physeal Injury

Prepared by:Dr.Amanj Mohsin

2nd year candidate -orthopedic KBMS

Supervised by:Ass. Prof. Dr. Omer Barawi

Content

• OverView

• Anatomical View

• Classification

• Mechanism of Injury

• Clinical Feature

• X-Ray

• Treatment

• Complication

OverView- Above 10% ( 15-20%)• Hypertrophic or calcified layer of growth plate• often veering off into metaphysis at one of

edges to include a triangular lip of bone

• little effect on longitudinal growth, which takes place in germinal and proliferating layers of physis

• fracture traverses cellular ‘reproductive’ layers of physis, result in premature ossification of injured part and serious disturbances of bone growth.

ClassificationSalter and Harris (Salter and

Harris, 1963)Type 1

• A transverse # through hypertrophic or calcified zone

• Even if fracture is quite alarmingly displaced, growing zone of physis is usually not injured & growth disturbance is uncommon.

• Prognosis excellent

Type 2- similar to type 1

- Most common type

- but towards edge fracture deviates away from physis & splits off a triangular metaphyseal fragment of bone ( Thurston– Holland fragment).

- Prognosis Excellent

Type 3

A fracture that splits epiphysis & then veers off transversely to one or other side through hypertrophic layer .

• Inevitably it damages ‘reproductive’ layers of

physis & may result in growth disturbance.

• Good but for intra-articular

deformity need ORIF

Type 4

• fracture splits epiphysis, but it extends into metaphysis.

• liable to displacement & a consequent misfit between separated parts of physis, resulting in asymmetrical growth.

• Good but unstable need ORIF

Type 5

• A longitudinal compression injury of physis.

• There is no visible fracture but G.P is crushed & may result in growth arrest

• Poor with growth arrest

Rang (Rang, 1969)• added a Type 6, an injury to perichondrial ring

( peripheral zone of Ranvier), which carries a significant risk of growth disturbance.

• Diagnosis is made usually in retrospect after development of deformity.

• Good but may cause angular

deformity

SALTR

Straight Above

(metaphysis)

Lower

(epiphysis)

T hrough

Physis

Ram

(Crush)

Mechanism of injury

• Falls or traction

• They occur mostly in road accidents and during sporting activities or playground tumbles.

Clinical features

• Boy > Girl 2:1

• Infancy or age 10-12 years

• Defomity usually minimal

• Any injury in a child followed by pain and tenderness near joint should arouse suspicion,

x-ray examination is essential.

X ray

• physis itself is radiolucent & epiphysis may be incompletely ossified

• makes it hard to tell whether bone end is damaged or deformed

• Don’t Hesitate to comparison with normal side

• Telltale features are widening of physeal ‘gap’, incongruity of joint or tilting of epiphyseal axis.

• .

• Any suspicion of a physeal fracture, a repeat x-ray after 4 or 5 days is essential

• Types 5 and 6 injuries are usually diagnosed only in retrospect

Treatment

Undisplaced

1.splinting 2-4 weeks (site & age)

2. Type 3 &4 : re xray after 4 days and 10 days mandatory in order not to miss late displacement.

Displaced

• should be reduced as soon as possible

• types 1& 2 this can usually be done closed; then splinted securely for 3–6 weeks.

• Types 3 and 4 fractures demand perfect anatomical reduction.

• An attempt can be made by gentle manipulation UGA; if successful, limb is held in a cast for 4–8 weeks (longer periods for type 4)

• If not immediate ORIF

Complication • Types 1 & 2

if properly reduced, have an excellent prognosis and bone growth is not adversely affected

• Exceptions to this rule are injuries around knee distal femoral or proximal tibial physis (undulating Growth plate)

• Complications Such as malunion or non-union may oocure.

• Types 3 and 4 injuries may result in premature fusion of part of G.P or asymmetrical growth of bone end

• Types 5 and 6 fractures cause premature fusion & retardation of growth.

• Size and position of bony bridge across physis can be assessed by tomography or (MRI).

• If bridge is relatively small (less than one-third width of physis) it can be excised and replaced by a fat graft, with some prospect of preventing or diminishing growth disturbance (Langenskiold, 1975; 1981).

• But if bone bridge is more extensive operation is contraindicated as it can end up doing more Harm than good.

If complication established then treatment accordingly

• Never try aggressive manipulation

• Don’t hesitate to compare with normal side by X ray

• Follow up not mean under confidance

Take Home Message

Reference

• Apleys

(System of orthopedic and fractures)

Ninth edition• Langenskiold A. An operation for partial closure of an epiphysial plate in children, and

its experimental basis. J Bone Joint Surg 1975; 57B:325–30.

• Langenskiold A. Surgical treatment of partial closure of the growth plate. J Pediatr Orthop 1981; 1: 3–11.

• Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963; 45A: 587–622.

• Campbells (operative orthopedics ) (12th Edition)

• Miller Review of Orthopedic (Sixth Edition)

• Pediatric orthopedic Secret (3rd Edition)