1EPIPHYSEAL INJURIES (1).ppt
- 1. Morning five minute presentation By:- Dr. Abdulshekur Abduljebar (MD, GSR3)
- 2. Osseous Anatomy Growth Plate Histology Epiphyseal injuries Classification Management Principles Management By Type Complications Treatment Options for Complications References
- 3. Epiphysis Secondary Ossification Center The epiphysis is the bone located between the articular surface and the physis Epiphyseal Plate/Physis Metaphysis Bone adjacent to the physis on the opposite side of the epiphysis. Diaphysis The shaft of the bone
- 4. Zones of the Physis Germinal Zone Minimally active, scattered chondrocytes Proliferative Zone Columns of chondrocytes actively dividing Hypertrophic Zone Chondrocytes accumulate and release calcium Weakest zone of physis Zone of endochondral ossification
- 5. These are fractures through a growth plate They are unique to pediatric patients Injuries and fractures at the region of epiphyseal plate carry the bad and serious complications. Physeal fractures account for 15% to 30% of all bony injuries in children and commonly occur in the tibia. Each plate growth rate is different and disappear at different time. Location Avg grt (mm/yr) % of bone Ltl grt Prxl Humerus 7mm 80% DisaHumerus 2mm 20% Prxal Radius 1.75mm 25% Distal Radius 5.25mm 75% Promal Ulna 5.5mm 80% Distal Ulna 1.5mm 20% Prxl Femur 3.5mm 30% Distal Femur 9mm 70% Proximl Tibia 6mm 60% Distal Tibia 3-5mm 40% Levine RH, Foris LA, Nezwek TA, Waseem M. Salter-Harris Fractures. StatPearls. StatPearls Publishing; 2021.
- 6. Classification of any injury is important Salter-Harris is the most widely used classification for epiphyseal injuries The classification is based on:- Mechanism of injury Relationship of # line to the physis Method of treatment Prognosis Other historical classification systems used for epiphyseal injuries Poland Bergenfeldt Aitken Peterson
- 7. A type 1 fracture is a transverse fracture through hypertrophic zone of the physis A type II fracture is a fracture through physis and metaphysis A type III fracture is a fracture through physis and epiphysis. Type IV fracture involves all 3 elements of the bone. Type V fracture is compression or crush injury of the epiphyseal plate with no associated metaphyseal injury.
- 8. X-ray:- It is difficult to assess as the physis is radiolucent and the epiphysis is incompletely ossified. What to look for? 1. The physeal widening of the gap 2. Tilting of the epiphysis 3. Repeating X ray within few days 4. Comparing the injured side with the normal Sometimes advanced imaging is needed. CT Scan MRI
- 9. Achieve fracture healing with maintenance of growth potential Achieve acceptable reduction and alignment Maintenance of achieved reduction and alignment Limit iatrogenic injury to physis Repeated, forceful reduction attempts Hardware across physis
- 11. Treatment options for Type 2 include: • Closed reduction and casting • Closed reduction and percutaneous screw or wire fixation Screw for larger metaphyseal fragment Wires crossing physis for smaller metaphyseal fragment
- 12. Treatment options for type 3 include: • Closed reduction and casting • Closed vs open reduction, screw fixation Screw along width of epiphysis avoiding physis Screws in epiphysis may increase pressure on adjacent articular cartilage and are often removed quickly after fracture healing Advanced imaging may be needed to plan intervention
- 13. Treatment for type 4 is surgery Anatomic reduction of physis required to minimize risk of physeal bar CT is crucial and gives 3D visualization of fracture patterns; Essential for surgical planning Fixation best accomplished from epiphysis to epiphysis and/or metaphysis to metaphysis
- 14. Treatment for type 5 It is very difficult initial diagnosis as minimal displacement Late diagnosis after complication of physeal arrest and deformity has occurred Initial nonoperative treatment
- 15. When an entire physis arrests Longitudinal bone growth ceases completely at that physis When only part of physis arrests Angular deformity associated with shortening Often a much more difficult problem to address How to pick? Loss of abnormal physeal contour Sharply defined connection between epiphysis and metaphysis Tapering of Harris growth arrest line towards area of growth arrest Obvious angular deformity or segment shortening
- 16. Surgical Physeal Arrest Resection Removal of arrest with continuation of physeal growth Complete Physis Arrest Ablation of growth in physis on one or both sides Hemi-ephiphysiodesis (angular) vs epiphysiodesis (growth correction of affected and/or unaffected side) Treatment of angular or growth deformities Guided growth Osteotomies Fixators
- 17. Levine RH, Foris LA, Nezwek TA, Waseem M. Salter-Harris Fractures. StatPearls. StatPearls Publishing; 2021.