BKK EPIPHYSEAL INJURIES IN CHILDREN- Copy.pptx

BKK EPIPHYSEAL INJURIES IN CHILDREN- Copy.pptx

1. Epiphyseal injuries, Types, classification and management Moderators Dr.T.Venkateshwara Rao Prof.& HOD Dr.J.Venkateshwarlu Asso.prof . Dr.K.Venkatswamy Asst.prof . Dr.Prasad reddy Tutor Presented by Dr.B.Kiran Kumar PG in Orthopaedics

2. Terminology Epiphyseal Plate = Growth Plate = Physis Epiphysis Secondary Ossification Center Epiphysis and growth plate are NOT synonyms The epiphysis is the bone located between the articular surface and the physis Metaphysis Bone adjacent to the physis on the opposite side of the epiphysis. Diaphysis The shaft of the bone

3. During growth, the epiphyseal and metaphyseal regions are separated by the organized cartilaginous physis , which is the major contributor to longitudinal growth of the bone. The larger long bones (clavicle, humerus , radius, ulna, femur, tibia, and fibula) have physes at both ends, whereas the smaller tubular bones (metacarpals, metatarsals, and phalanges) usually have a physis at one end only. At birth, with the exception of the distal femur and occasionally the proximal tibia, all of the above-mentioned epiphyses are purely cartilaginous. At various stages of postnatal growth and development, a secondary ossification center forms within the epiphysis. This development helps define the radiolucent zone of the physis , which persists until the physis closes at skeletal maturation.

4. C- 1 yr R – 3yr I - 5yr T- 7 yr O – 9yr E – 11yr Typical age (and range) of development of the secondary ossification centers of the epiphyses in the (A) upper extremity and (B) lower extremity

5. Typical age (and range) of closure of physes in the (A) upper extremity and (B) lower extremity.

6. Microscopic Anatomy of the physis 2 growth plates Spherical Horizontal 3 layers in the physis Reserve zone Proliferative zone Hypertrophic zone Maturation zone Degenerative zone Zone of provisional calcificaton

7. Reserve zone Chondrocytes store lipids, glycogen and proteoglycan aggregates Blood vessels pass through this layer causing low pO 2 Diseases with defects of this layer Pseudoachondroplasia Diastrophic dwarfism

8. Proliferative zone Longitudinal growth occurs Good blood supply inhibits calcification Diseases with defects in this layer Gigantism Achondroplasia Hypochondroplasia Malnutrition, irradiation injury, glucocorticoid excess

9. Hypertrophic zone Maturation zone Degeneration zone Provisional calcification zone Accumulate calcium in their mitochondria releasing Ca from matrix vesicles

10. Hypertrophic zone Osteoblasts use cartilage as a scaffold for bone formation Low pO 2 facilitates this Diseases with defects in this layer Mucopolysaccharidoses Morquio’s, Hurler’s, Hunter’s Rickets, osteomalacia Insufficient Ca 2+ / P for normal calcification Physis appears widened Enchondromas originate in this zone Physeal fractures

11. The peripheral margin of the physis comprises two specialized areas important for mechanical integrity peripheral growth of the physis The zone (or groove) of Ranvier : a triangular microscopic structure at the periphery of the physis , containing fibroblasts, chondroblasts , and osteoblasts responsible for peripheral growth of the physis . The perichondral ring of LaCroix : a fibrous structure overlying the zone of Ranvier, connecting the metaphyseal periosteum and cartilaginous epiphysis, and has the important mechanical function of stabilizing the epiphysis to the metaphysis.

12. Classification of epiphyseal blood supply according to Dale and Harris. A. Type A epiphyses are nearly completely covered by articular cartilage. Blood supply must enter via the perichondrium. This blood supply is susceptible to disruption by epiphyseal separation. The proximal femur and proximal humerus are examples of type A epiphyses.

13. B. Type B epiphyses are only partially covered by articular cartilage. Such epiphyses are more resistant to blood supply impairment by epiphyseal separation. The distal femur, proximal and distal tibia, and distal radius are clinical examples of type B epiphyses.

14. Contributions to Longitudinal Growth Approximate percentage of longitudinal growth provided by the proximal and distal physes for each long bone in the upper (A) and lower (B) extremities.

15. Histologic Review Important for understanding prognosis The germinal layer of the cartilage is on the epiphysis Cartilage cells grow from the epiphysis towards the metaphysis. The fragments of cells then mineralize.

16. Histology (cont’d) Neovascularization occurs from the metaphysis towards the epiphysis. Damage to either epiphyseal or metaphyseal vascular supply disrupts bone growth Damage to the layer of cartilage may not be significant if the surfaces are reapposed, and vascular supply to the growing cartilage is not permanently interrupted.

17. Overview Salter-Harris fractures are fractures through a growth plate (physis); therefore, they are unique to pediatric patients. Several types of fractures have been categorized by the involvement of the physis, metaphysis, and epiphysis. The classification of the injury is important because it affect the treatment of the patient and provides clues to possible long-term complications.

18. Epidemiology 18% to 30% of children’s fractures involve the physis Male-to-female ratio is about 2:1 Most common site is phalanges of the fingers (~37%) Next is distal radius (18%)

19. Physeal Fractures Traditionally believed to occur primarily through zone of hypertrophy Some fractures may traverse more than one zone Growth disturbance/arrest potentially related to location of fracture within physeal zones, disruption of vascularity

20. ETIOLOGY OF PHYSEAL INJURIES Trauma (most common ) Infection(long bone OSTEOMYELITIS or SEPTIC ARTRITIS) Tumor(BENIGN OR MALIGNANT) Vascular insult Repetitive stress Miscellaneous ( Irradiation , Thermal injury, Electrical )

21. Classification

22. Classifications Poland 1898 Salter - Harris 1963 Aitken 1965 Rang 1969 Weber 1980 Ogden 1981 Peterson 1994

23. Classification Multiple classification systems Salter-Harris – most commonly used (1963) Poland – earliest scientific approach (1895) Bergenfeldt – later modified by Salter & Harris (1933) Aitken – standard from 1930’s until S-H proposed (1936) Peterson – newer and more thorough, but more complicated (1994)

24. SALTER HARRIS CLASSIFICATION

25. Type 1 E piphyseal separation without metaphyseal fragment, or extension into the epiphysis . ZONE OF HYPERTROPHY

26. Type I A type 1 fracture is transverse fracture through the hypertrophic zone of the physis . In this injury, the width of the physis is increased. The growing zone of the physis usually is not injured, and growth disturbance is uncommon. Usually dx’d by clinical presentation alone. On clinical examination, the child has point tenderness at the epiphyseal plate, which is suggestive of a type I fracture.

27. X-rays of undisplaced type I physeal fractures, therefore, are normal except for associated soft tissue swelling, making careful patient examination particularly important in this injury

28. Type 2 physeal fracture line extends into the metaphysis. THURSTON HOLLAND FRAGMANT OR SIGN

29. Type II A type II fracture is a fracture through the physis and metaphysis , but the epiphysis is not involved in the injury. These fractures may cause minimal shortening; however, the injuries rarely result in functional limitations. mechanism: shear or avlusion with angular force; healing is rapid, and growth is rarely disturbed; Type II is the most common

30. Type 3 F racture extends from the articular surface to the physis and continues peripherally through the physis

31. Type III A type III fracture is a fracture through the physis and the epiphysis. This fracture passes across the hypertrophic layer of the physis and extends to split the epiphysis, inevitably damaging the reproductive layer of the physis . Prone to chronic disability because, by crossing the physis, it extends into the articular surface of the bone. Rarely result in significant deformity; therefore, they have a relatively favorable prognosis. A type of ankle fracture termed a Tillaux fracture is a type of Salter-Harris type III fracture that is prone to disability. Treatment is often surgical.

32. Type 4 The fracture line extends across the physis from the epiphysis and articular surface into the peripheral metaphysis. The fracture line extends across the physis

33. Type IV A Type IV fracture involves all 3 elements of the bone: The fracture passes through the epiphysis, physis , and metaphysis . Similar to a type III fracture, a type IV fracture also is an intraarticular fracture; thus, it can result in chronic disability. By interfering with the growing layer of cartilage cells, these fractures can cause premature focal fusion of the involved bone. Therefore, these injuries can cause deformity of the joint. – Even w/ perfect reduction, growth is affected & prognosis is guarded;

34. Type V compression or crush injury of the epiphyseal plate

35. Type V A type V injury is a compression or crush injury of the epiphyseal plate with no associated epiphyseal or metaphyseal fracture. This fracture is associated with growth disturbances at the physis . Initially, diagnosis may be difficult, and it often is made retrospectively after premature closure of the physis is observed. In the older teenagers, the diagnosis is particularly difficult. The clinical history is paramount in the diagnosis of this fracture. A typical history is that of an axial load injury. These injuries have a poor functional prognosis. Angulation and limb length inequality may be long term complications

36. S H TYPE 6 Perichondrial injury as described by Mercer Rang(1969) Rare injury Blow to periosteum / perichondrial ring pgmedicalworld.com

37. Type 6

38. Rare Salter-Harris Fractures Type VI : This is a rare injury and consists of an injury to the perichondral structures. Type VII : This is an isolated injury to the epiphyseal plate. Type VIII : This is an isolated injury to the metaphysis , with a potential injury related to endochondral ossification. Type IX : This is an injury to the periosteum that may interfere with membranous growth.

39. Poland classification of physeal fractures. Compare to the Salter-Harris classification, Poland type I, epiphyseal separation without metaphyseal fragment, or extension into the epiphysis. Poland 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 epiphysis & physis .

40. Aitken classification of physeal fractures: types I, II, and III. Types 1 2 3 is equivalent of Salter-Harris type 2,3 & 4

41. Peterson Classification of Physeal Fractures His classification retained Salter-Harris types I through IV as Peterson types II, III, IV, and V and added two new types It is important to know the two new patterns that Peterson described, because they are clinically relevant. type I is a transverse metaphyseal fracture with a longitudinal extension to the physis partial physeal loss Lawnmower injuries are a frequent mechanism for type VI injuries

42. Principles of management Diagnosis Goals Reduction Avoid growth plate arrest Return of function Operative or non-operative

43. Evaluation of Physeal Fractures Plain radiograph CT Arthrography MRI scans Ultrasound X-rays should be taken in true orthogonal views and include the joint both above and below the fracture. If a physeal injury is suspected, views centered over the suspected physis should be obtained to decrease parallax and increase detail. Oblique views may be of value in assessing minimally displaced injuries.

44. CT scans provide excellent definition of bony anatomy, particularly using reconstructed images MRI scans are excellent for demonstrating soft tissue lesions and minor osseous injuries, which may not be seen using standard radiation techniques. Both arthrography and ultrasound have been used to assess the congruency of articular surfaces Arthrography may help define the anatomy in young patients with small or no secondary ossification centers in the epiphyses . Ultrasonography occasionally is useful for diagnostic purposes to identify epiphyseal separation in infants

45. Principles of management Goals Reduction Avoid growth plate injury Return of function

46. Salter Harris Classification - General Treatment Principles Type I & Type II - closed reduction, immobilization Exceptions = proximal femur, distal femur

47. Salter Harris Classification - General Treatment Principles Type III & IV - intraarticular and physeal step-off needs anatomic reduction, ORIF if necessary

48. Damage to physis must be avoided while oRIF Generally growth plate must be traversed with k wires and not with lag screw Ideally , k-wires should be inserted at low speed and should cross the physis at a right angle. When placing wires across the growth plate , repeated drilling , starting several wires from a single point and a very peripheral insertion must be avoided to minimize damage to the proliferation zones Generally , k wires can be removed after 3-4 weeks If it is necessary for a screw to cross the physis then it must be removed as soon as possible

49. PROGNOSIS Severity of injury Age of the child Site of injury Amount of physis injured

50. Treatment Goal of treatment of all physeal fractures is to maintain function and normal growth Attainment of these goals is most likely when all structures are anatomically reduced Therefore goal is to obtain and maintain anatomic reduction May be done by open or closed means All reductions should be gentle to prevent damage to the delicate physeal cartilage Forceful, repeated manipulations should be avoided!

51. Treatment Salter-Harris I Most common with fractures of the phalanges, distal radius and fibula All layers of the physis may be involved Should be managed by closed reduction if possible, as internal fixation would require crossing the physis In a young child, better to accept an imperfect reduction than risk hazards of fixation across physis

52. Treatment Salter-Harris II Most can be easily reduced with closed reduction Important to have good relaxation to prevent physeal damage Intact periosteum on side of metaphyseal fragment imparts further stability to fracture ORIF often unnecessary Periosteum can become impinged at fracture site, especially in distal tibia

53. Treatment Salter-Harris II If ORIF is necessary Internal fixation is best accomplished by pins or screws from metaphysis to metaphysis, avoiding the physis If Thurstan Holland fragment is small, smooth pins may be placed across physis Growth arrest less likely if Pins avoid perichondrial ring Are longitudinal as possible Remain in place short time (< 3 wks)

54. Treatment Salter-Harris II Prognosis depends greatly on Amount of physis involved Site of injury Degree of displacement Patient age Site of injury important because Irregular and undulating physes produce more scraping of irregular surfaces of delicate cartilage (e.g. distal femur)

55. Treatment Salter-Harris III Cartilage of physis and articular surface are both disrupted Best result achieved by anatomic reduction of joint and physis Reduce the likelihood of degenerative arthrosis Reduce the likelihood of growth arrest

56. Treatment Salter-Harris III Usually require open reduction of joint Most desirable internal fixation is epiphysis to epiphysis, especially in younger children

57. Treatment Salter-Harris IV Anatomic reduction and maintenance of reduction are essential to align both physis and articular surface If any displacement, open reduction usually required Closed reduction and percutanous fixation may be acceptable in some situations (e.g. lateral hum. condyle) Fixation best accomplished from epiphysis to epiphysis and/or metaphysis to metaphysis Growth arrest is common!

58. Treatment Salter-Harris V Rarely diagnosed at time of injury “No fracture on radiograph” Often diagnosed in retrospect after growth arrest discovered Occasionally seen in severe triradiate acetabular injuries Rarely require initial treatment as usually minimal displacement and/or instability But subsequent deformity may require treatment

59. COMPLICATIONS Premature growth arrest 1.length discrepancy 2.angular deformity Compartment syndrome/arterial occlusion Neurological complications sepsis & osteomyelitis Overgrowth & hypoplasia Malunion /delayed union/non union

60. summary Type II is most common Types III & IV are more prone to chronic disability Type V associated with growth disturbances and has a poor functional prognosis Only 2% of Salter-Harris fractures result in a significant functional disturbance

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