Fracture in pediatrics

1. Morning five minute presentation
By:- Dr. Abdulshekur Abduljebar (MD, GSR3)

2.  Osseous Anatomy
 Growth Plate Histology
 Epiphyseal injuries
 Classification
 Management Principles
 Management By Type
 Complications
 Treatment Options for Complications
 References

3.  Epiphysis
 Secondary Ossification Center
 The epiphysis is the bone located
between the articular surface and
the physis
 Epiphyseal Plate/Physis
 Metaphysis
 Bone adjacent to the physis on the
opposite side of the epiphysis.
 Diaphysis
 The shaft of the bone

4.  Zones of the Physis
 Germinal Zone
 Minimally active, scattered
chondrocytes
 Proliferative Zone
 Columns of chondrocytes actively
dividing
 Hypertrophic Zone
 Chondrocytes accumulate and
release calcium
 Weakest zone of physis
 Zone of endochondral ossification

5.  These are fractures through a growth
plate
 They are unique to pediatric patients
 Injuries and fractures at the region of
epiphyseal plate carry the bad and serious
complications.
 Physeal fractures account for 15% to
30% of all bony injuries in children and
commonly occur in the tibia.
 Each plate growth rate is different
and disappear at different time.
Location Avg grt (mm/yr) % of bone Ltl grt
Prxl Humerus 7mm 80%
DisaHumerus 2mm 20%
Prxal Radius 1.75mm 25%
Distal Radius 5.25mm 75%
Promal Ulna 5.5mm 80%
Distal Ulna 1.5mm 20%
Prxl Femur 3.5mm 30%
Distal Femur 9mm 70%
Proximl Tibia 6mm 60%
Distal Tibia 3-5mm 40%
Levine RH, Foris LA, Nezwek TA, Waseem M. Salter-Harris
Fractures. StatPearls. StatPearls Publishing; 2021.

6.  Classification of any injury is important
 Salter-Harris is the most widely used classification for epiphyseal injuries
 The classification is based on:-
 Mechanism of injury
 Relationship of # line to the physis
 Method of treatment
 Prognosis
 Other historical classification systems used for epiphyseal injuries
 Poland
 Bergenfeldt
 Aitken
 Peterson

7.  A type 1 fracture is a transverse
fracture through hypertrophic zone of
the physis
 A type II fracture is a fracture through
physis and metaphysis
 A type III fracture is a fracture through
physis and epiphysis.
 Type IV fracture involves all 3
elements of the bone.
 Type V fracture is compression or
crush injury of the epiphyseal plate
with no associated metaphyseal injury.

8.  X-ray:- It is difficult to assess as the physis is radiolucent and the
epiphysis is incompletely ossified.
 What to look for?
1. The physeal widening of the gap
2. Tilting of the epiphysis
3. Repeating X ray within few days
4. Comparing the injured side with the normal
 Sometimes advanced imaging is needed.
 CT Scan
 MRI

9.  Achieve fracture healing with maintenance of growth potential
 Achieve acceptable reduction and alignment
 Maintenance of achieved reduction and alignment
 Limit iatrogenic injury to physis
 Repeated, forceful reduction attempts
 Hardware across physis

10.  Type 1
1. Undisplaced
• P/Exam:- tenderness, swelling at physis
• Normal radiographs
• Casting/immobilization for 2-4 weeks
2. Displaced
• P/Exam:- obvious deformity and pain
• Displacement seen on radiographs
• Reduce efficiently either by closed or open reduction
• internal fixation should be with smooth wires or pins
 Reduces risk of iatrogenic physeal injury

11.  Treatment options for Type 2 include:
• Closed reduction and casting
• Closed reduction and percutaneous
screw or wire fixation
 Screw for larger metaphyseal
fragment
 Wires crossing physis for smaller
metaphyseal fragment

12.  Treatment options for type 3 include:
• Closed reduction and casting
• Closed vs open reduction, screw
fixation
 Screw along width of epiphysis avoiding
physis
 Screws in epiphysis may increase
pressure on adjacent articular cartilage
and are often removed quickly after
fracture healing
 Advanced imaging may be needed to
plan intervention

13.  Treatment for type 4 is surgery
 Anatomic reduction of physis
required to minimize risk of physeal
bar
 CT is crucial and gives 3D
visualization of fracture patterns;
Essential for surgical planning
 Fixation best accomplished from
epiphysis to epiphysis and/or
metaphysis to metaphysis

14.  Treatment for type 5
 It is very difficult initial diagnosis as minimal
displacement
 Late diagnosis after complication of physeal
arrest and deformity has occurred
 Initial nonoperative treatment

15.  When an entire physis arrests
 Longitudinal bone growth ceases completely at that physis
 When only part of physis arrests
 Angular deformity associated with shortening
 Often a much more difficult problem to address
 How to pick?
 Loss of abnormal physeal contour
 Sharply defined connection between epiphysis and metaphysis
 Tapering of Harris growth arrest line towards area of growth arrest
 Obvious angular deformity or segment shortening

16.  Surgical Physeal Arrest Resection
 Removal of arrest with continuation of physeal growth
 Complete Physis Arrest
 Ablation of growth in physis on one or both sides
 Hemi-ephiphysiodesis (angular) vs epiphysiodesis (growth correction of affected
and/or unaffected side)
 Treatment of angular or growth deformities
 Guided growth
 Osteotomies
 Fixators

17. Levine RH, Foris LA, Nezwek TA, Waseem M. Salter-Harris Fractures.
StatPearls. StatPearls Publishing; 2021.