FIGURE 111.40 Common fractures of the knee in children: distal femoral physis (A ), tibial spine (B ), tibial tubercle (C ), patella (D ), and proximal tibial physis (E ) Distal Femoral Fractures This injury is typically the result of very high shear and translational forces These fractures are usually associated with a knee effusion, local soft tissue swelling, and physeal tenderness On examination, tenderness and swelling may be noted proximal to the joint line, usually on bilateral sides of the distal femoral physeal site With displaced fractures, there may be obvious deformity, and soft crepitus with motion may be felt ( Fig 111.41 ) If the fracture is anteriorly displaced, the patella may be prominent with dimpling of the anterior skin ( Fig 111.42 ) If the epiphysis is posteriorly displaced, the distal metaphyseal fragment becomes prominent above the patella These fractures can also cause damage to the popliteal vessels or peroneal nerve by direct compression Intra-articular physeal fractures (Salter–Harris type III and IV) are transitional fractures that occur when the physis is starting to close These injuries may be missed by x-ray Advanced imaging (e.g., CT or MRI) should be obtained for evaluation if the adolescent patient has a large knee effusion Nondisplaced fractures should be splinted in place with urgent orthopedic consultation for casting Displaced fractures should have immediate orthopedic consultation for reduction under anesthesia Unlike other epiphyseal fractures, even Salter-Harris type I and II