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physeal Injury
Prepared by:Dr.Amanj Mohsin
2nd year candidate -orthopedic KBMS
Supervised by:Ass. Prof. Dr. Omer Barawi
Content
• OverView
• Anatomical View
• Classification
• Mechanism of Injury
• Clinical Feature
• X-Ray
• Treatment
• Complication
OverView- Above 10% ( 15-20%)• Hypertrophic or calcified layer of growth plate• often veering off into metaphysis at one of
edges to include a triangular lip of bone
• little effect on longitudinal growth, which takes place in germinal and proliferating layers of physis
• fracture traverses cellular ‘reproductive’ layers of physis, result in premature ossification of injured part and serious disturbances of bone growth.
ClassificationSalter and Harris (Salter and
Harris, 1963)Type 1
• A transverse # through hypertrophic or calcified zone
• Even if fracture is quite alarmingly displaced, growing zone of physis is usually not injured & growth disturbance is uncommon.
• Prognosis excellent
Type 2- similar to type 1
- Most common type
- but towards edge fracture deviates away from physis & splits off a triangular metaphyseal fragment of bone ( Thurston– Holland fragment).
- Prognosis Excellent
Type 3
A fracture that splits epiphysis & then veers off transversely to one or other side through hypertrophic layer .
• Inevitably it damages ‘reproductive’ layers of
physis & may result in growth disturbance.
• Good but for intra-articular
deformity need ORIF
Type 4
• fracture splits epiphysis, but it extends into metaphysis.
• liable to displacement & a consequent misfit between separated parts of physis, resulting in asymmetrical growth.
• Good but unstable need ORIF
Type 5
• A longitudinal compression injury of physis.
• There is no visible fracture but G.P is crushed & may result in growth arrest
• Poor with growth arrest
Rang (Rang, 1969)• added a Type 6, an injury to perichondrial ring
( peripheral zone of Ranvier), which carries a significant risk of growth disturbance.
• Diagnosis is made usually in retrospect after development of deformity.
• Good but may cause angular
deformity
SALTR
Straight Above
(metaphysis)
Lower
(epiphysis)
T hrough
Physis
Ram
(Crush)
Mechanism of injury
• Falls or traction
• They occur mostly in road accidents and during sporting activities or playground tumbles.
Clinical features
• Boy > Girl 2:1
• Infancy or age 10-12 years
• Defomity usually minimal
• Any injury in a child followed by pain and tenderness near joint should arouse suspicion,
x-ray examination is essential.
X ray
• physis itself is radiolucent & epiphysis may be incompletely ossified
• makes it hard to tell whether bone end is damaged or deformed
• Don’t Hesitate to comparison with normal side
• Telltale features are widening of physeal ‘gap’, incongruity of joint or tilting of epiphyseal axis.
• .
• Any suspicion of a physeal fracture, a repeat x-ray after 4 or 5 days is essential
• Types 5 and 6 injuries are usually diagnosed only in retrospect
Treatment
Undisplaced
1.splinting 2-4 weeks (site & age)
2. Type 3 &4 : re xray after 4 days and 10 days mandatory in order not to miss late displacement.
Displaced
• should be reduced as soon as possible
• types 1& 2 this can usually be done closed; then splinted securely for 3–6 weeks.
• Types 3 and 4 fractures demand perfect anatomical reduction.
• An attempt can be made by gentle manipulation UGA; if successful, limb is held in a cast for 4–8 weeks (longer periods for type 4)
• If not immediate ORIF
Complication • Types 1 & 2
if properly reduced, have an excellent prognosis and bone growth is not adversely affected
• Exceptions to this rule are injuries around knee distal femoral or proximal tibial physis (undulating Growth plate)
• Complications Such as malunion or non-union may oocure.
• Types 3 and 4 injuries may result in premature fusion of part of G.P or asymmetrical growth of bone end
• Types 5 and 6 fractures cause premature fusion & retardation of growth.
• Size and position of bony bridge across physis can be assessed by tomography or (MRI).
• If bridge is relatively small (less than one-third width of physis) it can be excised and replaced by a fat graft, with some prospect of preventing or diminishing growth disturbance (Langenskiold, 1975; 1981).
• But if bone bridge is more extensive operation is contraindicated as it can end up doing more Harm than good.
If complication established then treatment accordingly
• Never try aggressive manipulation
• Don’t hesitate to compare with normal side by X ray
• Follow up not mean under confidance
Take Home Message
Reference
• Apleys
(System of orthopedic and fractures)
Ninth edition• Langenskiold A. An operation for partial closure of an epiphysial plate in children, and
its experimental basis. J Bone Joint Surg 1975; 57B:325–30.
• Langenskiold A. Surgical treatment of partial closure of the growth plate. J Pediatr Orthop 1981; 1: 3–11.
• Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963; 45A: 587–622.
• Campbells (operative orthopedics ) (12th Edition)
• Miller Review of Orthopedic (Sixth Edition)
• Pediatric orthopedic Secret (3rd Edition)