Physeal injuries DR. FARAN MAHMOOD

PHYSEAL INJURIESPHYSEAL INJURIESDR. FARAN MAHMOOD FCPS Orthop.DR. FARAN MAHMOOD FCPS Orthop.

ANATOMY OF BONE ENDANATOMY OF BONE END

EPIPHYSISEPIPHYSIS PHYSISPHYSIS METAPHYSISMETAPHYSIS

ANATOMY OF BONE ENDANATOMY OF BONE END

EPIPHYSISEPIPHYSIS PHYSISPHYSIS METAPHYSISMETAPHYSIS

HISTOLOGYHISTOLOGY

IMPORTANT POINTSIMPORTANT POINTS Growth plate is the Growth plate is the weakestweakest area in children's area in children's

bones.bones.

The germinal layer of the cartilage is on the The germinal layer of the cartilage is on the epiphysisepiphysis

Growth is from epiphysis towards metaphysisGrowth is from epiphysis towards metaphysis

Damage to either epiphyseal or metaphyseal Damage to either epiphyseal or metaphyseal vascular supply disrupts bone growthvascular supply disrupts bone growth

Only the proliferative zone has an abundant Only the proliferative zone has an abundant blood supply. blood supply.

CLASSIFICATION CLASSIFICATION

SALTER – HARRIS classification has SALTER – HARRIS classification has six typessix types

OGDEN in 1982 added another three OGDEN in 1982 added another three types. types.

Growth plate injuries occur more often Growth plate injuries occur more often in boys.in boys.

Approximately 30 % of all physeal Approximately 30 % of all physeal injuries will result in some measurable injuries will result in some measurable shortening or angulation. shortening or angulation.

Only 2 % will significantly interfere with Only 2 % will significantly interfere with function if treated adequately. function if treated adequately.

Salter- Harris - ISalter- Harris - I

Favourable Favourable prognosisprognosis

The vital portions The vital portions of the growth plate of the growth plate remain attached to remain attached to the epiphysis.the epiphysis.

Salter- Harris - IISalter- Harris - II

most common typemost common type

Salter- Harris - IIISalter- Harris - III

chronic disability chronic disability because it typically because it typically involves the involves the articular surface of articular surface of the jointthe joint

Salter- Harris - IVSalter- Harris - IV

Unless perfect Unless perfect alignment is achieved alignment is achieved and maintained during and maintained during healing, prognosis for healing, prognosis for growth is poor.growth is poor.

premature focal fusionpremature focal fusion

Salter- Harris - VSalter- Harris - V

Prognosis is poor, Prognosis is poor, since premature since premature stunting of growth is stunting of growth is almost inevitable. almost inevitable.

Emergency TreatmentEmergency Treatment

Type I & II ---- Closed reduction & Type I & II ---- Closed reduction & maintainance of maintainance of

reductionreduction

Type III & IV – Internal fixation in Type III & IV – Internal fixation in additionaddition

Aetiology of premature partial growth Aetiology of premature partial growth plate arrestplate arrest

Trauma:Trauma: 80 %80 %

Salter-Harris Type 1: Salter-Harris Type 1: 5 %5 %

Salter Harris Type 2: Salter Harris Type 2: 85%85%

Salter Harris Type 3: Salter Harris Type 3: 5 %5 %

Salter Harris Type 4: Salter Harris Type 4: 5 %5 %

Salter Harris Type 5: Salter Harris Type 5: 0 % ?0 % ?

Infection:Infection: 10 %10 %

Tumour:Tumour: 5 %5 %

Iatrogenic Iatrogenic (pins, stapes): (pins, stapes): 2 %2 %

Irradiation:Irradiation: 2 %2 %

Burns:Burns: 1 %1 %

Locations of physeal arrestLocations of physeal arrest Distal Femur: Distal Femur: 39%39%

Proximal Tibia: Proximal Tibia: 18%18%

Distal Tibia: Distal Tibia: 30%30%

Distal Radius: Distal Radius: 5%5%

Distal Ulna: Distal Ulna: 3%3%

Distal Fibula: Distal Fibula: 1%1%

Proximal Humerus: Proximal Humerus: 1%1%

Proximal Phalanx Great Toe: Proximal Phalanx Great Toe: 1%1%

Pelvis (tri-radiate): Pelvis (tri-radiate): 1% 1%

Types of Bridge formationTypes of Bridge formation 1. Peripheral1. Peripheral – Zone of Ranvier, involves latitudinal growth of the Zone of Ranvier, involves latitudinal growth of the

physis.physis.– May May severe angular deformity severe angular deformity surgical surgical

approach from the periphery excising the overlying approach from the periphery excising the overlying periosteum. periosteum.

2. Linear2. Linear

Across the physis. Most common site is medial Across the physis. Most common site is medial malleolus. May also lead to significant angular deformity; malleolus. May also lead to significant angular deformity; may be removed making a tunnel through the bone. may be removed making a tunnel through the bone.

3. Central3. Central

The most severe and most difficult to rectify surgically. The most severe and most difficult to rectify surgically. Bridge is completely surrounded by normal cartilage. Bridge is completely surrounded by normal cartilage. Affects longitudinal growth predominantly. Needs to be Affects longitudinal growth predominantly. Needs to be approached from the metaphysis. approached from the metaphysis.

Excision of an osseous bridge that Excision of an osseous bridge that constitutes 50% or more of the entire constitutes 50% or more of the entire area of the physis usually gives a area of the physis usually gives a poor result.poor result.

Harris LinesHarris Lines

Harris LinesHarris Lines

Harris linesHarris lines appear after restoration appear after restoration of growth following a physeal injury,of growth following a physeal injury,

Being due to slowing of growth for a Being due to slowing of growth for a

variable period following injury. If variable period following injury. If these lines are parallel to the physis these lines are parallel to the physis then damage to growth is unlikelythen damage to growth is unlikely

Substances used to fill Substances used to fill defectdefect

Fat Fat – Autogenous, no need to remove Autogenous, no need to remove – May need second incision to get graft May need second incision to get graft – May float out with release of tourniquet May float out with release of tourniquet – Shown to enlarge as growth occurs Shown to enlarge as growth occurs

SilasticSilastic – Inert, mouldable to cavity and easily removed Inert, mouldable to cavity and easily removed – Need special authorisation for use Need special authorisation for use – Must be sterilised, infections reported Must be sterilised, infections reported – Fractures at site of insertion reported Fractures at site of insertion reported

PMMAPMMA – Light, inert, non-conductive, transparent (no barium) Light, inert, non-conductive, transparent (no barium) – Mouldable to defect, good haemostasis, Mouldable to defect, good haemostasis, – No fractures reported No fractures reported – No need to remove later but may be difficult if necessary No need to remove later but may be difficult if necessary – Packed sterile, no infections reported Packed sterile, no infections reported

Final ThoughtsFinal Thoughts

Type II is most commonType II is most common Types III & IV are more prone to Types III & IV are more prone to

chronic disabilitychronic disability Type V associated with growth Type V associated with growth

disturbances and has a poor functional disturbances and has a poor functional prognosis prognosis

Only 2% of Salter-Harris fractures Only 2% of Salter-Harris fractures result in a significant functional result in a significant functional disturbancedisturbance

Anatomical reduction is the key to Anatomical reduction is the key to successful outcome.successful outcome.