-
ply is a continuation of ex-
traosseous vessels within the
coxofemoral joint capsule. The
Figure 1B intracapsular vessels form a vas-

VASCULAR SUPPLY ■ FEMORAL ARTERIES ■ COXOFEMORAL JOINT

Small Animal The Compendium November 1996

Figure 2—The physis has a distinct orientation and can be divided into zones based on the activity of the cells in each layer. The
reserve zone is beneath the epiphyseal bone and is followed by the zone of proliferation, zone of hypertrophy, and zone of endo-
chondral ossification. (Illustrated by Lisa Makarchuk, Auburn University.)

cular ring or retinaculum at the base of the femoral
neck.11,17,18 The dorsal retinacular artery supplies a ma-
jority of the proximal femoral epiphysis as a single ves-
sel or as a part of a vascular arcade with the ventral reti-
nacular artery.17 Retinacular vessels course along the
femoral neck in an intracapsular, extraosseous position
as they cross the physis and penetrate the femoral epi-
physis.
The intraosseous blood supply of the proximal femur
has been studied in mature dogs and is composed of
terminal branches of metaphyseal and epiphyseal arter-
ies supplying endosteum and cancellous and cortical
bone.19 Retinacular vessels pass through the epiphyseal
cartilage and become epiphyseal vessels that anastomose
and arborize, providing blood to the entire epiphysis.17
In immature dogs, the intraosseous arteries of the epi-
physis and metaphysis are separated by the physis. Nor-
mally, the physeal barrier is not breached until after
maturity, when anastomosis of epiphyseal and meta-
physeal vessels can occur.17,20,21 Trauma such as a phy-
seal fracture compromises the physeal barrier, and
metaphyseal vessels thus cross and revascularize the epi-
physis.7,23
The round ligament, which originates in the ventral
acetabulum and inserts on the medial aspect of the
femoral epiphysis, helps to maintain coxofemoral joint
congruency, but does not contribute to the blood sup-
ply of the proximal femur.14 Histologic, vascular, and
angiographic studies of dogs have not found evidence
of significant vascular supply to the proximal femoral
epiphysis from vessels in the round ligament.17,18,20 Sim-
ilarly, vessels in the round ligament do not contribute
to revascularization of the proximal femoral epiphysis
after experimental fracture repair.7,23
Retinacular vessels supplying the femoral epiphysis
are exposed along the femoral neck, predisposing them
to compression and obstruction from increased intra-
articular pressure. Increased intraarticular pressure from
joint effusion or trauma has been hypothesized to cause
vascular tamponade, which can result in pathologic
damage to the femoral head.17,24,25 Measurement of the
accumulation of a radiolabeled phosphorus (P32) dur-
ing experimental studies on the proximal femoral circu-
lation found that puppies had decreased uptake as in-
traarticular pressures increased.17 Traumatic injury with
rigid fracture fixation results in revascularization from

PHYSEAL ZONES ■ ROUND LIGAMENT ■ RETINACULAR VESSELS

Small Animal
metaphyseal vessels crossing the fractured physis,7,23
suggesting that revascularization could not occur with-
out partial or complete physeal closure. Similar vascular
patterns are described in the osteoarthritic hip joint of
mature dogs, where anastomosing networks of epiphy-
seal and metaphyseal vessels have developed as a re-
sponse to chronic injury.26 Such findings suggest a stan-
dard vascular response to acute or chronic trauma
affecting the coxofemoral joint.
Clinical management of fractures of the proximal
femoral physis should take into consideration the blood
supply to the femoral head and neck. Gentle tissue han-
dling during the surgical approach to the coxofemoral
joint for fracture repair is important to avoid iatrogenic
damage to branches of the medial and lateral circumflex
femoral arteries.18 While a craniolateral approach is used
by many surgeons, the craniolateral approach using a
trochanteric osteotomy27 has been recommended.7,19,23,28
Regardless of the approach used to expose the fracture,
accurate anatomic reduction and rigid fracture stabiliza-
tion are recommended to promote rapid revasculariza-
tion of the proximal epiphysis.7,23
ANATOMY OF THE CANINE PHYSIS
The function and normal anatomy of the physes
(growth plates) of the long bones have been well estab-
lished. The canine femur has three physes: the proximal
femoral physis, the physis of the greater trochanter, and
the distal femoral physis.15,29 The proximal femoral phy-
sis and the physis of the greater trochanter begin as a
single physis that divides as a result of the pull of the
gluteal muscles on the greater trochanter.15 Longitudi-
nal growth of the proximal femur and femoral neck oc-
curs from the proximal femoral physis.
Histologically, the physis has a distinctive orientation
(Figure 2). It is divided into four sections: reserve zone,
zone of proliferation, zone of hypertrophy, and zone of
endochondral ossification.30 The reserve zone (germinal
or resting zone) is on the epiphyseal side of the physis.
The function of this zone is not clear but is believed to
be one of nutritional storage for later utilization.30 The
zone of proliferation is where cell division for physeal
growth occurs.30 The zone of hypertrophy is an area of
abrupt change. The chondrocytes become five times
larger, lose their glycogen stores, and start showing
signs of cellular death.30 This zone, which is believed to
be the weakest area of the physis, is where physeal frac-
tures classically occur, although this finding has been
disputed in dogs.9,31 The zone of endochondral ossifica-
tion is where degenerative chondrocytes are calcified
and incorporated into metaphyseal bone.30 No blood
vessels exist in the hypertrophic zone of the physis, the
results of which are very low oxygen tension and anaer-
NORMAL ANATOMY ■ SALTER-HARRIS CLASSIFICATION ■ RADIOGRAPHY
The Compendium November 1996
obic depletion of glycogen stores within the chondro-
cytes.30 These metabolic stresses may be the stimulus
for the changes undergone by the chondrocytes in the
zone of hypertrophy.30
CLASSIFICATION OF PHYSEAL FRACTURES
Fractures involving the physis (growth plate) were
classified by Salter and Harris.9 Such classification pro-
vides information on the prognosis for fracture healing
and subsequent growth abnormalities. Salter-Harris
type I fractures involve only the physis. Type II frac-
tures involve the physis and a portion of the metaphy-
sis. Type III fractures involve the physis, the epiphysis,
and usually the articular surface. Type IV fractures in-
volve the physis, metaphysis, and epiphysis. Type V
fractures are nondisplaced and crush the cells in the
proliferative zone, resulting in premature physeal clo-
sure. Application of the Salter-Harris classification sys-
tem and management of physeal fractures in veterinary
medicine have been described.8 Type I or II physeal
fractures should heal rapidly with minimal chance of
future growth abnormalities; however, clinical experi-
ence reveals that this often is not the case. Indeed, the
proximal femur was recognized as an exception to the
classification system:
. . . the prognosis for future growth is
excellent unless the epiphysis involved
is totally covered by cartilage (for ex-
ample, upper end of the femur).9
Physeal fractures are classically reported to occur
through the zone of hypertrophy; but 76% of naturally
occurring physeal fractures in dogs involved a portion
of the proliferative zone, possibly resulting in a higher
than expected number of poor results after surgical
intervention.9,31
As mentioned, fractures of the proximal femoral phy-
sis account for 16% of reported physeal injuries in
dogs. In two studies, the fractures were overwhelmingly
(91% and 96%) Salter-Harris type I or II fractures.1,10
The physis is weaker than bone, tendon, ligament, or
the fibrous joint capsule complex.9,14,32 Inherent weak-
ness in the zone of hypertrophy makes the physis a like-
ly point of failure when fracture forces are applied to an
immature limb.
Growth abnormalities after physeal fracture may
depend on whether the affected physis has reached
physiologic closure. Occurring before radiographic
closure, physiologic closure denotes the end of growth
from the physis. Despite the potential for no further
growth, the physis is still inherently weak. Physeal
fracture occurring after physiologic closure should not
result in growth abnormalities. Radiographic closure
The Compendium November 1996
begins with radiographic evi-
dence of narrowing or oblitera-
tion of the physeal line, which
occurs at approximately 6 to 11
months of age.29,33
DIAGNOSIS AND
CAUSATIVE FACTORS
Most cases of proximal femoral
physeal fractures in animals are re-
ported in dogs, although fractures
are reported in other species.11,34–37
The fracture only occurs in imma-
ture animals because the physis of
the proximal femur must be open
for fracture to occur. The average
age of dogs that sustain fracture
to this area is 5.6 months.1,6 No
breed or sex distribution has been
reported, although fracture in
Labrador retrievers was more
prominent in one report.2,6,11
Most dogs present with a histo-
ry or physical findings of acute
trauma. In contrast, children de-
velop slipped capital femoral epi-
physes from the chronic trauma
of normal activities.38–40 Causative
factors in dogs are not clearly un-
derstood. Shearing and avulsion
forces are reported to be the cause
of most physeal fractures.9,10 The
fact that the round ligament re-
mains intact in most cases of prox-
imal femoral physeal fracture sup-
ports speculation that this fracture
is an avulsion fracture created after
severe and sudden abduction of
the rear leg.32,41–43
Because of the correlation be-
tween proximal femoral physeal
fractures and physical trauma, the
physical examination should eval-
uate all body systems.1 Thoracic
radiographs and an electrocardio-
gram should be obtained before
general anesthesia and surgical in-
tervention.44 Clinical history may
include acute onset of partial or
non–weight-bearing lameness in
the rear leg, reluctance or inability
to stand or move, and observation
of the traumatic event. Specific
PHYSICAL TRAUMA ■ CLINICAL HISTORY ■ EARLY TREATMENT TECHNIQUES
Figure 3A
Figure 3B
Figure 3— These radiographs taken before
surgery show a Salter-Harris type I fracture of
the canine proximal femoral physis. (A) The lat-
eral view fails to show the physeal fracture defini-
tively. (B) The ventrodorsal view is important to
provide adequate visualization of the fracture.
Small Animal
orthopedic findings may include
slight swelling or bruising of the
coxofemoral area, shortening of
the injured leg attributable to
dorsocranial pull of the gluteal
muscles, and pain and crepitus
during palpation or range of mo-
tion (especially extension) of the
coxofemoral joint. Diagnostic dif-
ferentials include hip dysplasia
(coxofemoral laxity and subluxa-
tion), coxofemoral luxation,
femoral neck fractures, pelvic
fractures, sacroilial luxations, and
proximal femoral shaft fractures.
Radiographs are needed to con-
firm a diagnosis. Dogs tend to
have significant displacement of
the femur from the epiphysis, as
opposed to the mild displacement
or slips reported in children. 38
Some dogs, however, have min-
imal fragment displacement.
Therefore, good-quality radio-
graphs and careful evaluation of
the physis are important for accu-
rate diagnosis. Standard lateral
and ventrodorsal views of the coxo-
femoral joint are needed because a
single radiographic view does not
provide adequate visualization of
the proximal femur (Figure 3). A
ventrodorsal frog-legged view dis-
tracts the fracture and may aid in
making a diagnosis. As previously
indicated, a majority of these frac-
tures are Salter-Harris type I or
II.1,10
MANAGEMENT OPTIONS
Early techniques for treating
fractures of the proximal femoral
physis focused on external coapta-
tion. Schroeder-Thomas splints,
Stader apparatus, and Ehmer or
non–weight-bearing slings have
been used but are no longer ac-
cepted as appropriate treatment
options.11,42,45,46 Because there are
no acceptable methods of external
fixation or coaptation, internal
fracture fixation is recommended
for dogs. The goals of internal
Small Animal The Compendium November 1996

fracture fixation are accurate beyond into the joint.47,52 The articu-
anatomic reduction; rigid fracture lar surface should be inspected care-
stability to promote rapid fracture fully with a curved surgical instru-
healing; early return to function and ment in areas where the surgeon’s
activity; and, in the case of articular vision is limited.47,54,55 Once the sur-
fractures, preservation of a normal, geon is satisfied with the fracture re-
pain-free joint.44,47 Experimental and duction and stability, the pins can be
clinical use of threaded or smooth bent and cut below the trochanter.
pins, screws placed with or without The joint should then be lavaged
generation of interfragmentary com- with sterile saline and closed in a
pression, or combinations of pins routine fashion. If a greater tro-
and screws have been reported and chanteric osteotomy was performed,
are currently considered the staples the trochanter must be secured with
of fracture repair of the proximal a tension band and the incision
femoral physis.32,41,48–51 closed in a routine fashion47,52 (Figure
The hair on the femur should be 4).
clipped from the dorsal midline, Lag-screw repair can be per-
continuing down the leg until distal formed in a similar manner. 1,4,-
to the stifle. The dorsal extent of 6,7,32,47,53,54
A hole should be drilled in
the clipped area can be extended for the femoral neck either from the
Figure 4— This ventrodorsal radiograph
epidural administration of anesthet-
taken after surgery shows a fractured proxi- fracture surface or from beneath the
ics or analgesics if desired. A hang- mal femoral physis repaired by placing greater trochanter. The thread hole
ing leg preparation is used, and the multiple pins from below the greater in the femoral neck must be over-
leg is draped for sterile surgery. Peri- trochanter. Careful evaluation during surgi- drilled to create a glide hole that al-
operative antibiotics should be ad- cal repair is required to ensure that the pins lows compression to be generated
ministered before a skin incision is do not penetrate the articular surface. Here across the fracture line by using the
made and continued every 2 hours the radiographic positioning suggests that lag- screw principle. The fracture
for the duration of the surgical pro- one pin may have penetrated beyond the should be reduced, a drill sleeve
cedure. A craniolateral approach articular surface. placed in the glide hole, and a thread
with or without a trochanteric os- hole drilled in the epiphysis. The
teotomy is recommended. 28 Al- surgeon is cautioned against pene-
though the approach is a matter of clinician preference, trating the articular surface.54 The depth of the thread
a trochanteric osteotomy has been suggested as being hole can be measured and the epiphysis tapped. The
less disruptive to the blood supply of the proximal fe- measured screw length should be reduced by 2 mm to
mur.7,19,23 ensure the screw tip does not penetrate the articular sur-
Multiple small pins are commonly used for fracture face or strip the threads after hitting the bottom of the
repair.1,4,6,47,52–54 The pins can be placed through the thread hole.32 The appropriate-length screw should be
femoral neck in either a retrograde or normograde fash- inserted and tightened, lagging the epiphysis back onto
ion.47,52,54–56 Retrograde placement involves inserting the the femoral neck. Fracture reduction and stability can
pins from the metaphyseal fracture surface and exiting be evaluated and the articular surface examined to con-
the lateral femur distal to the greater trochanter. Nor- firm that the screw has not protruded into the joint.
mograde placement involves inserting the pins from the Placement of a single small pin in addition to the lag
lateral femur distal to the trochanter up the femoral screw has been recommended to provide a second point
neck and exiting at the fracture site. Regardless of the of epiphyseal fixation and counteract rotational forces
method of placement, the pins should be retracted un- on the epiphysis6,54,55 (Figure 5). Other reports have
til they are flush with the fracture surface. Pins can be suggested that the undulating nature of the fracture bed
placed in either a parallel or diverging manner.47,52,54–56 and the compression achieved by the lag screw are suffi-
The width of the epiphysis should be estimated and cient to prevent rotation.6,11,41,54 Once the surgeon is
the pins marked so that the surgeon can reduce the frac- satisfied with the fracture reduction and stability, the
ture and advance the pins the estimated distance into joint can be lavaged with sterile saline and closed in a
the epiphysis to avoid penetration of the articular sur- routine fashion. If a greater trochanteric osteotomy was
face.47,52,55,56 The joint should be subjected to a gentle performed, the trochanter should be secured with a ten-
range of motion to ensure that no pins are protruding sion band and the incision closed in a routine fashion.

PIN FIXATION ■ LAG-SCREW REPAIR ■ JOINT PRESERVATION

The Compendium November 1996
Another method is the articu-
lar lag-screw technique, which
uses screws placed in lag fashion.5
To perform this repair, the
femoral epiphysis is removed
from the acetabulum by severing
the round ligament. The epiph-
ysis should be reduced and se-
cured to the femoral neck by
placing a small pin in the fovea
capitis. Doing so allows visual-
ization of the entire femoral
head to help ensure accurate
anatomic reduction of the frac-
ture.
After reduction, a 1.5-mm drill
bit should be used to drill a
thread hole through the epiphysis
and approximately 25 to 30 mm
deep into the femoral neck (Fig-
ure 6). After drilling the thread
hole, the epiphyseal portion is
overdrilled with a 2-mm drill bit.
A countersink should be used so
that the screw head is set well
below the surface of the articular
cartilage. A 20-mm long, 2-mm
screw should be placed and gen-
tly tightened, with a second 2-
mm screw placed in a similar
manner. Screw placement should
avoid the weight-bearing surface
of the coxofemoral joint. The ar-
ticular surface can be palpated to
ensure that the screw heads are
adequately countersunk below
the joint surface. Once the sur-
geon is satisfied with the fracture
reduction and stability, the joint
should be lavaged with sterile
saline and closed. Joint capsule
closure is important for joint sta-
bility because the round ligament
was severed. If a trochanteric os-
teotomy was performed during
the approach, transposition of
the trochanter to a more caudal
and distal position tightens the
gluteal muscles and provides ad-
ditional joint stability.23,57
Each of the repairs discussed
has advantages and disadvan-
tages. Clinician experience plays
ARTICULAR LAG-SCREW TECHNIQUE ■ FRACTURE LINE DISTRACTION ■ STABILITY
Figure 5—This ventrodorsal radiograph taken af-
ter surgery shows repair of a proximal femoral
physis via a single lag screw. A small pin has
been added as a second point of fixation to pre-
vent rotation of the epiphysis around the bone
screw.
Figure 6—This ventrodorsal radiograph taken af-
ter surgery shows repair of a fractured proximal
femoral physis by placing two small screws from
the articular surface. The screw heads are counter-
sunk beneath the level of the articular cartilage to
avoid damage to the acetabular cartilage.
Small Animal
a large role in determining the
type of fixation selected. Multi-
ple-pin fixation of proximal
femoral physeal fractures is wide-
ly described in veterinary surgical
texts.47,52,54–56 The procedure has
been reported to be technically
easier than lag-screw fixation. 6
Multiple-pin fixation also is cited
as the least likely method of re-
pair to cause premature physeal
closure47,55,56 because the proce-
dure does not generate compres-
sive force across the fracture line,
which can result in cessation of
physeal growth.
The importance of this is ques-
tionable because premature phy-
seal closure apparently occurs de-
spite the meth- od of fixation used,
probably because both the zone
of hypertrophy and the zone of
proliferation are involved, thereby
predisposing the physis to prema-
ture closure.11,31 Visualization of
the femoral epiphysis is limited,
which can make accurate
anatomic reduction difficult.52,54
Fracture line distraction may oc-
cur during pin placement in the
epiphysis. 4 Care must be exer-
cised to avoid unreco g n i z e d
penetration of the pins into ar-
ticular cartilage.47 Multiple-pin
fixation does not meet the crite-
ria for rigid fracture fixation and
can possibly lead to decreased
bone formation and increased
bone resorption.32 Multiple di-
verging pins have been found to
be significantly weaker against
tensile forces than other methods
of repair. 43 Fracture of the soft
metaphyseal or epiphyseal bone
can occur while bending the
pins.55 Despite these drawbacks,
multiple pins have provided a
method of stable fixation with
acceptable clinical results.1,6,11
Lag-screw repair provides
rigid fracture fixation and
interfragmentary compres-
sion, which promote early epi-
The Compendium November 1996
physeal revascularization.7,49,51 Lag-screw fixation also has
been reported to be a simple surgical technique.32 Pre-
mature physeal closure can occur with interfragmentary
compression; but, as previously noted, fracture trauma
has likely predisposed the physis to premature closure.11
As with multiple pins, visualization of the femoral head
is limited during reduction and fixation, thus increas-
ing the difficulty and requiring the surgeon to evaluate
the reduction carefully as well as check whether a screw
extends beyond the articular surface of the cartilage.47,52
There may be minimal bone purchase by screw threads
in the proximal femoral epiphysis because it is a thin,
caplike piece of bone.4,5,47,52,56 Iatrogenic fracture of the
femoral neck repaired with lag-screw fixation has been
reported, and fracture of the epiphysis during lag-screw
placement or tightening can occur.11
Articular lag-screw fixation allows complete visualiza-
tion of the femoral capitis and thus helps with accurate
fracture reduction.5 There is rigid fracture fixation and
compression across the fracture line, which allows rapid
epiphyseal revascularization.7,13,23 The surgical tech-
nique is reported to be simpler and less time-consum-
ing than traditional methods of repair.5
Problems associated with premature physeal closure
as a result of interfragmentary compression have been
addressed. With this method, a greater amount of dam-
age occurs to the articular cartilage with varying degrees
of degenerative joint disease, although proper place-
ment and countersinking places the screw heads in a
non–weight-bearing area and beneath the articular car-
tilage, thereby allowing implant coverage with fibrocar-
tilage.5,13,23 Tensile forces that may distract the fracture
are eliminated when the round ligament is severed.5,23,43
Severing the round ligament, however, necessitates
strict attention to joint stabilization during closure.
Coxofemoral joint destabilization created by severing
the round ligament was believed to be a complicating
factor in four cases of failed repair in which articular
screws were used.13
In vitro biomechanical evaluations of various repair
options for proximal femoral physeal fractures have
been performed. Fracture repair with one or two small
pins was found to equal the original physeal strength
when tested in shear, while repair with three pins sig-
nificantly exceeded original strength.58 A second study
found that two pins were significantly weaker than the
original physis while a single lag screw exceeded ori-
ginal physeal strength.59 Comparison using diverging
small pins, a single lag screw, and two screws placed
from the articular surface revealed no significant differ-
ence in strength or stiffness when tested in shear, but
found pins to be significantly weaker and hence less
able than other repair methods to maintain fracture re-
TENSILE FORCES ■ BIOMECHANICAL EVALUATION ■ SALVAGE OPTIONS
Small Animal
duction against distracting (tensile) forces.43 The inabil-
ity to neutralize this fracture force with diverging pins
could complicate fracture healing.
Radiographs should be obtained after surgery to assess
fracture reduction and implant placement. Multiple
views (lateral, ventrodorsal, and frog-legged ventrodor-
sal) may be required to ensure that no implant protru-
sion beyond the joint surface has occurred. Fracture
healing has been reported to occur within 3 to 6 weeks
after surgical repair.7,23,32 We, however, do not routinely
obtain radiographs until 8 weeks after surgery and then
repeat the radiographs in 4 weeks if there are questions
about the healing. Sudden worsening of clinical progress
any time after surgery warrants radiographic evaluation.
During the postoperative period, distinctive radiograph-
ic changes are common with this type of fracture; as dis-
cussed later, such changes should not be overinterpreted.
Immediate postoperative care consists of pain man-
agement and exercise restriction. Epidural administra-
tion of analgesics may eliminate the requirement for
additional postoperative analgesia; otherwise, systemic
analgesics should be administered. When taking the dog
for a walk after surgery, a supportive sling under the ab-
domen should be used for support and to prevent slip-
ping or falling, which could disrupt the fracture repair.
Although we do not use it, a non–weight-bearing sling
on the affected limb has been recommended.47,51 Home
care should include strict cage confinement and exercise
restriction, gentle range-of-motion therapy, and use of a
supportive sling during the first week of ambulation.
Cage confinement, with only short walks for urination
and defecation, should be enforced until radiographs
confirm the fracture has healed.
If the fracture repair fails, salvage options exist.
Femoral head and neck excision can be done when the
fracture repair is too expensive for the owner, the frac-
ture occurred several weeks before diagnosis, articular
cartilage damage occurs to the proximal femur or ac-
etabulum, fracture comminution exists, the surgeon is
not experienced with repair procedures, or referral to a
surgical specialist is not possible. During femoral head
and neck excision, the femoral epiphysis is removed;
however, the surgeon must also remove the femoral
neck to ensure pain-free pseudoarthrosis.52,60 Total hip
replacement is another salvage option after the dog has
reached skeletal maturity.60 This procedure can be done
for dogs with working or athletic potential or when
femoral head and neck excision is not a valid option.
Expense, however, may be a limiting factor in the deci-
sion for total hip replacement. Because both procedures
are salvage options, they should not be considered the
first choice of treatment for dogs with fractures of the
proximal femoral physis.11
Small Animal
COMPLICATIONS
Degenerative joint disease is the most common com-
plication reported in dogs after a fracture of the proxi-
mal femoral physis has been repaired, regardless of the
procedure used.1,6,11 Radiographic changes consistent
with degenerative joint disease were present in all dogs,
but degenerative changes were more severe in dogs
younger than 4 to 6 months of age at the time of in-
jury.1,6 Dogs with ipsilateral limb injuries were more
likely to develop coxofemoral degenerative joint dis-
ease.1 Technical errors or inadequate fracture reduction
were apparently related to the most severe cases of de-
generative joint disease. 6,11 Mild articular cartilage
changes were found after experimental repair using ar-
ticular lag screws, with severe cartilage damage in one
dog after implant loosening and migration.23 The ef-
fects of concurrent injuries and age on the development
of degenerative joint disease have been reported; but
the influence of developmental orthopedic diseases,
such as hip dysplasia, is unknown. Owners should be
counseled about the high frequency of degenerative
joint disease after a fractured proximal femoral physis
has been repaired; however, it should be stressed that
radiographic degenerative changes after fracture repair
have not correlated with decreased limb function or ac-
tivity levels.6,11,49
Femoral neck narrowing (apple coring) was observed
in radiographs in 38% to 100% of dogs that under-
went fracture repair of the proximal femoral physis.1,7,23
There was no correlation between femoral neck thin-
ning and the intervals before or after surgery.1 Experi-
mental repair showed significant decreases in femoral
neck thickness 4 weeks after surgery compared with 2
or 8 weeks after surgery.23 Partial restoration of femoral
neck width at 8 weeks after surgery suggests that
femoral neck thinning is part of the normal reparative
process.23 Similar findings have been reported in other
experimental cases.7 Femoral neck thinning should not
be overinterpreted during the postoperative period. A
dog progressing in a manner consistent with the post-
operative interval should be managed by reinforcing ex-
ercise restrictions and frequent radiographic monitor-
ing of the fracture repair. Surgical intervention is
warranted if improvement does not occur or if discom-
fort increases. Remodeling of the proximal femur
should continue as the fracture matures.
Premature physis closure apparently is a more signifi-
cant problem in dogs that are young at the time of in-
jury. A trade-off between interfragmentary compression
and rigid fixation across the fracture site and the poten-
tial for continued growth from the physis must be bal-
anced; and in doing so, several findings should be con-
sidered. In children, closed pinning of slipped capital
DEGENERATIVE JOINT DISEASE ■ APPLE CORING ■ PROGNOSIS
The Compendium November 1996
physes resulted in significantly earlier physeal closure—
an average of 10.2 months earlier than the nonpinned
side.61 In naturally occurring canine physeal fractures,
76% of the fractures examined involved both the pro-
liferative and hypertrophic zones of the physis.62
Experimental studies evaluating epiphyseal revascu-
larization after fracture repair of the proximal femoral
physis found that the revascularization was primarily
from metaphyseal vessels that crossed the fractured
growth plate. Such findings suggest that irreparable
damage to the proximal femoral physis occurs when it
is fractured, which predisposes it to premature closure.
Dogs younger than 4 to 6 months of age at the time of
fracture had more severe degenerative changes in the
coxofemoral joint, thus supporting the hypotheses that
the proximal femoral physeal fracture itself results in
premature closure and that the growth potential re-
maining and not the repair method used influences the
prognosis.1,6
Other complications include failure of fracture re-
duction, nonunion, collapse of the fracture repair,
resorption of the femoral head and neck, penetration of
the coxofemoral joint by the implant, and infec-
tion.1,4,6,11 Technical failures are frequently associated
with these complications.1,6,11 Severe lameness in one
dog 5 years after repair was attributed to compression
of the sciatic nerve by a nonneoplastic mass arising
from the healed femoral neck.12 Femoral head and neck
excision resolved the lameness.
PROGNOSIS
The prognosis varies according to age, presence of
concurrent injuries, and successful early surgical stabi-
lization. A good prognosis for normal limb function
has been reported.11,47,52 Using a more restrictive de-
finition of success (development of coxofemoral joint
degenerative changes) has suggested a guarded progno-
sis, particularly in dogs younger than 6 months of age
at the time of injury.6 Despite radiographic changes,
limb function was not reported to be severely compro-
mised in these dogs.6 Dogs with concurrent orthopedic
injuries had increased chances of subsequent degenera-
tive joint disease, which suggests a guarded prognosis.1
CONCLUSION
Fractures of the proximal femoral physis are common
in young dogs with the potential for severe degenerative
changes and pathologic damage to the coxofemoral
joint. Anatomic considerations for repair include
preservation of the proximal femoral blood supply and
the extent of damage to the proximal femoral physis.
Anatomic reduction and rigid stabilization are impor-
tant factors in achieving rapid and uncomplicated frac-
Small Animal
ture healing. Traditional methods of external coapta-
tion for fracture management have been replaced by
open reduction and internal fixation. Use of interfrag-
mentary compression is recommended, although good
results have been achieved using multiple-pin fixation.
The decision as to which repair method is to be used
should be based on patient signalment, fracture classifi-
cation, presence of concurrent injuries, and clinician
preference and experience. The prognosis for return to
function after surgical repair is guarded to good, with
the best results in dogs older than 6 months of age at
the time of fracture. Femoral head and neck excision
remains an option for selected canine patients or if the
primary fracture fixation fails. Early repair, accurate re-
duction, and stable fixation help to maintain the coxo-
femoral joint and have achieved good clinical results.
About the Authors
Dr. Tillson is affiliated with the Department of Small
Animal Surgery and Medicine, College of Veterinary
Medicine, Auburn University, Auburn, Alabama. Drs.
McLaughlin and Roush are with the Department of Clini-
cal Sciences, College of Veterinary Medicine, Kansas
State University, Manhattan, Kansas. Drs. Tillson,
McLaughlin, and Roush are Diplomates of the American
College of Veterinary Surgeons.
REFERENCES
1. DeCamp CE, Probst CW, Thomas MW: Internal fixation
of femoral capital physeal injuries in dogs: 40 cases
(1979–1987). JAVMA 194:1750–1754, 1989.
2. Lee R: Proximal femoral epiphyseal separation in the dog.
J Small Anim Pract 11:669–679, 1976.
3. Nelson CA: Operative treatment of fractures of the neck of
the femur and epiphyseal separation of the head of the femur
in the dog. North Am Vet:557–559, 1941.
4. Aron DN, Kaddatz LA, Dueland R: A review of reduction
and internal fixation of proximal femoral fractures in the dog
and man. JAAHA 15:455–462, 1979.
5. Kuzma A, Sumner-Smith G, Miller C, McLaughlin R: A
technique of repair of femoral capital epiphyseal fractures in
the dog. J Small Anim Pract 30:444–448, 1989.
6. Gibson KL, vanEe RT, Pechman RD: Femoral capital phys-
eal fractures in dogs: 34 cases (1979–1989). JAVMA
198:886–890, 1991.
7. Hulse DH, Wilson JW, Abdelbaki YZ: Revascularization of
femoral capital physeal fractures following surgical fixation.
J Vet Orthop 2:50–57, 1981.
8. Berzon JL: The classification and management of epiphyseal
plate fractures. JAAHA 16:651–658, 1980.
9. Salter RB, Harris WR: Injuries involving the epiphyseal
plate. J Bone Joint Surg 45-A:587–622, 1963.
10. Marretta SM, Schrader SC: Physeal injuries in the dog: A re-
view of 135 cases. JAVMA 182:708–710, 1983.
11. Daly WR: Femoral head and neck fractures in the dog and
cat: A review of 115 cases. Vet Surg 2:29–38, 1978.
The Compendium November 1996
12. Newton GT: Sciatic impairment following proximal femoral
physeal fracture: Two case reports. JAAHA 25:239–242,
1989.
13. Miller A, Anderson TJ: Complications of articular lag screw
fixation of femoral capital epiphyseal separations. J Small
Anim Pract 34:9–12, 1993.
14. Evans HE, Christensen GC: Miller’s Anatomy of the Dog.
Philadelphia, WB Saunders Co, 1979, pp 1–275.
15. Riser WH: Growth and development of the normal canine
pelvis, hip joints and femur from birth to maturity: A radio-
graphic study. J Vet Radiol Soc 14:24–34, 1973.
16. Smith GK, Biery DN, Gregor TP: New concepts of coxo-
femoral joint stability and the development of a clinical
stress-radiographic method for quantitating hip joint laxity
in the dog. JAVMA 196:59–70, 1990.
17. Bassett FH, Wilson JW, Allen BL, Azuma H: Normal vascu-
lar anatomy of the head of the femur in puppies with em-
phasis on the inferior retinacular vessels. J Bone Joint Surg
51-A:1139–1153, 1969.
18. Kaderly RE, Anderson WD, Anderson BG: Extraosseous
vascular supply to the mature dog’s coxofemoral joint. Am J
Vet Res 43:1208–1214, 1982.
19. Kaderly RE, Anderson BG, Anderson WD: Intracapsular
and intraosseous vascular supply to the mature dog’s coxo-
femoral joint. Am J Vet Res 44:1805–1812, 1982.
20. Rivera LA, Abdelbaki YZ, Titkemeyer CW: Arterial supply
to the canine hip joint. J Vet Orthop 1:20–32, 1979.
21. Fitzgerald TC: Blood supply to the head of the canine fe-
mur. VM SAC:389–394, 1961.
22. Wilson JW, Allen BL, Bassett FH: Normal vascular supply
of the femoral head in young puppies and revascularization
following experimental aseptic necrosis. Anat Rec 157:
342–343, 1967.
23. Tillson DM, McLaughlin RM, Roush JK: Evaluation of ex-
perimental proximal femoral physeal fractures repaired with
two cortical screws placed from the articular surface. Vet
Comp Orthop Traumatol 7:140–147, 1994.
24. Wilson JW, Allen BL, Bassett FH: Circulatory studies in
aseptic necrosis of the femoral head in young dogs. Anat Rec
154:442, 1966.
25. Kristensen KD, Kiaer T, Pedersen NW: Intraosseous PO2 in
femoral neck fracture: Restoration of blood flow after aspira-
tion for hemarthrosis in undisplaced fractures. Acta Orthop
Scand 60:303–304, 1989.
26. Whiteside LA, Lange R, Capello WR, Fraser B: The effects
of surgical procedures on the blood supply to the femoral
head. J Bone Joint Surg 65-A:1127–1133, 1983.
27. Gorman HA: Hip joint prostheses. Vet Scope 7:3–9, 1962.
28. Piermattei DL: An Atlas of Surgical Approaches to the Bones and
Joints of the Dog and Cat. Philadelphia, WB Saunders Co,
1993.
29. Smith RN: Radiological observations on the limbs of young
greyhounds. J Small Anim Pract 1:84–90, 1993.
30. Brighton CT: Structure and function of the growth plate.
Clin Orthop 136:22–32, 1978.
31. Johnson JM, Johnson AL, Eurell JC: Histological appear-
ance of naturally occurring canine physeal fractures. Vet Surg
23:81–86, 1994.
32. Hulse DH, Wilson JW, Butler HC: Use of the lag screw
principle for stabilization of femoral neck and femoral capi-
tal epiphyseal fractures. JAAHA 10:29–36, 1974.
33. Sumner-Smith G: Observations on epiphyseal fusion of the
canine appendicular skeleton. J Small Anim Pract 7:303–
311, 1966.
34. Wilson DG, Ulm MJ: Holding power of orthopaedic screws
The Compendium November 1996
in bovine femoral heads. A comparison of 7.0 mm cannulat-
ed screws to 5.5 mm cortical and 6.5 mm cancellous screws.
Vet Comp Orthop Traumatol 6:160–162, 1993.
35. Wilson DG, Crawford WH, Stone WC, Frampton
JW: Fixation of femoral capital physeal fractures with 7.0 mm
cannulated bone screws in five bulls. Vet Surg 20:240–244,
1991.
36. Hunt DA, Snyder JR, Morgan JP, Pascoe JR: Femoral capi-
tal physeal fractures in 25 foals. Vet Surg 19:41–49, 1990.
37. Hunt DA, Snyder JR, Morgan JP, et al: Evaluation of an in-
terfragmentary compression system for the repair of equine
femoral capital physeal fractures. Vet Surg 19:107–116,
1989.
38. Ward WT, Stefko J, Wood KB, Stanitsli CL: Fixation with a
single screw for slipped capital femoral epiphysis. J Bone
Joint Surg 74-A:799–809, 1992.
39. Chung SMK, Batterman SC, Brighton CT: Shear strength
of the human femoral capital epiphyseal plate. J Bone Joint
Surg 58-A:94–103, 1976.
40. Pritchett JW, Perdue KD: Mechanical factors in slipped cap-
ital femoral epiphysis. J Pediatr Orthop 8:385–388, 1988.
41. Cawley AJ, Archibald J, Ditchfield WJB: Fractures of the
neck of the femur in the dog: A technique for repair of frac-
tures of the femoral neck. JAVMA 129:354–358, 1956.
42. Denny HR: Simultaneous epiphyseal separation and frac-
tures of the neck and greater trochanter of the femur in the
dog. J Small Anim Pract 12:613–621, 1971.
43. Tillson DM, Roush JK, McLaughlin RM, et al: Biomechan-
ical comparison of three repair methods for proximal
femoral physeal fractures in shear and tension. Vet Comp Or-
thop Traumatol 7:136–139, 1994.
44. Roush JK: Fracture management decisions. Vet Clin North
Am Small Anim Pract 25:1059–1072, 1995.
45. Schroeder EF: The treatment of fractures in dogs. North Am
Vet 14:27–31, 1933.
46. Schroeder EF: Recent progress in canine orthopedic surgery.
North Am Vet 20:54–61, 1939.
47. Brinker WO, Piermattei DL, Flo GL: Handbook of Small
Animal Orthopedics and Fracture Treatment. Philadelphia,
WB Saunders Co, 1990, pp 1–560.
48. Anderson WD, Schlotthauer CF, Janes JM: Method for
treatment of fractures of the head of the femoral neck in the
dog. I. An experimental study. JAVMA 122:158–160, 1953.
49. Nunamaker DM: Repair of femoral head and neck fractures
Small Animal
by interfragmentary compression. JAVMA 162:569–572,
1973.
50. Bjorling DE: Fracture of the proximal femoral physis and
femoral neck in two dogs. Canine Pract 13:5–11, 1986.
51. Brinker WO: Factors influencing the result in fractures of
the femoral neck. Anim Hosp 2:160–166, 1966.
52. Milton JL: Fractures of the femur, in Slatter D (ed): Text-
book of Small Animal Surgery. Philadelphia, WB Saunders
Co, 1993, pp 1805–1816.
53. Nunamaker DM: Fractures and dislocations of the hip joint,
in Newton CD, Nunamaker DM (eds): Textbook of Small
Animal Orthopedics. Philadelphia, JB Lippincott Co, 1985,
pp 403–414.
54. Gilmore DR: Internal fixation of femoral fractures, in Bo-
jrab MJ (ed): Current Techniques in Small Animal Surgery.
Philadelphia, Lea & Febiger, 1990, pp 682–694.
55. Olmstead ML: Fractures of the bones of the hindlimb, in
Olmstead ML (ed): Small Animal Orthopedics. St. Louis, CV
Mosby Co, 1995, pp 219–246.
56. Eaton-Wells RD, Matis U, Robins GM, Whittick WG:
The pelvis and the pelvic limb, in Whittick WG (ed):
Canine Orthopedics. Philadelphia, Lea & Febiger, 1990, pp
387–491.
57. McLaughlin RM: Traumatic joint luxations in small animals.
Vet Clin North Am Small Anim Pract 25:1175–1196, 1995.
58. Belkoff SM, Millis DL, Probst CW: Biomechanical compar-
ison of three internal fixations for treatment of slipped capi-
tal femoral epiphysis in immature dogs. Am J Vet Res 53:
2136–2140, 1992.
59. Belkoff SM, Millis DL, Probst CW: Biomechanical compar-
ison of 1-screw and 2-divergent pin internal fixations for
treatment of slipped capital femoral epiphysis, using speci-
mens obtained from immature dogs. Am J Vet Res 54:
1770–1773, 1993.
60. Manley PA: The hip joint, in Slatter DJ (ed): Textbook of
Small Animal Surgery. Philadelphia, WB Saunders Co, 1993,
pp 1786–1804.
61. Stanton RP, Shelton YA: Closure of the physis after pinning
of slipped capital femoral epiphysis. Orthopedics 16: 1099–
1103, 1993.
62. Janes GC, Collopy DM, Price R, Sikorski JM: Bone density
after rigid plate fixation of tibial fractures. J Bone Joint Surg
75-B:914–917, 1993.