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"The incidence of subtle growth plate fractures following high-velocity techniques in children is surely under-appreciated because of the occult nature of these injuries… Despite the seemingly 'plastic' osseous component of the child's vertebrae, the cartilaginous growth plates have been shown, in both humans and other large mammals, to be the primary sites of mechanical energy absorption during trauma. The potential for acquired growth plate injuries is very real, and for this reason, it is important that the physician trained in spinal manipulation be acquainted with the structural and functional differences between individuals of different skeletal ages. Awareness of such dissimilarities may persuade the physician to treat the pediatric spine more conservatively than the adult spine in an effort to avoid damaging the cartilaginous growth mechanisms…. Although there has not been a definite cause-and-occurence relationship established between spinal manipulation in children and growth plate injuries, the potential for growth plate fractures and other subtle injuries of the pediatric spine, including facet avulsion or dislocation, must be appreciated by the physician utilizing manipulation as a manual therapy modality. This might avoid creating irreversible injury that may not be initially recognized… The overall incidence of total injuries sustained from manipulation of the adult spine are underestimated. It is therefore likely that growth plate injuries in children following spinal manipulation are substantially underestimated." Michael L. O'Neal, DO, Assistant Professor, Department of Family Medicine, University of South Florida College of Medicine (Comprehensive Therapy 2003) [pdf]