Physeal injuries Principles of management

The Statistics

• Phalanges 37%

• Distal Radius 18%

• Distal Tibia 11%

• Distal Fibula 7%

• Metacarpal 6%

Distal Femur is < 2%

Average of six combined series= 21%

Classifications- Are They Helpful ??

OGDEN Two ComplicatedPETERSON: Probably the best for prognosis

The Salter- HarrisClassification

HasStood The

Test Of Time!!

Descriptive more than Prognostic

Major Contribution of Peterson’s Types

Callous and fracture lines Extend to the physis

Peterson Type I

Cast Removal19 mo. post- fracture

Beware!!

Unique Physeal Anatomy

Blood supply

Growth

Maturation

OssificationRemodeling

Transformation

Blood Supply

Dangerous Side

Safe Side

Safe Side -Effects

Factors Contributing to Physeal Failure

1.Torsion > Tension

Most Occur at End of Growth

2.Weakened Perichondral Ring

3.Increased Skeletal Mass -- KE=MV2

Distal Femur

Thus high rate of growth arrest in this area

SHEAR

Physeal ArrestBasic Pathology

Fracture Line Through Zone of Hypertrophy

Can be Anywhere

Resting Cells

Basic Pathology

Physeal Bar

Sclerotic Bone On X-Ray Cortical Bone From Tension Forces

Patterns of Arrest (Peterson)

Central

Asymmetrical Harris- Park Migration

Central

Perirheral Physis Remains Intact

Central

PeripheralIpsilateral

distal femoral

Ipsilateral proximal tibial

Linear

D O I 1 Yr. P.I.Asymmetrical Harris- Park Migration

LinearUsually associated withType IV S-H Injuries

X- Ray criteria

Physeal Narrowing

Sclerotic Bone

Absent Harris-Park Migration

Angular Deformity

Making the diagnosis

C-T Scans

Other imaging studies more helpful

Good polytomography can be useful

M R Imaging

TheGold Standard

M R Imaging

May be too sensitive

Location Affects:

1. Type of Deformity

2. Surgical Approach

3. Success Of Resection

Location affects Deformity

• Central Volcano Effect

• Peripheral Severe Angulation

• Longitudinal AngulationShortening

Location affects Success of Resection

Central Linear

Physis-Bridge-PhysisSymetrical Growth

Peripheral Physis-Bridge

Asymetrical Growth

Expected results

Not 100% Successful

Three Series = 64 Cases

Excellent: 23 (36%)

Good: 16 (25%)

Fair/Poor: 24 (24%)

Factors Contributing To Success

1. Size

2. Age

3. Duration Since Injury

4. Etiology

1. 30%

2. Younger The Better > 2 yrs Growth Left

3. > 2 yrs---Poor

4. Trauma= GoodInfection,Irradiation= Poor

Will Resection Help ?

1. Young

2. Small Bridge

3. Trauma Origin

4. Recent Onset

5. Central or Linear Bridge

1. Older

2. Large Bridge

3. Infectious or Irradiation Origin

4. Peripheral Bridge

2.Poor Candidate1. Ideal Candidate

Location affects Surgical Approach

Central

LargeMetaphyseal Window

Peripheral

Direct Approach

Metaphysis

Epiphysis

Physis

Location affects Surgical Approach

Osseous Tunnel

Cortex to Cortex

Linear Bridge

Technical Points Location Of Bridge

Must Be Perpendicular To The Physis

Need to see 3600

Not Perpendicular To The Physis

Easier, less vital structures

Close to Perpendicular to The Physis

OK

More dangerous structures

To Serve As A Barrier To Bridge Reformation

Peripheral Bridge

Sclerotic bridge

remains

Grey physis now

visible

Physis now in profile

Cranioplastspacer

Cranioplastspacer

Metal marker for growth

Technical PointsUse Dental Mirror toVisualize Proximal Physeal Border

Can usean arthroscope as well

Technical Points Remove All Sclerotic Bone

Interposed Material

Autogenous Fat

Cranioplast ( Methymethacrolate

with out barium)

Silastic (no longer available in US)

Illustrative Cases

D P 6 y.o.Injury x-ray

S-H IV injury 1 yr. P. I.

Longitudinal bridge

D.P. Cont. 4 mo. p.o. bridge resection Silastic Insertion

Migration of

growth arrest lines begins

Osseous bridge

Silastic spacer

D.P. Cont.3 yrs. P.O.

Despite Proximal Migration of Silastic, Normal Growth Re-established

Alternatives to resection

11 y.o. 5 yrs p.i.

Poorly Defined Bridge

Problems ?

1.Physeal bar

2.Angulation Shortening

Close to End of GrowthSolution ??

Physeal Distraction

Alignment corrected

Will It Grow?

2 years post op.

Growth arrest lines have

migrated 2 cm.

What If The Arrest Recurs ?

OK to Re-Resect if Criteria Met

3 y.o. Injury at 18 m.o.

Central Bridge

Following three resections over 8 years

Radio-Ulnar Relationships Re-established

Normal Side

So What Have Learned ??

To Have Good Results One Needs to Have

• Knowledge of the Physeal Anatomy

• Understanding of Physeal Arrest Patterns

• What Cases Can Benefit From Resection

• How To Effectively Pre-Operative Plan

• Technical Aspects of The Resection Proceedure

• Alternatives to Resection

• How to Manage Recurrences

Thank you