When a fracture has healed, adults often think of the problem as over. In children, the situation can be different.
If the fracture involved the growth plate, also called the physis, two aspects of recovery matter. One is the healing of the fracture. The other is how the growth plate behaves over the following months and years.
In most cases, growth continues normally. In a minority, however, the injury can cause part or all of the growth plate to close. Some fractures therefore need follow-up even when the child has no pain, walks normally and the X-ray shows a healed bone.
The growth plate is more than a line on an X-ray
The growth plate is the structure through which a long bone grows. In children, it is also mechanically more vulnerable than some ligament structures in adults.
Fractures through it are often described using the Salter–Harris classification. However, the X-ray classification is not the only factor affecting later risk. The site, displacement, energy of the injury, damage to the growth plate and amount of remaining growth all matter.
A 2026 review estimates that up to about 10% of growth plate fractures may be followed by a growth disturbance, with substantial differences between sites and injury patterns. [1]
A healed fracture answers a different question
X-rays during the first few weeks mainly assess fracture alignment, stability and healing.
Once the fracture has healed, later appointments look for different findings: is growth continuing symmetrically? Is a bony bridge forming? Is limb alignment changing? Is one leg growing less than the other?
A later X-ray is therefore not necessarily an unnecessary repeat. It may be answering a new question.
What is growth arrest?
After a growth plate injury, a bony bridge can form between the epiphysis and metaphysis across part of the growth plate. If it affects only one part, growth continues on one side while being restricted on the other. An angular deformity may gradually develop.
If the whole growth plate closes, the main consequence may instead be a difference in limb length.
Neither change has to be obvious in the first few weeks. This delay helps explain why follow-up matters.
Risk varies greatly between sites
A fracture of the growth plate at the lower end of the femur is different from an injury at a site with little growth remaining. The distal femur contributes substantially to lower-limb growth and has historically shown a high risk of growth disturbance after a growth plate fracture. A meta-analysis reported growth disturbance in more than half of the distal femoral fractures studied, with greater risk in displaced fractures. [2]
Growth plate fractures at the lower end of the tibia also warrant attention, particularly when considerable growth remains. The literature on paediatric ankle fractures recommends monitoring high-risk injuries until the risk of growth disturbance has been reasonably excluded. [3]
These figures should not be applied automatically to every growth plate fracture. They help explain why the injury site makes such a difference to follow-up.
Salter–Harris I and II fractures still need context
Some fracture patterns generally have a better prognosis than others, but classification alone cannot predict with certainty how growth will continue.
Even an apparently simple fracture may have resulted from significant trauma. Conversely, a carefully treated fracture involving a joint is not certain to cause growth arrest.
Follow-up is therefore based on the actual risk, rather than only the Roman numeral in the report.
How long does follow-up continue?
There is no single duration for every child.
An adolescent close to skeletal maturity has little growth remaining, so the consequences of an arrest may differ from those in a seven-year-old. Some sites require a few targeted reviews; others may warrant longer radiographic monitoring.
Research highlights that longer follow-up is often necessary for growth plate fractures at risk, because early signs of arrest can be subtle and difficult to interpret. [4]
What if a bony bridge develops?
Finding a bridge early does not automatically mean surgery is needed. Decisions depend on its size and position, remaining growth, any existing deformity and the predicted difference in limb length.
Options in selected cases include removal of the growth plate bridge, epiphysiodesis, guided growth or a corrective osteotomy. [1,5] These are different approaches. Recognising a problem while it is still developing may leave more options than discovering it after a substantial deformity has appeared.
Symptoms alone do not determine follow-up
If an appointment has been arranged to monitor a growth plate at risk, the child feeling well is not enough reason to stop attending. Alignment can change slowly without causing symptoms.
Equally, every minor childhood fracture should not lead to years of X-rays. Monitoring needs a reason: a high-risk site, significant growth plate involvement, remaining growth and the characteristics of the injury.
This does not justify indefinite X-rays “just in case”. The duration should reflect the complication being monitored, the injury site and the remaining growth.
A fracture can therefore be healed while growth plate follow-up still needs to continue. In children, bone healing and confirmation of normal growth do not always finish at the same time.
References
[1] Lou M, Knebel A, Eberson J, Eberson C. Pediatric physeal fractures and growth disturbance: current concepts and surgical approaches. World journal of pediatric surgery. 2026. PubMed: 42553822 · DOI.
[2] Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. Journal of orthopaedic trauma. 2009. PubMed: 19897989 · DOI.
[3] Su AW, Larson AN. Pediatric Ankle Fractures: Concepts and Treatment Principles. Foot and ankle clinics. 2015. PubMed: 26589088 · DOI.
[4] Banting N, Schaeffer EK, Bone J, Habib E, Hooper N, Reilly CW, Cooper A, Mulpuri K. Inter-rater and Intra-rater Reliability in the Radiographic Diagnosis of Growth Arrest in Paediatric Physeal Fractures. Indian journal of orthopaedics. 2021. PubMed: 34306559 · DOI.
[5] Singh V, Garg V, Parikh SN. Management of Physeal Fractures: A Review Article. Indian journal of orthopaedics. 2021. PubMed: 33995857 · DOI.
Disclaimer: this article provides general information. Whether follow-up is needed, and for how long, depends on the fracture site and pattern, the child's age and remaining growth.
Related information
For a broader overview, see injuries and fractures in children. If pain continues despite an initially normal X-ray, see a normal X-ray but persistent pain.
