Physeal injuries

PHYSEAL INJURIES

Dr . LOKESH SHAROFFOrthopaedic surgeon, mumbai, india

ANATOMY OF PHYSIS GERMINAL LAYER ZONE OF PROLIFERATING

CARTILAGE ZONE OF HYPERTROPHIC CELLS ZONE OF PROVISIONAL

CALCIFICATION ZONE OF ENCHONDRAL

OSSIFICATION

CLASSIFICATIONS

AITKENS (1936) SALTER&HARRIS(1963) OGDEN(1981) PETERSON(1994)

SH TYPE 1 Complete seperation of

epiphysis without true # through bone with or without displacement

From shearng/torsion/avulsion

No findings on x-ray Good prognosis

SH TYPE 2 # seperation line traverses along

physis to a variable distance & then out through a portion of triangular shaped metaphyseal fragment(Thurstan-Holland sign)

Intact periosteum on the side of metaphyseal fragment

Prognosis-good

SH TYPE 3 Vertical split from joint

surface to physis & then along physis to periphery(intra-articular)

Uncommon Lower tibial epiphysis Prognosis-good

SH TYPE 4

Intra-articular # extending from joint surface through epiphysis,entire physis & a portion of metaphysis-Lateral condyle of humerus Prognosis-bad

S H TYPE5

Severe crushing force applied through epiphysis damaging the germinal layer of physis

No osseous injury-diagnosed in retrospect

S H TYPE 6 Perichondrial injury as described

by Mercer Rang(1969) Rare injury Blow to periosteum/perichondrial

ring

scarring tethering and bony bar formation can occur

OGDEN 7

INTRA-ARTICULAR OSTEOCHONDRAL FRACTURE

OGDEN 8 AND 9

METAPHYSEAL AND DIAPHYSEAL #S RESPECTIVELY BUT SEEN TO STIMULATE THE LONGITUDINAL GROWTH OF THAT BONE.

PETERSON

He described 2 new types of fractures ..1st and 5th in his classification

PETERSON TYPE1 Transverse # of metaphysis

with # line extending to physis

Comminution-common MOI:longitudinal compression Sites:distal radius,finger

phalanges,MC Prognosis:good

PETERSON TYPE 2

Seperation of physis with a portion of metaphysis attached to epiphysis (THURSTAN-HOLLAND sign)

Most common type Site:finger phalanges

PETERSON TYPE 3

Seperation of metaphyis from epiphysis through the physis disrupting the physis

Site:distal fibula

PETERSON TYPE 4 # of epiphysis extending to &

along the physis May be comminuted/double Common in older children Premature growth arrest

common Sites:finger phalanges,distal

tibia(medial malleolus0

PETERSON TYPE 5 # that traverses the

metaphysis,physis,epiphysis & atricular cartilage

Tri-plane # Comminution & open# common Premature growth arrest occurs sites: lateral condyle humerus,

distal tibia

PETERSON TYPE 6 # in which part of

metaphysis,physis & epiphysis is removed/ missing

Found in open # Premature closure of

epiphysis occurs

PROGNOSIS

Severity of injury Age of the child Site of injury Amount of physis injured

TREATMENT

To obtain & maintain reduction by closed/open means

To maintain function & normal growth

PRINCIPLES OF TREATMENT Physeal # should be reduced

immediately All reductions open/closed

should be gentle Forceful repeated manipulations

should be avoided During open reduction pressure

on physis should be avoided

PETERSON TYPE 1

CMR & casting Immobilisation for 3-4 weeks

Follow up to ensure normal growth

P TYPE 2/S H TYPE 2 CMR & casting under GA/block Metaphyseal fragment & intact

periosteum provide stability Surgical intervention 1.periosteal impingement 2.unstable fragment ? Bio-degradable pins

P TYPE 3/S H TYPE 1

CMR & casting

P TYPE 4/S H TYPE 3 Anatomical reduction of physeal &

articular cartilage by ORIF

P TYPE 5/S H TYPE 4

OR & IF

P TYPE 6

Initial debridement followed by reconstructive surgery later on

COMPLICATIONS Premature growth arrest 1.length discrepancy 2.angular deformity Compartment syndrome/arterial

occlusion Neurological complications sepsis & osteomyelitis Overgrowth & hypoplasia Malunion/delayed union/non union

HARRIS GROWTH ARREST LINES Symmetrical, thin white lines Perpendicular to long axis of bone Metaphyseal at first Most marked in rapidly growing ends of

bones, e.g. distal femur and proximal tibia

They migrate towards the diaphysis with further growth and may disappear

HARRIS GROWTH ARREST LINES Denote activity of physeal plate If asymmetric , denotes partial

arrest If lines are absent , denotes growth

arrest