Epiphyseal injury

Moderator: Dr B. shaikh nazeer.

Introduction • The growth plate, also known as epiphyseal/physeal plate or physis.

Ephyseal injury is a disruption in the cartilaginous physis of long bones that may involve epiphyseal and/or metaphyseal bone. Mostly involves the ossification centre even sometimes may involve only its cartilaginous portion making radiographic diagnosis difficuly.

It is a fairly common injury with a propensity for lifelong diminution of productivity and quality of life. it is therefore imperative for today’s surgeon to have adequate knowledge and skill in order to diagnose this condition early and institute appropriate treatment expeditiously.

Introduction• The paediatric skeleton differs from that of an adult in that

the bones are more elastic and they contain growth plates (physes).

• Physeal injuries affect the growth plates of children and adolescents. A basic understanding of the anatomy and physiology of the physis is mandatory in order that injuries to the growth plate can be managed effectively

• A child’s long bone consists of two epiphyses, two physes (or growth plates), two metaphyses and a diaphysis.

• The periosteum is the envelope around the bone; It is very thick in the young child and contributes to the growth in the width of the bone.

• The physis is responsible for longitudinal growth. With the completion of growth at skeletal maturity, the physis disappears and the periosteum becomes a thin fibrous layer.

• Physeal injury in comparison to long bone fractures.

1. Physeal injury may disturb growth causing progressive shortening or angular deformity.

2. Bone remodeling doesn’t remodel displaced fractures that traverse physis and articular surface at right angle to the axis of movement of joint.

3. Rate of healing is extremely rapid. 4. Non- union may occur when there is a soft tissue(periosteum or tendon)

interposed between fragments.

• Epiphysis: is the portion of the long bone which develop from secondary centre of ossification.

• growth in length• formation of joints• acts as an attachment for muscles and tendons.• At birth epiphysis consists of a completely cartilaginous structure

chrondroepiphysis. A secondary centre of ossification form for each of these chrondoepiphysis which gradually enlarge as chrondroosseous epiphysis.

• External surface- covered by either by articular cartilade or perichondrium. Muscles fibres, tendons and ligaments may attach directly to perichrondrium which is directly contiguous with underlying hyaline cartilage.

• These perichrondrium bends with periosteum which contribute to biomechanical strength of eliphyseal/metaphyseal junction.

• Epiphyseal cartilage: plate like,thin layer of cartilage which separates the growing diaphysis from epiphysis. Responsible for the growth of a long bone. Cell continuously proliferates.

• Epiphyseal line: The peripheral margin of the epiphyseal cartilage.

Diaphysis: Portion of a long bone between the two cartilaginous ends. Ossifies from primary centre of ossification develops first early fetal life in the hyaline cartilage model of future bone.

• Metaphysis: Part of diaphysis immediately adjacent to the epiphyseal carlilage

PHYSEAL HISTOLOGY• The physis is divided into four zones:

• The germinal zone,• the proliferative zone, • the hypertrophic zone,• and the zone of endochondral ossification.

1. Germinal layers(Resting/Undifferrentiated cartilage cells) located adjacent to the bone plate supplies developing cartilage cells for all new growth injury ---- cessation of growth.

2. Proliferative zone. No germinal layer Actively growing cartilage cells abundant cartilage matrix.

3. Zone of hypertrophy or vacuolization chondrocytes become swollen & vacuolated in the process of maturation before

ossification decrease in amount of intracellular matrix weakest zone in physis

4. Zone of provisional calcification: Longitudinal bars of dying condrocytes become calcified Strength enhanced by calcification Physeal/metaphyseal junction has many small undulations.

Blood supply To physis Epiphyseal vessels ( supply germinal layer) Metaphyseal vessels (supply central ¾ of physis) Periosteal vessels. Vessels entering Epiphysis: Directly from periosteum Indirectly through adjacent capsular attachment Epiphyseal vessels terminate as loops in the resting cells of epiphyseal

plate while metaphyseal vessels extend only as far as the zone of endochrondral ossification.

Thus epiphyseal circulation is responsible for nutriation of proliferative cells of growth plate. Any damage to epiphyseal circulation may cause AVN of epiphyseal closure in growth plate.

Metaphyseal ischemia is transient while epiphyseal ischemia is usually permanent.

Types of epiphysis• Pressure epiphysis: develop inline of weight transmission at the articular

ends of long bones. Protect epiphysis cartilage from stress and strain.

• Traction epiphysis: sites of attachment of certain muscles which exerts a pulling actions. Tuberosities of humerus

• Atavstic epiphysis: Independent skeletal bone and fused with other bone. Coronoid process of scapula.

• Aberrant epiphysis: 2nd to 5th metacarpal bone develop an epiphysis at its proximal end.

Physeal Biomechanics • Proliferation of chondrocytes in the epiphyseal plate is responsible for growth

in length of a long bone. In diaphyseal side of the plate the chondrocytes hypertrophy and the matrix become calcified and the cells die.

• Osteoblast lay down a layer of primary bone on the calcified cartilage matrix.

• Physiologic stress ---- compression and tension

• The mechanical modulation of epiphyseal growth is often referred to as the ‘Hueter-Volkmann Law’.

• “The ‘Hueter-Volkmann Law’ proposes that growth is retarded by increased mechanical compression, and accelerated by reduced loading in comparison with normal values”

PHYSEAL INJURIES• Etiology of Physeal Injuries.

Can be injured in many ways,the most frequent mechanism of injury is fracture. Most commonly, fracture injury is direct, with the fracture pattern involving the physis itself.

Occasionally, physeal injury from trauma is indirect and associated with a fracture elsewhere in the limb segment, either as a result of ischemia or perhaps compression.

Infections : osteomyelitis or septic arthritis :further complicated by joint disruption resulting from associated epiphyseal destruction, articular cartilage damage, and capsular adhesions, particularly in the hip and shoulder.

PHYSEAL INJURIES

Both malignant and benign tumors and tumor-like disorders can disrupt normal physeal architecture, resulting in direct physeal destruction.

Tumor

enchondromata, and unicameral bone cysts.

Valgus deformity of the distal femur associated with the presence of an enchondroma of the distal lateral femur involving the lateral physis.

The patient's leg was caught under heavy pipes rolling off a rack, resulting in stripping of the soft tissues from the distal thigh, open comminuted fracture of the distal femur, and popliteal artery injury

Physeal injury from vascular insult

In follow-up, after arterial and soft tissue reconstruction, the patient has physeal growth arrests of the distal femur and proximal tibia.

PHYSEAL INJURIES

Stress injury of the distal radius and ulna in both wrists of a competitive gymnast. There was no history of specific injury. The wrists were tender to touch. Note distal radial and ulnar physeal widening and irregularity

Repetitive Stress:

PHYSEAL INJURIES• Radiation: therapeutic irradiation diagnostic x-rays. a dose as low as 400R can produce growth retardation. • Metabolic abnormality: vitamin A intoxication, vit c deficiency,

chronic renal failure.

• Heat injury: physeal damage in severe burns not well understood. physeal cartilage more sensitive to irradiation and cold than the articular cartilage.

PHYSEAL INJURIES

• COLD BITE (frost bite) • Physeal closure becomes evident 6-12months after cold exposure,

probably resulting from direct injury to vulnerable chondrocytes or ischemic vascular changes due to arterial spasm.

• On x-ray charestistic : physis disappears completely, short and small phalynx, epiphysis often have v shape.

• very few children require surgery: arthrodesis,angular osteotomy, soft tissue arthroplasty.

Classification of Physeal Fractures

Poland type I: epiphyseal separation without metaphyseal fragment, or extension into the epiphysisPoland type II: physeal fracture line extends into the metaphysis. Poland type III: fracture extends from the articular surface to the physis and continues peripherally through the physis. Poland type IV: T-condylar fracture of the epiphysis and physis.

Salter & Harris Classification ofEpiphyseal plate injuries

• Salter-Harris Classifications are a straightforward and reliable way to diagnose and treat growth plate fractures.

• There are five types of classifications that are listed by the location of the fracture.

• This is the most widely used method for classification today since its conception in the 1960s.

• The importance of this classification system is to accurately diagnose a fracture so the correct method of treatment can be performed swiftly to decrease the chances of growth disturbances and angular growth deformities.

• The epiphyseal plate is the weakest area in children’s anatomy, weaker than their associated ligaments and tendons, causing fractures to occur in the growth plate when trauma occurs

Salter & Harris Classification ofEpiphyseal plate injuries

Type I

Slipped Capital Femoral Epiphysis

Type II

Type III

Type IV

Type V

Investigation

Advantages of MRI

• Dr. Cardinal suggests using MRI over other modalities for a follow up exam. MRI beats other modalities in diagnostic quality (especially diagnosing microfractures

• Kleinman. Shah, Kritsaneepaiboon, and Murray (2009) used MRI images of several patients’ knees to demonstrate the value of MRI exams.

• The MRI’s on these patients were done because the clinical findings still persisted despite normal plain films.

• Due to the higher level of diagnostic quality “in some cases, the findings may be noted only on MRI”

Sagittal image showing type II fracture line (solid arrow).

Posterior physical widening and periosteal (arrowhead) and capsular (open arrow) disruption are evident. Findings pointing to hyperextension injury.

14yr. old boy who presented with hyperextension injury to left knee AP radiograph reveals only a subtle oblique metaphyseal fracture extending to medial cortex. (arrow) B. Coronal image confirms Salter-Harris II fracture with adjacent periosteal elevation (open arrow). Lateral physis is widened with increased fluid (curved arrow). Bone bruise in medial tibial epiphysis and joint effusion

• Principle of Management: 1. closed reduction attempts, GA or sedation 2. reduction maneuver consists of traction followed

manipulation. 3 >10 days after fracture. 4. Anatomical reduction in III & IV 5. avoid Internal fixationi

Distal femoral physeal injury • Distal femoral physeal injury represent 7% of all lower limb extremity physeal

fracture• Categorized into two group newborn and adolescent.• Salter Harris classification alone has not been accurate in predicting the overall

outcome thus mechanism of injury and degree of initial evaluation.• CLINICAL FEATURES• H/O initial trauma, more energy required to produce fracture in juvenile than adult.• On physical examination: acute distress secondary to pain in knee, unable to walk • displaced- knee swollen, tense • non displaced: less pain, may able to ambulate• knee is flexed position and deformity with extension of distal or valgus. • Ecchymotic areas give information of deforming force

Distal femoral physeal injury• Radiograph Finding: • AP and lateral images of knee and entire femur.• oblique view and stress view.• CT help to define amount of displacement• MRI

• Salter and colleagues stated that when excessive manipulation appears to be necessary to achieve acceptable reduction, it is better to maintain growth potential and perform corrective osteotomy at a later date than to overstress the physis and cause more damage.

• The goal is to gain anatomical reduction with stable fixation(>10)• Younger children acceptable alignment Upto 20 degrees of angular in

sagittal plane, less than 5 degree of varus or valgus angulation and no rotational deformity.

• Salter harris type I: newborn by immobilization without attempt at reduction.

• Older child with complete physeal separation closed reduction.• In hyperextension fracture - immobilization with hip spica or long-leg cast

with knee flexed (60’). Followed by gradual extension of knee in 3 to 4 weeks.

• Salter harris type I: 60 to 70% displaced at the time of initial evaluations • nondisplaced or minimally displaced – closed reduction and external

immobilization. When metaphyseal fragment is on lateral side, the distal fragment is in valgus and can be reduced with a varus- producing maneuver to overcorect the deformity. Long knee cast with 20 to 30’ knee flexion.

• Displaced: closed reduction with percutanious fixation to fix the metaphyseal fragment

• young child – kirschner wire• Adolecent -- cannulated screws (4.0- or 6.5mm screws) percutaniously.• Although litreture suggest in 10 to 15% need internal fixations• Failed closed reduction require open reduction in 5% of case. This

irreducuble type II caused by interposed periosteum on the tension side of fracture or less often, muscle interposition and this require open reduction followed by internal fixation.

• Salter harris type III: less common open reduction and internal fixation, fracture must be anatomically reduced to preserve the articular anatomy and reduce the likelihood of growth arrest.

• Anteromedial or anterolateral incision, followed by percutaneous fixation of the epiphysis(canulated cancellous screw) preferably 2 screw.

• Long knee cast immobilization for 6 weeks with knee 20 to 30’ flexion• Salter harris type IV: • All type – long leg cast continued for 6 to 8 weeks

• Prognosis - depends on age , fracture displacement, reduction, types • juvenile (<11). Growth problem • Complication Acute late

Proximal tibial physeal fracture • Fracture to proximal tibial physis are rare and account for 0.5 to 3% in

children. This rareness reflects the lack of collateral ligamentous attachments to the proximal tibial epiphysis, which allow valgus or varus forces to be transmitted through these ligaments to their attachment on the distal femoral physis, fibular head and tibial metaphysis.

Anatomy: the proximal tibia ossific nucleus forms at 2 months of age, with secondary ossification of tibial tuberosity 10 and 14 years. It unites with proximal tibial physis at 15 years

radiolographic investigation of patients 12 to 20 years of age hve shown that the proximal tibial physis appears to fuse posteriorly, followed by anterior fusion.

Proximal tibial physeal fracture • Mechanism of injury: both direct and direct to the knee result in

fracture of proximal tibial physeal. Indirect blow to a hyperentended knee when the lower part of the leg is in fixed position.

• Varus and valgus, even rarely flexion type indirect trauma.• The patients are typically older (16 years), an age when the anterior

proximal tibial physis remain open but the proximal physis is closed.

• Clinical presentations: knee effusion held in flexion position.• knee extension painful and restricted to hamstring

spasm.• hyperextension injury the knee may be flexed in only 10 degree, while

in flextion type the knee is more flexed at the time of evaluations.

Proximal tibial physeal fracture

• Management:• Closed reduction: • Non operative indication: Nondisplaced and Minimally displaced fracture.• Reduction is performend by anteriorly directed translation of the

metaphysis fragment while traction is applied to the leg with the thigh stabilized by assistant . To obtain reduction knee to be in flexion.

• Cast immobilized for 4 to 6 weeks with knee not more than 60 degree flexion. After weeks latter cast be removed to reduce the amount of knee flexion to 20 to 30 degree of flexion.

• Radiograph :weekly for initial 2 weeks to ensure fracture reduction maintained. Mild displacement is acceptable.

Proximal tibial physeal fracture • Indication for operative treatment : 1. Failed closed reduction in type I & II 2. Failure to maintain reduction in long leg cast,less than 60’ of flexion 3. All displaced type III & IV 4. Presence of arterial complication. Unstable physeal fractue which cannot be maintained with external

immobilization, smooth pins should be placed in crossed fashion, crossed distal to physis. Cast immobilization for 6 to 8 weeks.

Displaced type II: pin or screw fixation needed to stabilized mhyseal fragments thus preventing violation of physis.

Open reduction with Intrnal fixation required for displaced type III & IV.

Distal fibula and tibial fracture• Distal tibia and fibula fracture are relatively common, second to distal

radius fractures as the most common in physeal fracture in children.• The horizontal orientation of the physis and the strong ligamentous

attachment distal to the physis make the physis more vanerable to injury. occurs between 10 and 15 years of age more in boys than girls.

clinical presentation: h/o twisting of ankle. Pain at the time of initial trauma, pain on weight bearing, predominant area of swelling.

Distal fibula and tibial fracture• Isolated nondisplaced distal fibular salter harris type I – short leg walking

cast or fracture boot for 4 weeks.• Displaced fracture- closed reduction and short leg Non weight bearing cast

for 4 to 6 weeks.• Salter harris type II treated with a short leg non weight bearing cast for 4

to 6 weeks and it heals without complications.

• Salter harris type I distal tibial fracture: rare in children and account for 15% of all distal tibiofibular fracture in children.

• Closed reduction followed by long leg cast for 4 weeks for displaced at the time of initial injury. After 4 weeks short leg cast for additional 2 weeks. Complication of premature physeal arrest with subsiquent limb length discrepency reported in 3% of cases.

Distal fibula and tibial fracture• Salter harris type II distal tibial fracture : most common distal tibial

fracture in children. Account for 40% of all ankle fracture.• Nondisplaced fracture required well moulded long leg cast for 3

weeks latter can be modified for short leg cast for another 2 weeks.• Displaced fracture require gentle closed reduction with long cast for

4 weeks followed by 2 weeks of short leg cast.• Salter harris type III distal tibial fracture : 20 % of all distal

tibiofibular fracture in children at an aveage age of 11 to 12 years.• Nondisplaced fracture require 4 weeks in a long leg cast followed by

4 weeks in short leg cast. The initial plaster must be applied with foot in 5 to 10 degree of eversion.

• Displaced fracture of more than 2mm should be reduced in operation room by either closed or open reduction followed by screw fixation.

Distal fibula and tibial fracture• Salter harris type IV distal tibial fracture: open reduction and internal

fixation required because these fracture are displaced and fracture line extends into the joints. These fracture likely to be associated for early degenerative arthritis and growth arrest.

• Postoperatively short leg cast for 6 weeks adviced.• Complications :• premature closure of the physis: germinal layer of physis lead to

asymmetric or symmetric growth arrest. Average shortening of 1.6 to 1.1 reported in type III & IV.

• delayed union or non union: rare in young children, in adolecent if non union exists then open procedure to debride fibrous tissue at fracture site, followed by autologous bone graft and internal fixator.

Management according to Type:

• Type I Salter-Harris fractures occur when there is a complete separation of the entire physis and the surrounding bone is not involved.

• commonly seen when considering growth plate injuries and tends to occur more frequently in younger children.

• Physis being radiolucent.

• Simple closed reduction and immobilization is needed because healing is rapid in children and the risks after immobilization of complications is extremely low

• Type II fractures are the most commonly diagnosed and “are usually easily identified on routine radiographs).

• The fracture exists along the physis and continues up through a small section of the metaphysis.

• triangle-like and the periosteum is torn on the opposite side to where the metaphysis is fractured, but it is still intact on the adjacent side.

• The intact periosteum makes it easier to perform a closed reduction without on over-reduction.

• INCOMPLETE REDUCTION

• YOUNG PATIENTS OLDER CHILDREN

• Acceptable. Get more accurate reduction over manipulation not adviced

if can’t be reduced Distal tibia fracture

Tendon, nerve and vascular structure impingement

surgery

INTERNAL FIXATION BY PINS OR SCREWS

SMALL METAPHYSEAL FRAGMENTS

SMALL DIAMETER SMOOTH PINS FROM EPIPHYSIS ACROSS PHYSIS

AND INTO MAIN METAPHYSIS

USE BIODEGRADE

ABLE PINS

REMOVE AFTER 3 WEEKS

FALLOW UP AFTER >=6 MONTHS TO

LOOK FOR PERSISTANT OF

GROWTH

FROM METAPHYSIS TO METAPHYSIS AVOIDING PHYSIS

Surgery is usually required to ensure the bones are properly aligned and then

kept immobilized for optimal recovery

The prospect of recovery is positive as long as the vascular supply to the bones

remains intact

• Type III fractures run along the joint surface and persist deep into the epiphyseal plate.

• fracture is uncommon when they are diagnosed, it is usually found in the distal tibia of an adolescent whose growth plate is nearly finished.

ANATOMIC REDUCTION

OF ARTICULAR SURFACE

AVOID DEGENARATIVE ARTHROSIS

OF PHYSEAL CARTILAGE

DECREASE CHANCE OF GROWTH ARREST

• Type IV fractures start above the growth plate (in the metaphysis) and cut all the way through the epiphysis.

• “These fractures are usually caused by axial loading or shear stress, comminution is common”

• Damages the joint cartilage normal growth of the individual may be impaired.

• Surgery is required in order to properly re-align the joint surface, if not aligned correctly growth problem occurs

• “Close follow-up to monitor for bone-length discrepancies and angular deformities is essential”.

• Type V fractures crushing of the epiphysis.• Hardest fracture type to diagnosis and the most difficult to heal.• This injury is most likely to occur in the weight-bearing joints of the

knee and ankle.• “Crush injuries where complete disruption of the Salter Harris

Fractures epiphyseal vascular system has resulted in death of the growth plate cartilage”

• Increased risk of pre-mature fusion. “In the arm this may produce only a cosmetic deformity, but in the

leg any consequent inequality of length may cause considerable disability

TYPE OF IMMOBILISATION

SALTER AND HARRIS

TYPE I/II

IMMOBILIZE FOR HALF THE TIME IT WOULD TAKE A METAPHYSEAL

FRACTURE IN THE SAME BONE TO HEEL

TYPE III/IV

IMMOBILIZE FOR SAME AMOUNT OF TIME AS WE WOULD FOR A PURELY METAPHYSEAL INJURY IN THE SAME

AREA

LONGER PERIOD OF IMMOBILIZATION IN CHRONIC ILLNESS

IMMUNOSUPRESSION RENAL/LIVER DISEASE

MALIGNANCY

• Period of immobilization:• In lower limb type I/II – Non weight bearing or toe-touch for initial

7-14 days. Latter gradually progression to full weight bearing.

• Type III/IV or internal fixation fracture toe-touch for 3-4 weeks till K-wire is removed then cast

immobilization with full weight bearing.

Prognosis

• Depends on• 1. severity of injury displaced, comminution and compounding• 2 Age of patients – Any physeal trauma in 13/F or a 15/Male results in

significant length discrepency or angular deformity.• 3 Anatomical site• A. types of physeal present• B. blood supply to the physis

TYPES OF PHYSIS

SMALL AND UNIPLANARDISTAL FIBULA

PROXIMAL RADIUS AND ULNA

SHEARING DOES NOT CAUSE MUCH DAMAGE

GROWTH ARREST/DISTURBAN

CE UNLIKELY

LARGE,UNDULATING,MULTIPLANARDISTAL FEMER

PROXIMAL TIBIA

PRONE TO ARREST EVEN WITH MILD DISPLACEMENT

CONTRIBUTE HIGHLY TO LONGITUDINAL

GROWTH

BLOOD SUPPY TO PHYSIS

TYPE ABLOOD REACHES EPIPHYSIS AFTER CROSSING

PHYSIS AND METAPHYSIS EXTERNALLY

EX:PROXIMAL FEMER

ANY DISPLACEMENT OF EPIPHYSIS MAY OCCLUDE BLOOD SUPPLY

4.XRAY TYPE:

• Petersons classification type 1 has least damage to physis and gradually the damage increases over subsequent type vi which has greatest damage.

5 sex:• No statistical data show any difference in outcome based on gender

COMPLICATIONS 1. Sepsis ---seen in compound injuries 2. Overgrowth---very rare may be seen in capitullum fractures of lateral humeral

condyle rarely require treatment3. Hypoplasia of epiphysis 4. Delayed union and malunion5. Compartment syndrome ---may be assosiated with proximal

tibial or distal radial injuries .6. Avn---seen in proximal femoral capital epiphysis.

7.PHYSIAL ARREST

PARTIAL

ANGULAR DEFORMITY

COMPLETE

REDUCTION IN BONE GROWTH

MANAGEMENT OF COMPLETE ARREST

1. shoe lift 2. physial arret 3. ipsilateral bone lengthing 4. contralateral bone shortening 5. combination of 3 and 4

MANAGEMENT OF PARTIAL ARREST 1. Shoe lift –lower limb -central bar

-no angular deformity -leg length discrepancy less than 2.5cm2. Arrest remaining growth of injured physis 3. Arrest remaining growth of injured physis and physis of

adjacent bone4. Arrest remaining growth of injured physis and physis of

adjacent bone/corresponding physis of contralateral bone

MANAGEMENT OF PARTIAL ARREST

5. open/closed wedge osteotomy to correct angular deformity 6. bone lengthening .7. bone shortening of contralateral/companion bone. 8.exision of physial bar and insertion of on interposition

material.9.breaking bone bar by physial distraction .10.transplantation of an epiphysis and physis.