7 physeal injuries  prinicples of mangement kaye
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7 physeal injuries prinicples of mangement kaye

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  • 1. Physeal injuries Principles of management
  • 2. The StatisticsAverage of six combined series= 21% • Phalanges 37% • Distal Radius 18% • Distal Tibia 11% • Distal Fibula 7% • Metacarpal 6% Distal Femur is < 2%
  • 3. Classifications- Are They Helpful ?? The Salter- Harris Classification Has Stood The Test Of Time!!Descriptive more the best for prognosis OGDEN Two than Prognostic PETERSON: Probably Complicated
  • 4. Major Contribution of Peterson’s Types Peterson Type I 19 mo. post- fracture Cast Removal Beware!! Callous and fracture lines Extend to the physis
  • 5. Unique Physeal Anatomy Blood supply Growth Maturation Transformation Ossification Remodeling
  • 6. Blood Supply
  • 7. Dangerous Side
  • 8. Safe Side
  • 9. Safe Side -Effects
  • 10. Factors Contributing to Physeal Failure 1.Torsion > Tension 2.Weakened Perichondral Ring Most Occur at End of Growth 3.Increased Skeletal Mass -- KE=MV2
  • 11. SHEAR Distal FemurThus high rate of growth arrest in this area
  • 12. Physeal Arrest Basic Pathology Resting Cells Can beAnywhereFracture Line Through Zone of Hypertrophy
  • 13. Basic Physeal BarPathology Cortical Bone FromSclerotic Bone On X-Ray Tension Forces
  • 14. Patterns of Arrest (Peterson)
  • 15. CentralAsymmetrical Harris- Park Migration
  • 16. CentralPerirheral Physis Remains Intact
  • 17. Central
  • 18. Peripheral Ipsilateral distal femoral Ipsilateral proximal tibial
  • 19. LinearDOI 1 Yr. P.I. Asymmetrical Harris- Park Migration
  • 20. LinearUsually associated with Type IV S-H Injuries
  • 21. Making the diagnosis X- Ray criteria Physeal Narrowing Sclerotic Bone Absent Harris-Park Migration Angular Deformity
  • 22. Good polytomography can be useful C-T ScansOther imaging studies more helpful
  • 23. M R Imaging TheGold Standard
  • 24. M R ImagingMay be too sensitive
  • 25. Location Affects:1. Type of Deformity2. Surgical Approach3. Success Of Resection
  • 26. Location affects Deformity• Central Volcano Effect• Peripheral Severe Angulation• Longitudinal Angulation Shortening
  • 27. Location affects Success of Resection Central Physis-Bridge-Physis Linear Symetrical Growth Peripheral Physis-Bridge Asymetrical Growth
  • 28. Expected resultsNot 100% Successful Three Series = 64 Cases Excellent: 23 (36%) Good: 16 (25%) Fair/Poor: 24 (24%)
  • 29. Factors Contributing To Success 1. Size 1. 30% 2. Age 2. Younger The Better > 2 yrs Growth Left 3. Duration Since Injury 3. > 2 yrs---Poor 4. Etiology Infection, 4. Trauma= Good Irradiation= Poor
  • 30. Will Resection Help ?1. Ideal Candidate 2.Poor Candidate1. Young 1. Older2. Small Bridge 2. Large Bridge3. Trauma Origin 3. Infectious or4. Recent Onset Irradiation Origin5. Central or Linear 4. Peripheral Bridge Bridge
  • 31. Location affects Surgical Approach Central Large Metaphyseal Window
  • 32. Peripheral Metaphysis Direct Approach PhysisEpiphysis
  • 33. Location affects Surgical Approach Linear Bridge Osseous Tunnel Cortex to Cortex
  • 34. Technical Points Location Of Bridge
  • 35. Must Be Perpendicular To The Physis Need to see 3600
  • 36. Not Perpendicular To The Physis Easier, less vital structures
  • 37. Close to Perpendicular to The Physis OK More dangerous structures
  • 38. To Serve As A Barrier To Bridge Reformation
  • 39. Peripheral Bridge
  • 40. Physis now inSclerotic Grey physis bridge profile nowremains visible
  • 41. Metal marker for growth Cranioplast Cranioplast spacer spacer
  • 42. Technical Points Use Dental Mirror to Visualize Proximal Physeal Border Can use an arthroscope as well
  • 43. Technical Points Remove All Sclerotic Bone
  • 44. Interposed MaterialAutogenous Fat Cranioplast( Methymethacrolate with out barium) Silastic (no longer available in US)
  • 45. Illustrative Cases D P 6 y.o.Injury x-ray Longitudinal bridgeS-H IV injury 1 yr. P. I.
  • 46. D.P. Cont. Osseous 4 mo. p.o. bridge resection bridge Silastic Insertion Silastic spacer Migration of growth arrest lines begins
  • 47. D.P. Cont. 3 yrs. P.O.Despite Proximal Migration of Silastic, Normal Growth Re-established
  • 48. Alternatives to resection 1.Physeal bar Poorly Defined Bridge 2.Angulation 11 y.o. 5 yrs p.i. Shortening Problems ? Close to End of Growth Solution ??
  • 49. Physeal Distraction
  • 50. Alignment corrected Will It Grow?
  • 51. 2 years post op.Growth arrest lines havemigrated 2 cm.
  • 52. What If The Arrest Recurs ? OK to Re-Resect if Criteria Met
  • 53. 3 y.o. Injury at 18 m.o. Central Bridge
  • 54. Following three resections over 8 yearsRadio-Ulnar Relationships Re-established Normal Side
  • 55. So What Have Learned ?? To Have Good Results One Needs to Have• Knowledge of the • How To Effectively Physeal Anatomy Pre-Operative Plan• Understanding of • Technical Aspects of Physeal Arrest The Resection Proceedure Patterns • Alternatives to• What Cases Can Resection Benefit From • How to Manage Resection Recurrences
  • 56. Thank you