physeal injuries.pptx

physeal injuries
physeal fractures
PAEDIATRIC FRACTURES INVOLVING THE PHYSIS. CLASSIFICQTION BASED ON SALTER HARRIS.

1. Discuss the p athology and management of Physeal fractures D r PJ Shindang O rthopedic Dept NHA

2. O utline I ntroduction D efinition E pidemiology Mechanism of injury A natomy of the physis P athology of the physis C lassification M anagement Resuscitation H istory P hysical examination I nvestigation T reatment C omplication follow up/rehabilitation P rognosis C urrent trend Conclusion

3. I ntroduction Physeal injury is a disruption in the cartilaginous physis of bones with or without the involvement of the epiphysis and or metaphysis. The physis is weaker than the surrounding ligament or bone and, therefore, it is more susceptible to disruption. E arly commencement of appropriate management is necessary to prevent complications such as growth arrest and progressive angular deformities.

4. E pidemiology 18% to 30% of pediatric fractures involve the physis M: F – 2:1 P eak age 12- 16yrs in males; 10-12yrs in females The upper limbs tend to be more commonly injured than the lower limbs. The most common site is Phalanges of the fingers (~40%) Distal radius (18%)  Distal Tibia (11%)  Distal Fibula (7%)

5. M echanism of injury Etiology Road traffic accident Falls (FOOSH) Sports Domestic abuse Iatrogenic injury Biomechanics Compression Shear Tension Fracture configuration usually transverse

6. A natomy of the physis Physis is made up of hyaline cartilage Responsible for the longitudinal growth of bones Located at the ends of growing bones between the epiphyses and metaphyses. It is the weakest part of an immature bone. Normal width; 2 - 4 mm. Appears radiolucent on x-ray. Gradually ossifies and disappears at the time of skeletal maturity

7. Anatomy: Histology(4 zones) Germinal (resting) zone: Contains chondrocytes in the quiescence phase Replenishes proliferative zone  Proliferative zone: Contains chondrocytes in mitosis Has an abundant blood supply Responsible for the increase in bone length Hypertrophic (maturation) zone: Chondrocytes accumulate glycogen/lipids ,  undergo hypertrophy then apoptosis. Weakest zone and site of physeal fractures Zone of calcification: Mineralisation of matrix Infiltration by metaphyseal blood vessels

8. A natomy: Blood supply To physis Epiphyseal vessels (supply germinal layer) Metaphyseal vessels (supply central ¾ of physis) Periosteal vessels.

9. Relative contribution to growth by various physis

10. C lassification of physeal injury Several classification systems have been described for physeal fractures. Salter-Harris system described in 1963 is the most widely used classification. Others P oland Foucher Aitken O gden and Rang modification of Salter-Harris Peterson

11. Salter Harris classification 5% 75% 10% 10% <1% F requency

12. Salter-Harris 1 A transverse fracture through the physis. Physeal separation without any bony injury: The growing zone is not injured, so growth disturbance is uncommon. Clinically - point tenderness over the epiphyseal plate with swelling.  X-ray is normal, except for widening of physeal plate

13. Salter-Harris 2 The most common type Fracture occurs through the physis and metaphysis; epiphysis is spared. The metaphyseal fragment is sometimes called the 'Thurston-holland fragment’. Limited growth disturbance; may cause minimal shortening.

14. Salter-Harris 3 Fracture through the physis and epiphysis Prone to chronic disability, because it extends into the articular surface of the bone. However, rarely results in significant deformity.

15. Salter-Harris 4 Involves the epiphysis, physis, and metaphysis. An intra-articular fracture; thus, it can result in chronic disability. Interfere with the growing layer of cartilage cells. Leading to premature focal fusion with deformity. Frequent around the medial malleolus and lateral condylar.

16. Salter-Harris 5 Compression or crush injury of the physis, with no associated epiphyseal or metaphyseal fracture A typical history of an axial load injury. X-ray at the time of injury shows no abnormality. Usually diagnosed retrospectively. (Minimum 6 months) worst prognosis

17. Rare types of Salter-Harris I nclude the following: Type VI - Injury to the perichondral structures Type VII - Isolated injury to the epiphyseal plate Type VIII - Isolated injury to the metaphysis, with a potential injury related to endochondral ossification Type IX - Injury to the periosteum that may interfere with membranous growth

18. M anagement Resuscitation using the ATLS protocol History: Pain/swelling around the affected joint. Upper limb - function limited by pain. Lower limb - inability to bear weight on the affected limb. History of trauma.   On examination: Swelling Deformity +/- (minimal if present) Focal tenderness over physis Limited range of motion of the joint

19. I maging X rays F irst line imaging approach C ost effective, available Features Physis appears radiolucent Physeal widening Epiphyseal displacement of physis , fragmentaion CT Scan O ffers more detailed analysis than radiographs F urther detail on fracture extent and alignment esspecially when exvaluating intra-articular fractures unable to directly image the physis

20. I maging MRI C an demonstrate location , morphology, presise size of physeal injury S how subtle physeal widening and irregularities M etaphyseal intrusion of physeal cartillage

21. D iff diagnosis ligamentous sprain A ligamentous sprain may have a similar presentation and the patient may be unable to bear weight. However, the patient should not have bony point tenderness. Acute osteomyelitis A patient who has osteomyelitis may have other symptoms such as fever, swelling, and elevated ESR, FBC, or C-reactive protein. Torus fracture.

22. Principles: treatment Displaced physeal fracture should be reduced with sustained traction and gentle manipulation.  Forceful reduction maneuvers , repeated attempts of reduction or insertion of instruments into the physis to manipulate fracture fragments should be avoided. Intra-articular displaced physeal fractures (SH 3 and 4) should be reduced anatomically and stabilized by internal fixation, irrespective of their time of presentation. Implants used for internal fixation should be placed in a physical-respecting manner. 

23. Salter Harris type 1 non-displaced SH1 Non-operative with Casting/immobilization  displaced SH1 Closed reduction and casting favored Reduces risk of iatrogenic physeal injury

24. Salter-Harris type 2 Nonoperative indications non-displaced (< 2mm) fractur es stable Salter-Harris type II fractures Closed reduction and I mmobilization in cast for 6 weeks O perative I ndication unstable Salter-Harris type II fractures Re-displacement following closed treatment Closed reduction and percutaneous screw or wire fixation Screw for larger metaphyseal fragment 

25. S alter Harris 2 ORIF crossed smooth pins  Trans- physeal  if Salter-Harris type II with small Thurston-Holland fragment cannulated compression screws parallel to physis for Salter-Harris type II with large Thurston-Holland fragment POST OP cast in for 4-6 weeks

26. S alter Harris type 3 & 4 N on operative I ndication: < 2mm displacement Cast applied for 6-8 weeks Follow-up early with radiographs to assess for displacement

27. Salter Harris type 3 & 4 Operative fixation indications I rreducible fractures usually due to diaphyseal periosteal flap blocking reduction  D isplaced (> 2mm) type IV fractures V ascular injury ORIF with screws or Kwire ORIF with plates and screws

28. SH type 3

29. Salter Harris type 5 Crush injury to entire physis  Very difficult initial diagnosis as minimal displacement  Initial nonoperative treatment  Late diagnosis after complication of physeal arrest and deformity has occurred

30. Follow-up and Rehabilitation SH 1 and 2 should be immobilized for 3–6 weeks SH 3 and 4 should be immobilized for 4–8 weeks. A patient can start unrestricted physical activities only after 4–6 weeks of implant removal. Follow-up radiographs are done at 6 months and 12 months (which may be done at 2 years as well).

31. Prognosis It is multifactorial. initial fracture type location, time to treatment quality of reduction, and subsequent orthopedic follow-up. Generally, the prognosis for pediatric physeal fractures is good. Most cases heal with good alignment with closed treatment. Inappropriate initial management increases the risk of growth arrest, malalignment, and lifelong difficulty for the patient

32. R ecent advances Use of gene therapy and tissue engineering to regenerate articular cartilage Growth plate transplantations Physis distractions Some studies are being conducted to study the role of physeal distraction in stimulating physis in physeal fractures.

33. C omplications Growth arrest Malunion Iatrogenic injury of physis Joint stiffness Secondary posttraumatic arthritis of the joint can occur. Hardware-related complications Compartment syndrome Neurovascular complication

34. C onclusion Physeal injuries may not be readily obvious in children presenting with periarticular trauma; a high index of suspicion during evaluation, treatment and follow-up of such patients is essential in preventing complications

35. Thank you

36. R eferences Singh A, Mahajan P, Ruffin J, Galwankar S, Kirkland C. Approach to Suspected Physeal Fractures in the Emergency Department. J Emerg Trauma Shock. 2021 Oct 1;14(4):222.  Nayagam S. Principles of Fractures. In: Solomon L, Warwick D, Nayagam S. Apley's System of Orthopedics & Fractures. 9th ed. Hodder Arnold; 2010: 727 - 730. Mann DC, Rajmaira S. Distribution of physeal and non- physeal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop . Nov-Dec 1990;10(6):713-6.  Neer CS, Horowitz BS. Fractures of the proximal humeral epiphyseal plate. Clin Orthop Rel Res. Google images