PHYSEAL INJURY PHYSEAL INJURY 2005 년년 년년년년년년년 년년년년 년년년년년 년년 년년년 년 년년 2005 년 11 년 12 년
PHYSEAL INJURYPHYSEAL INJURY
2005 년도 소아정형외과학 연수강좌인제대학교 일산 백병원
주 석규2005 년 11 월 12 일
ANATOMYANATOMY
• VASCULAR SUPPLY– Epiphyseal a.:
Supplies proliferative zone chondrocytes
– Nutrient a.Capillary loops ends at the bone-cartilage interface of the growth plateAvascular lower proliferative and hyprtrophic zone
ANATOMYANATOMY
•VASCULAR SUPPLY– Metaphyseal a. and periosteal a.
Collateral supply
– Perichondral a.Supplies perichondral ring of LaCroix
ANATOMYANATOMY
• Cartilagenous Component
– Reserve Zone– Proliferative Zone– Hypertrophic Zon
e
ANATOMYANATOMY
• Cartilagenous Component
– Reserve Zone•Chondrocytes produce cartilagenous matrix.•Inactive in cell or matrix turnover•Low oxygen tension lowest calcium content•Not participate in longtitudinal growth
ANATOMYANATOMY
• Cartilagenous Component
– Proliferative Zone•Highest oxygen tension•Matrix production and cellular division contribute to longitudinal growth
ANATOMYANATOMY
• Cartilagenous Component
– Hypertrophic Zone•Weakest region within the growth plate(low matrix volume, high cellular volume)•Ultimate fate of the hypertrophic zone cell is cell death•Avascular and low oxygen tension•Zone of provisional calcification
Cause of Physeal InjuryCause of Physeal Injury
Fracture, disuse, radiation, infection,
tumor, vascular impairment, neural
involvement, metabolic abnormality,
frostbite, burns, electric burns, laser
injuries, chronic stress, iatrogenic injury
PHYSEAL FRACTURESPHYSEAL FRACTURES
• History– Fables of Amazon– Hippocrates– Severinus(1632)– Malgaigne(1855)– Poland(1898)
FRCTURE PLANEFRCTURE PLANE
-Between calcified and uncalcified cartilage-Proliferating cells remain with epiphysis.-The plane is avascular, less bleeding and swelling
ClassificationClassification
•Poland’s Classification(1898):
ClassificationClassification
Bergenfeldt(1933): First radiologic classification
ClassificationClassification
Aitken(1936)
ClassificationClassification
Peterson(1994):
ClassifcationClassifcation
Salter and Harris(1963):
Rang(1969):
ClassificationClassificationSalter-Harris Classification
Practical, easy to useGuide to rational treatmentCovers most fractures
ClassificationClassification
Salter-Harris I:Complete separation of epiphysis
The Germinal cells remain with the epiphysisX-ray may seem normalShearing, torsion or avulsion injuryScurvy, rickets, hormonal imbalance, infectionEarly healingProximal and distal femur
ClassificationClassificationSalter-Harris II:
Thurston-Holland FragmentEasy reductionOver reduction prevented by periosteum
Irreducible; shaft of the bone trapped in the buttonhole tear of periosteum
ClassificationClassification
Salter-Harris III:M/C in partially closed physisOften requires open reduction
ClassificationClassificationSalter-Harris IV:
Lateral condyle fx, med malleolar fx.Neglected: loss of position, nonunion,
growth arrestNot all type IV injuries are the same
Salter-Harris type IVSalter-Harris type IV
ClassificationClassification• SALTER-HARRIS V:
–Crushing injury vs there is no fracture
– X-ray at the time of injury shows no abnormality
– Can longitudinal force compress the physis enough to kill cells without causing any fracture?
– Possibility of disuse or arterial insufficiency
–In association with long bone fracture
ClassificationClassification• SALTER-HARRIS VI:
–Peichondral ring injury–Lawn mower injury–Skin loss, difficult skin coverage–Often growth arrest
EPIDEMIOLOGYEPIDEMIOLOGY
• Male:Female=2:1
• Boys 14yrs old, girls 11 to 12 yrs old most
common
• Phalanges of fingers > distal radius
• Distal > Proximal
EVALUATIONEVALUATION
• 2 Plane radiograph
• Stress view
• Tomogram
• Arthrograms
• CT scans
• MRI
• Ultra Sound
TREATMENTTREATMENT
• Gentle reduction
• Never forceful repeated reduction
• Reduce as soon as possible
TREATMENTTREATMENT
• PetersonType I:-Least potential damage to physis -Growth arrest 3.4%
TREATMENTTREATMENT•Salter-Harris I:
– Growth arrest :•Type I > type II
– Distal femur: frequent growth arrest– Proximal tibia:
Vascular injury
TREATMENTTREATMENT
• Salter-Harris II:– Scraping of the physis
•Relaxed by anesthesia
– Metaphyseal fragment prevents overreduction•Periosteum intact on the metaphyseal fragment side
– Periosteum impingement•Open reduction
– Intact proliferative layer
TREATMENTTREATMENTImpinged Periosteum (Gruber, JPO, 2002)
-Intact physis:Degradation of periosteumPeriostum pushed away
-Ablation of Physeal cartilage:Dramatic injury, growth arrest
TREATMENTTREATMENT•Salter-Harris III:
– Needs anatomic reduction– Epiphysis to epiphysis fixation
CONSIDERATIONS IN TREATMENTCONSIDERATIONS IN TREATMENT
Accurate diagnosis:CT, MRI, Stress view, arthrogram
CONSIDERATIONS IN TREATMENTCONSIDERATIONS IN TREATMENT
Reduce or not to reduce:
7-10 days?
CONSIDERATIONS IN TREATMENTCONSIDERATIONS IN TREATMENT
OR or CR:-Malreduction of Type I, II vs III,IV-Impinged periosteum
Immobilization period:
PROGNOSISPROGNOSIS
•SEVERITY OF THE INJURY
•AGE
•TYPE OF FRACTURE
COMPLICATIONSCOMPLICATIONS
• Sepsis
• Overgrowth
• Malunion
• Delayed or nonunion
• Compartment syndrome
• AVN: proximal femur
• Premature Growth Arrest
PHYSEAL ARRESTPHYSEAL ARREST
• Occur at the time of injury, during reduction, or internal fixation
• Study:– Skeletal age
– Leg length measurement
– Localization of bar;• Tomography, CT, scintigraphy, MRI
PHYSEAL ARRESTPHYSEAL ARREST• MRI
- Preop: for mapping the lesion-Early postop: to detect incomplete resection
-6mths postop: to detect bridge recurrence, migration and necrosis of the interpositional material
PHYSEAL ARRESTPHYSEAL ARREST
• Management
– Complete arrest vs partial arrest
–Cessation of growth without angular deformity
• U/E physis;– 10 cm > no treatment
• L/E physis;– Pelvic tilt and spine curvature
Low back pain
PHYSEAL ARRESTPHYSEAL ARREST
• Management–Osteotomy–Bar excision–Arrest of remaining physis–Shoe lift–Lengthening, –Contralateral shortening, –Physeal distraction,–Transplantation of epiphysis and physis
PHYSEAL ARRESTPHYSEAL ARREST
• Management– Leg length discrepancy;
• 2.5 cm > shoe lift
• 2.5 cm to 5 cm contralateral shortening– Only for femur
– Tibia muscle weakness
• 5 cm < lengthening
PHYSEAL BAR EXCISIONPHYSEAL BAR EXCISION
Physeal bar: Formed by primary ossification along areas of vertical septa
Indications of excision:< 50% of physis involved> 2 yrs of remaining growth
PHYSEAL BAR EXCISIONPHYSEAL BAR EXCISION
Interposition materialTo prevent blood from occupying the cavity, orga
nizing, and re-formation of a bone bar
-Bone wax
– Autogenous fat: lacks hemostasis function
– Cartilage: apophysis of iliac crest
– Silicone rubber: commercially not available
PHYSEAL ARRESTPHYSEAL ARREST• BAR EXCISION
– Interposition materialPolymethylmethacrylate: load sharing
better for large lesion
PHYSEAL BAR EXCISIONPHYSEAL BAR EXCISION
Animal Study-Cultured chondrocytes
(E.H. Lee)-Mesenchymal stem cell with TGF beta
(J.I. Ahn)
PHYSEAL ARRESTPHYSEAL ARREST• Classification
– Peripheral: approach directly– Elongated: common after S-H IV
– Central: approach through metaphysis
PHYSEAL ARRESTPHYSEAL ARREST•Classification
– Peripheral: approach directly
– Elongated: common after S-H IV– Central: approach through metaphysis
PHYSEAL ARRESTPHYSEAL ARREST
•Technique– Burr and dental mirror– Flat and smooth cavity– Do not weaken the epiphysis– Oreo cookie like
PHYSEAL ARRESTPHYSEAL ARREST
• Technique– Do not undermine epiphysis and metaphysis– Metal marker – Angular deformity > 20 degrees
Combine with osteotomy
PHYSEAL ARRESTPHYSEAL ARREST
•Results– Operated physis may close earlier– Bar 50% < usually fail– Bar 50% < excision should be tried in young children
PHYSEAL ARRESTPHYSEAL ARREST
• Results–Only 2.2% of all physeal injuries are at the knee–50% of bar excision are at the knee– Avg growth: 84 % of opposite side
• Distal tibia > prox tibia > distal femur
– Distal femur more large lesion
poorer result