Epiphyseal injuries

epiphyseal injuries

1. Epiphyseal injury

2. Importance The most predictable complication of epiphyseal injury is growth disturbance And so could be prevented if diagnosed properly and managed accordingly

3. Each epiphysis has its own epiphysial plate through which skeletal growth occurs
So it is important that a distinction be made between the epiphysis and epiphysial plate

4. Types of epiphysis Two types Pressure epiphysis Traction epiphysis Pressure epiphysis Location – at the end of a long bone
Subjected to pressure transmitted through the joint Could be considered articular epiphysis Provides longitudinal growth of long bone Pressure epiphysis itself could be divided into two depending on whether their nutrient vessels enter epiphysis directly like lower femoral epiphysis or indirectly like upper femoral epiphysis

5. Traction epiphysis Location – site of origin or insertion of major muscles or muscles group Subjected to traction rather than pressure Does not enter into joint formation , so extra articular Does not contribute to longitudinal growth of long bone
Examples : trochanters of femur

6. Normal epiphysial plate has four distinct layers Resting cells Proliferating cells
Layer of hypertrophy Endochondral ossification Space between cells filled with cartilage matrix ( intercellular substance) Made up of collagen embedded with chondroitin sulphate It is the inter cellular substance which provides strength to epiphysial plate

7. Collagen fibres are arranged longitudinally in the matrix
First two layers , matrix is abundant and the plate is strong In third layer ( hypertrophy layer ) matrix is scanty and so plate is weak. It is layer of hypertrophy which is a commen site of epiphysial injury

8. Mechanism of nutrition in epiphysial plates Two separate systems of blood vessels Epiphysial system Metaphyseal system Epiphyseal system – vessels penetrate the plate of epiphysis and end in capillary tufts or loops in a layer of resting cells Metaphyseal system – arises in marrow of shaft and ends in loops in layer of endochondral ossification So the epiphysial system is responsible for nutrition of proliferating cells
And metaphysial system is responsible for nutrition of endochondral ossification

9. Etiology Trauma ( shearing / avulsion / crushing ) Pathological separation of epiphysis ( rickets , scurvy , osteomyelitis ) Iatrogenic damage to epiphysial plates

10. Epiphysial injury mainly divided into two groups Fracture that cross the epiphysial plate Epiphysial separation Fracture crossing the epiphysial plate With or without longitudinal displacement When there is no displacement of fragment but fracture crossing the plate will lead to premature closure of epiphysis and ultimately leads to shortening When displacement is present it will be combined with shortening and angular deformity

11. Epiphysial separation : Healing of epiphysis separation is rapid if there is no vascular damage Prognosis is not good if it damages nutrient vessels to epiphysis Such as avascular necrosis of femoral head in slipped capital femoral epiphysis

12. Classification of epiphysial plate injuries Salter Harris classification Type 1 : complete separation of epiphysis from metaphysis More common in birth injuries or pathological separation as in scurvy, rickets Type 2 : commonest type of epiphysial plate injuries Line of separation extends along the epiphyseal plate to a variable distance and then out through a metaphysis Producing a triangular shaped metaphyseal fragment called Thurston Holland sign

13. Type 3: fracture which is intra articular extends from the joint surface to the weak zone of epiphyseal plate and then extends along the plate to its periphery Type 4 : fracture which is intra articular extends from the joint surface through epiphysis across ful thickness of epiphyseal plate and through a portion of metaphysis Producing a complete split Commonest example of this type is fracture of lateral condyle humerus

14. Type 5 Relatively uncommon injury
Occurs due to severe crushing force applied through epiphysis to epiphyseal plate More common in ankle and knee
Injury might be misdiagnosed on xray

15. Type 6 Injury by RANG Injury to perichondrial ring Type 7 Ogden – isolated epiphysis injury
Type 8 – isolated injury to metaphysis Type 9 – avulsion injury to periosteum

16. Factors in prognosis Type of injury Type 1,2,3 have a good prognosis provided the intact blood supply Type 4 has a bad prognosis unless the plate is completely realigned Type 5 has the worst prognosis Age of the child Depends on the amount of growth expected in particular epiphyseal plate for the remaining years of growth Younger the child , poor the prognosis

17. Blood supply Examples femoral head necrosis Method of reduction : Undue forceful manipulation further damages the plate Mostly carried out after tenth day of injury Damage by instruments Screws or wires traversing the plate

18. Open or closed injury : Open injuries of epiphysis uncommon But when associated , outcome is worst

19. Principles of treatment Time of reduction : Best time to reduce an epiphyseal plate injury is the day of injury Reduction becomes progressively more difficult with each passing day
After 10 days , forceful manipulation is required and which may Further damage the plate and so should be avoided And wiser to accept an imperfect reduction than to risk the danger of either forceful manipulation or open reduction

20. Method of reduction Closed or open Majority type 1&2 reduced by closed means Type 3 may require open reduction to obtain smooth joint surface Type 4 mostly requires open reduction always Follow up : growth disturbance may be delayed and so minimum of one year follow up is must

21. Common type of injury at upper radial epiphysis is type 2 Produced by valgus force on the elbow , resulting in angulation of radial head Reduction can be achieved by holding the extended elbow in varus and directly pressing over the radial head If angulation is > 15° after closed reduction , supination – pronation may get affected and open reduction is indicated Radial head should not be excised in children , if done loss of radius growth wll produce progressive radial deviation at the wrist joint and valgus deformity at the elbow

22. Fracture of lateral condyle humerus (capitellum ) is type 4 injury Weekly x-rays needed to check the alignment When it’s displaced , open reduction is must Elbow is immobilised for 3 weeks in 90° flexion If not reduced properly – may lead to over growth of radial head / valgus deformity / tardy ulnar nerve palsy

23. Largest of pressure epiphysis – lower femoral epiphysis Serious injury of lower femur epiphysis is hyper extension type with forward displacement of epiphysis Posterior corner of metaphysis may injur popliteal vessels Reduction is achieved by traction on semibent knee , pushing the proximal fragment forward and then flexing the knee Reduction is most stable in 90° knee flexion Total period of immobilisation 3 weeks

24. Traction epiphysis injuries Medial epicondyle humerus injury : common flexor muscles avulsion Severe valgus injury Tibial tubercle : traction epiphysis of quadriceps Lesser trochanter : iliopsoas inserted to lesser tubercle Sudden abduction and extension of hip may result in lesser trochanteric avulsion Anterior superior iliac spine – traction epiphysis of sartorius Anterior inferior iliac spine – traction epiphysis of rectus femoris

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