PHYSEAL INJURIES & GROWTH DISTURBANCE

Dr.Ghaznavi Pediatric Orthopedic Fellowship

TUMS

One of the unique aspects of pediatric orthopaedics is the presence of the physis (or growth plate), which provides longitudinal growth of children's long bones.

Physeal injuries

Obvious

Subtle

Etiology

Trauma

Infection

Tumor

Vascular

Repitative stress

Irradiation

Classification

Poland1898

Aitken1936

Salter-Harris1963

Peterson1994

Mercer Rang

Peterson

Type 1• Transphyseal plane of injury• soft tissue swelling, making careful

patient examination• phalanges, metacarpals, distal tibia,

and distal ulna.• Ultrasound,MRI,Arthtography• Stress Radiography unnecessary• fracture line in zone of Hypertrophy• subsequent growth disturbance is

relatively uncommon

Type 2

• limited propensity to subsequent growth disturbance

• (the Thurston-Holland fragment or sign).

• Hypertrophic zone

Type 3• through the articular surface

and extend vertically toward the physis

• Germinal and proliferative• high-energy or compression• higher risk of subsequent

growth disturbance.• Anatomic reduction (usually

open) and stabilization

Type 4• vertical shear fractures• metaphyseal-epiphyseal

cross-union• subsequent growth

disturbance.• Frequent around the medial

malleolus, Lateral condylar• anatomic reduction and

adequate stabilization

Type 5• Unrecognized

compression injuries with normal initial radiographs

• later produced premature physeal closure.

• most common example of such an injury is closure of the tibial tubercle

Salter-Harris classification remains aneasily recognized and recalled classification

SH

Prognostic

Tx. guidline

20%to 30% of all childhood fractures were physeal injuries.

Study between 1979 and 1988, in Olmstead County, Minnesota. 951 physeal Fx 1979-1988

The phalanges represent the most common location

Next most common site the distal radius

peak incidence at age 14 in boys and 11to 12 in girls

2 :1 male to female ratio

Treatment

Open physeal injuries

N.V compromise

Compartment synd.Emer

gent

SH 1,2Minimal risk of

growth retardationExcept distal femur &

proximal tibia

Excellent remodeling potential

not to create physeal injury by excessively forceful or invasive reductions.

SH 3,4Anatomic reduction

Restore articular surface

Prevent epiphyseal-metaphyseal crossunion

HARRIS GROWTH ARREST LINES

• Transversely oriented condensations of normal bone

• represent slowing or cessation of growth

• effective representation of the health of the physis

• If transverse and parallel, growing normally

• If partial injury, the growth arrest line will be asymmetric

PHYSEAL GROWTH DISTURBANCE

EtiologyPeterson

6

disruption architecture & function

bony bridges or physeal

bars.

Evaluation

plain radiography

CT scanning with sagittal & coronal reconstructions

hallmark of plain radiographic

loss of normal physeal contour

Frank physeal arrests

Sclerosis in the region of the arrest

MRI scan (three-dimensional spoiled recalled gradient echo images with fat saturation)Alignment view

Scanogeram

Classification

Angular DeformityLLD

Management

• Prevention of Arrest Formation.• Partial Physeal Arrest Resection.• Physeal Distraction• Repeated Osteotomies during Growth• Completion of Epiphysiodesis and

Management of Resulting Limb Length Discrepancy

Prevention

treatment principles

Gentle

Anatomic

Secure fixation

immediate fat grafting

NSAID

Physeal Arrest Resection

Factors should be consider

Etiology

Anatomic type

Physis

Extent of arrest

Amount of growth remaining

Good prognosis

Poor prognosis

Trauma ,ITV

Infection;Tumor;Irradiation

Central, Linear, Better prognosis

Good prognosis

Poor prognosis Distal Femur

Distal tibia

25%

>2y

Pre Op. planning

Extent & Location

CT ,MRI

Minimize trauma

Metaphyseal windowFluoroscopyBriliant light sourceMagnifictionDry surgical fieldArthroscopeHigh speed burr

Prevent reforming of bridge

Autogenous fatMethylmethacrylateSilicone rubberAutogenous cartilage

Marker implantation

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