Epiphyseal

plate

injury

Group : D 2015Supervised by: د الدبعي |سعيدالعريقي| غازي د

Approachintroduction

Who gets physis

injuries

Causes of physis

injuries

Diagnosis

classification

management

complication

Introduction• Types of bones

Introductionlong bones

A typical long bone consists of : - Epiphysis distal to the physis (growth plate )

-Metaphysis on the opposite side of the physis from the epiphysis

-Diaphysis is the long shaft beyond the metaphysis

physeal anatomy

• The growth plate (physis) is translucent , cartilaginous disk separating the epiphysis from the metaphysis .

and is responsible for longitudinal growth of long bones• The physis is the weakest area of the growing

skeleton , weaker than the nearby ligaments and tendons

Development

Epiphysis develop from secondary centres of ossification

They develop by process of enchondral ossification

Physeal anatomy

• The cells of the physis are arranged in layers or zones described as :

- Germinal or resting zone - the proliferative zone (metotic chondrocytes most metabolically active zone )

-Hypertrophic zone is the weakest because it lacks both collagen and calcified tissue

- provisional calcification zone

Who gets physis injuries ?

• these injuries occur in children and adolescents .

• Injuries to the physis are # .

• They comprise 10-15 % of all childhood fractures .

• Greatest incidence among 14-16 yrs boys and 11-13 yrs girls .

• Approximately , half of all physeal injuries occur in the lower end of the radius at the wrist .

• also occur frequently in lower bones ( tibia & fibula) also can occur in femur .

• Some injuries , if left untreated can cause permanent damage and interfere with proper growth of the involved limb .

Who gets physis injuries ?

• in growing child , a serious injury to a joint is more likely to damage the growth plate than the ligaments that stabilize the joint .

Mechanism of injury • Physeal fractures usually result from falls or traction

injuries.• They occur mostly in road accidents and during

sporting activities or playground tumbles.• Most commonly , # injury is direct .• Other mechanisms include : - Infections as osteomyelitis or septic arthritis - disruption by tumors , cyst - repetitive stress - irradation

• any injury in a child followed by pain and tenderness near the joint should arouse suspicion, and x-ray examination is essential.

• Deformity is usually minimal

Diagnosis

By radiographic # patterns .Can be of prognostic significance with respect to

growth disturbance potential .Guide general TTT principles Five types of growth plate injuries I-V .

Salter-Harris classificationOf physeal injurirs

•Accounts for 6% of all physeal injuries.

• Transverse fracture through the growth plate.• In a type I separation, the epiphysis separates from the metaphysis. The

plane of separation is horizontal and the germinal cells remain with the epiphysis.

• When the periosteum is torn, displacement may occur. The periosteum is usually torn on the convex side and is intact on the concave side. Displacement is usually easily reduced by reversing the deforming forces and these are often stable and treated by closed means.

• When the periosteum is not torn, there is no displacement and these injuries are diagnosed by suspicion, by the sign of local tenderness and by the normal appearance on x-ray.

• They are usually misdiagnosed as sprains because little is seen on the x-ray.• Healing is rapid for type I fractures, within 2-3 weeks of injury and problems

are rare especially in sites such as the distal radius.

Type I

Slipped Capital Femoral Epiphysis

• Most common type and accounts for 75% of all physeal injuries.

• Transverse fracture through the growth plate and an oblique or vertical fracture through the metaphysis.

• The type II injury starts as a horizontal separation (like type I) but this is completed by exiting through the metaphysis, resulting in a triangular fragment which varies in size.

• This is the most common type of physeal separation and is usually easily reduced but not always easy to hold reduced, in a cast. Sometimes the torn periosteum becomes trapped in the fracture site preventing a full reduction by closed means. The trapped periosteum sometimes needs to be released by open operation, especially at the ankle.

Type II

Type II

• Accounts for 8% of all physeal injuries.

• Transverse fracture through the growth plate and a vertical fracture through the epiphysis.

• Type III injuries are more commonly seen in older children where the growth plates have started to close. It is a combination of a horizontal fracture line through the physis and a vertical fracture line which runs from the growth plate through the epiphysis to the articular surface.

• Displaced injuries may result in a physeal bar, leading to growth disturbance and joint incongruity, leading to arthritis.

• Most displaced type III injuries require open reduction internal fixation (ORIF).

Type III

Type III

• Accounts for 10% of all physeal injuries.

• Vertical fracture through all three components, metaphysis, physis and epiphysis.

• These fractures are liable to displacement and a consequent misfit between the separated parts of the physis, resulting in asymmetrical growth

• In type IV separations, the fracture line is vertical. It extends through four distinct tissues/areas: metaphyseal bone, physeal cartilage, epiphyseal bone or cartilage and articular cartilage.

• The most common example of a type IV physeal injury is separation of the lateral condyle of the distal humerus.

• The four injured tissues must be accurately reduced and lined up with each other, to minimise the risk of a physeal bar and articular incongruity.

• Most displaced type IV injuries require ORIF and long-term follow-up to detect growth disturbance.

Type IV

TYPE IV

• A longitudinal compression injury of the physis. • There is no visible fracture but the growth plate is crushed and this may result in growth arrest.

• This injury is rare and difficult to see on x-ray.

• Compression fracture or crushing of the growth plate.

• These injuries are almost always diagnosed retrospectively, when a growth arrest has occurred.

Type V

Type V

Management

A) Undisplaced fractures :

- treated by splinting the part in a cast or a close-fitting plaster slab

for 2–4 weeks .

- However, with undisplaced types 3 and 4 fractures, a check x-ray

after 4 days and again at about 10 days is mandatory in order not to

miss late displacement

Management B ) displaced fractures :

- should be reduced as soon as possible.

- With types 1 and 2 this can usually be done closed;

the part is then splinted securely for 3–6 weeks.

- Types 3 and 4 fractures demand perfect anatomical reduction BY

open reduction and internal fixation with smooth K-wires is

essential. The limb is then splinted for 4–6 weeks .• Types 5 and 6 fractures cause premature fusion and retardation of growth. The size• and position of the bony bridge across the physis can• be assessed by tomography or magnetic resonance• imaging (MRI). If the bridge is relatively small (less• than one-third the width of the physis) it can be• excised and replaced by a fat graft, with some prospect• of preventing or diminishing the growth disturbance

Management

B ) displaced fractures :

- Types 5 and 6 fractures cause

premature fusion and retardation of growth. The sizeand position of the bony bridge across the physis canbe assessed by tomography or magnetic resonanceimaging (MRI). If the bridge is relatively small (lessthan one-third the width of the physis) it can beexcised and replaced by a fat graft, with some prospectof preventing or diminishing the growth disturbance

If the bone bridge is more extensive the operation is contraindicated

as it can end up doing more harm than good.

complications• The majority of physeal injuries heal quickly and

recover fully.• In a minority, growth disturbance or arrest may occur,

and can result in deformity and impaired function.Physeal growth may be disturbed by: - Avascular necrosis - Direct crushing (Salter-Harris type V) - The formation of a bony bar - Non-union - Hyperaemia

complications

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