Physeal injuries

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Information about Physeal injuries
Education

Published on March 16, 2014

Author: drlokeshsharoff

Source: slideshare.net

Description

Physeal injuries, Epiphyseal injuries, types, classifications, treatment, management of physeal injuries, growth arrest lines, parker lines

PHYSEAL INJURIES Dr . LOKESH SHAROFF Orthopaedic surgeon, mumbai, india

ANATOMY OF PHYSIS  GERMINAL LAYER  ZONE OF PROLIFERATING CARTILAGE  ZONE OF HYPERTROPHIC CELLS  ZONE OF PROVISIONAL CALCIFICATION  ZONE OF ENCHONDRAL OSSIFICATION

CLASSIFICATIONS  AITKENS (1936)  SALTER&HARRIS(1963)  OGDEN(1981)  PETERSON(1994)

SH TYPE 1  Complete seperation of epiphysis without true # through bone with or without displacement  From shearng/torsion/avulsion  No findings on x-ray  Good prognosis

SH TYPE 2  # seperation line traverses along physis to a variable distance & then out through a portion of triangular shaped metaphyseal fragment(Thurstan-Holland sign)  Intact periosteum on the side of metaphyseal fragment  Prognosis-good

SH TYPE 3  Vertical split from joint surface to physis & then along physis to periphery(intra-articular)  Uncommon  Lower tibial epiphysis  Prognosis-good

SH TYPE 4 Intra-articular # extending from joint surface through epiphysis,entire physis & a portion of metaphysis -Lateral condyle of humerus Prognosis-bad

S H TYPE5  Severe crushing force applied through epiphysis damaging the germinal layer of physis  No osseous injury -diagnosed in retrospect

S H TYPE 6  Perichondrial injury as described by Mercer Rang(1969)  Rare injury  Blow to periosteum/perichondrial ring scarring tethering and bony bar formation can occur

OGDEN 7  INTRA-ARTICULAR OSTEOCHONDRAL FRACTURE

OGDEN 8 AND 9  METAPHYSEAL AND DIAPHYSEAL #S RESPECTIVELY BUT SEEN TO STIMULATE THE LONGITUDINAL GROWTH OF THAT BONE.

PETERSON He described 2 new types of fractures .. 1st and 5th in his classification

PETERSON TYPE1  Transverse # of metaphysis with # line extending to physis  Comminution-common  MOI:longitudinal compression  Sites:distal radius,finger phalanges,MC  Prognosis:good

PETERSON TYPE 2  Seperation of physis with a portion of metaphysis attached to epiphysis (THURSTAN-HOLLAND sign)  Most common type  Site:finger phalanges

PETERSON TYPE 3  Seperation of metaphyis from epiphysis through the physis disrupting the physis  Site:distal fibula

PETERSON TYPE 4  # of epiphysis extending to & along the physis  May be comminuted/double  Common in older children  Premature growth arrest common  Sites:finger phalanges,distal tibia(medial malleolus0

PETERSON TYPE 5  # that traverses the metaphysis,physis,epiphysis & atricular cartilage  Tri-plane #  Comminution & open# common  Premature growth arrest occurs  sites: lateral condyle humerus, distal tibia

PETERSON TYPE 6  # in which part of metaphysis,physis & epiphysis is removed/ missing  Found in open #  Premature closure of epiphysis occurs

PROGNOSIS  Severity of injury  Age of the child  Site of injury  Amount of physis injured

TREATMENT  To obtain & maintain reduction by closed/open means  To maintain function & normal growth

PRINCIPLES OF TREATMENT  Physeal # should be reduced immediately  All reductions open/closed should be gentle  Forceful repeated manipulations should be avoided  During open reduction pressure on physis should be avoided

PETERSON TYPE 1  CMR & casting  Immobilisation for 3-4 weeks  Follow up to ensure normal growth

P TYPE 2/S H TYPE 2  CMR & casting under GA/block  Metaphyseal fragment & intact periosteum provide stability  Surgical intervention 1.periosteal impingement 2.unstable fragment ? Bio-degradable pins

P TYPE 3/S H TYPE 1  CMR & casting

P TYPE 4/S H TYPE 3  Anatomical reduction of physeal & articular cartilage by ORIF

P TYPE 5/S H TYPE 4  OR & IF

P TYPE 6  Initial debridement followed by reconstructive surgery later on

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

HARRIS GROWTH ARREST LINES  Symmetrical, thin white lines  Perpendicular to long axis of bone  Metaphyseal at first  Most marked in rapidly growing ends of bones, e.g. distal femur and proximal tibia  They migrate towards the diaphysis with further growth and may disappear

HARRIS GROWTH ARREST LINES  Denote activity of physeal plate  If asymmetric , denotes partial arrest  If lines are absent , denotes growth arrest

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