physeal injuries

PHYSEAL INJURIESDR. BASSEY, A EORTHOPAEDIC & TRAUMA SURGERYU.A.T.H, ABUJA

OUTLINE• INTRODUCTION

DEFINITION STATEMENT OF IMPORTANCE EPIDEMIOLOGY

• ANATOMY OF THE PHYSIS• AETIOPATHOGENESIS OF PHYSEAL INJURIES• CLASSIFICATION• MANAGEMENT

HISTORY EXAMINATION INVESTIGATION TREATMENT

• COMPLICATIONS• FOLLOW-UP/REHABILITATION• PROGNOSIS• CURRENT TRENDS• CONCLUSION

INTRODUCTION• DEFINITION - PHYSEAL INJURY IS A

DISRUPTION IN THE CARTILAGINOUS PHYSIS OF LONG BONES THAT MAY INVOLVE EPIPHYSEAL AND/OR METAPHYSEAL BONE

• 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.

EPIDEMIOLOGY• PREVALENCE: 10 – 30% OF CHILDHOOD

FRACTURES• AGE: BIMODAL PEAKS AT INFANCY & 10 – 12

YEARS• SEX: M>F• COMMONEST SITES:

UPPER EXTREMITY>LOWER EXTREMITY DISTAL RADIUS DECREASING

DISTAL HUMERUS FREQUENCY

PROXIMAL TIBIA/FIBULA

ANATOMY OF THE PHYSIS• THE PHYSIS IS A SLAB OF HYALINE

CARTILAGE LOCATED AT THE ENDS OF GROWING BONES BETWEEN THE EPIPHYSES AND METAPHYSES AND WHICH ARE RESPONSIBLE FOR THE GROWTH OF SUCH BONES

• IT IS DIVIDED INTO 4 DISTINCT ZONES HISTOLOGICALLY:

GERMINAL (RESTING) ZONE PROLIFERATIVE ZONE HYPERTROPHIC (MATURATION) ZONE ZONE OF CALCIFICATION

ANATOMY OF THE PHYSIS• GERMINAL ZONE

CONTAINS CHONDROCYTES IN QUISENCE REPLENISHES PROLIFERATIVE ZONE INJURY CESSATION OF GROWTH

• PROLIFERATIVE ZONE CONTAINS CHONDROCYTES IN MITOSIS RESPONSIBLE FOR INCREASE IN BONE LENGTH INJURY CESSATION OF GROWTH

• HYPERTROPHIC ZONE CELLS ACCUMULATE GLYCOGEN/LIPIDS INCREASED ALKALINE PHOSPHATASE ACTIVITY WEAKEST ZONE AND SITE OF PHYSEAL FRACTURES

• ZONE OF CALCIFICATION MINERALISATION OF CHONDROID MATRIX INFILTRATION BY METAPHYSEAL BLOOD VESSELS

ANATOMY OF PHYSIS

AETIOPATHOGENESIS OF PHYSEAL INJURIES• AETIOLOGY –

RTI FALLS SPORTS PLAYGROUND ACTIVITIES

• BIOMECHANICS COMPRESSION SHEAR TENSION

• FRACTURE CONFIGURATION USUALLY TRANSVERSE

CLASSIFICATION• SALTER-HARRIS (1963) – MOST WIDELY USED:

▫ TYPE 1: TRANVERSE FRACTURE IN HYPERTROPHIC ZONE▫ TYPE 2: ABOVE FRACTURE VEERING OFF INTO

METAPHYSIS TO INCLUDE A TRIANGULAR CHIP OF BONE▫ TYPE 3: FRACTURE SPLITS EPIPHYSIS AND RUNS

TRANVERSELY IN HYPERTROPHIC ZONE ▫ TYPE 4: FRACTURE RUNS LONGITUDINALLY SPLITTING

EPIPHYSIS, PHYSIS & METAPHYSIS▫ TYPE 5: LONGITUDINAL COMPRESSION INJURY

• TYPE 6 ADDED IN 1969 – INJURY TO PERICHONDRAL RING

• COMMONEST IS TYPE 2 (75% OF PHYSEAL INJURIES)• TYPE 5 IS RARE, MAY BE ASSOCIATED WITH

DIAPHYSEAL FRACTURE• TYPES 3 – 6 HAVE HIGH RISK OF GROWTH ARREST

CLASSIFICATION

MANAGEMENT• HISTORY

▫ PAIN/SWELLING AROUND THE CONTIGUOUS JOINT

▫ UPPER LIMB – FUNCTION LIMITED BY PAIN▫ LOWER LIMB – INABILITY TO BEAR WEIGHT

ON AFFECTED LIMB▫ PRECEEDING TRAUMATIC EVENT

• EXAMINATION▫ SWELLING▫ DEFORMITY +/- (MINIMAL IF PRESENT)▫ FOCAL TENDERNESS OVER PHYSIS▫ LIMITED ROM

INVESTIGATION

•X-RAYS WIDENING OF PHYSEAL GAP JOINT INCONGRUITY TILTING OF EPIPHYSIS PRESENCE OF DISPLACEMENT MAKES

DIAGNOSIS MORE OBVIOUS TYPES 5 & 6 INJURIES ARE USUALLY

DIAGNOSED RETROSPECTIVELY

X-RAY FINDINGS IN PHYSEAL INJURY – NORMAL PHYSIS

SALTER HARRIS TYPE 1

SALTER HARRIS TYPE 2

SALTER HARRIS TYPE 2

SALTER HARRIS TYPE 3

SALTER HARRIS TYPE 4

INVESTIGATION

• CT TO VISUALISE FRACTURE ANATOMY IN SEVERELY

COMMINUTED FRACTURES OF EPIPHYSIS AND METAPHYSIS

• MRI MOST ACCURATE FOR FRACTURE ANATOMY IF DONE IN

ACUTE PERIOD IDENTIFIES FORMATION OF BONY BRIDGE EARLIER

THAN X-RAYS

TREATMENT• DEPENDS ON THE FOLLOWING FACTORS

TYPE OF INJURY AGE OF PATIENT FRACTURE STABILITY

• FOR TYPES 1 & 2 CLOSED REDUCTION AND IMMOBILIZATION IN

CAST WILL USUALLY SUFFICE CHECK X-RAY IN 7 – 10 DAYS

• FOR TYPES 3 & 4 REQUIRE ANATOMICAL REALIGNMENT VIA ORIF ORIF CAN BE WITH LAG SCREWS OR KIRSCHNER

WIRES RUNNING PARALLEL TO PHYSIS • FOR TYPES 5 & 6

USUALLY DIAGNOSED RETROSPECTIVELY HOWEVER HIGH INDEX OF SUSPICION MUST BE MAINTAINED IN HIGH RISK INJURIES

COMPLICATIONS• GROWTH ARREST

OCCURS BY DISRUPTION OF PHYSEAL BLOOD SUPPLY OR BONE BRIDGE FORMATION

MAY BE PARTIAL OR COMPLETE

• GROWTH ACCELERATION

• SECONDARY OSTEOARTHRITIS

FOLLOW-UP/REHABILITATION

• TYPES 1 & 2 FRACTURES ARE IMMOBILIZED FOR 3 – 6 WEEKS

• TYPES 3 & 4 FRACTURES ARE IMMOBILIZED FOR 4 – 8 WEEKS

• PATIENT RESUMES UNRESTRICTED PHYSICAL ACTIVITIES 4 – 6 WEEKS FOLLOWING REMOVAL OF IMPLANTS FOR FRACTURES THAT REQUIRED OPERATIVE FIXATION

FOLLOW-UP/REHABILITATION

• FOLLOW-UP CHECK XRAYS ARE DONE AT 6 MONTHS AND 12 MONTHS POST INJURY AND MAY BE EXTENDED UP TO 2 YEARS AS GROWTH ARREST MAY BE DELAYED FOR THAT LONG

PROGNOSIS• AGE OF PATIENT AT TIME OF INJURY

• TYPE OF INJURY

• EXTENT OF CHONDRO-OSSEOUS DISRUPTION

CURRENT TRENDS• GROWTH PLATE INTERPOSITION

FAT BONE WAX SILICON RUBBER POLYMETHYLMETHACRYLATE LABORATORY-DERIVED CHONDROCYTE

ALLOGRAFT

• GENE THERAPY & TISSUE ENGINEERING USE OF RETROVIRUSES TO INTRODUCE GENES

CODING BMP-7 INTO RABBIT PERIOSTEAL MESENCHYMAL CELLS

CONCLUSION

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 OF THE ESSENCE TO FORESTALL FUTURE COMPLICATION.

THANK

YOU

REFERENCES• Nayagam S. Principles of Fractures. In: Solomon L,

Warwick D, Nayagam S. Apley’s System of Orthopaedics & 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. 1965;41:24-31.

• http://emedicine.medscape.com/article/1260663-overview• http://www.wheelessonline.com/ortho/growth_plate_anatomy• http://www.orthobullets.com/pediatrics/4002/physeal-considerations