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1. PHYSEAL INJURIES
Presenter :- Dr. Danish Rauf
l

2. Introduction:-
The physis or the growth cartilage is a
specialized layer of tissue unique to children
which provides for both longitudinal and
latitudinal growth of bone located between
the epiphysis and metaphysis.
Appears radiolucent on X-ray.
Injuries to the physis can cause cessation
of growth and resultant angular deformities.

3. Prevalence – 10 – 30 % of all childhood fractures
• AGE :- INFANCY & 10-12 yrs of age.
• Males > Females
• Common sites :- Upper extremity > Lower Extremity
-Phalanges are the most common site 37%,
distal radius 18% and
distal tibia 10%, other sites including distal femur ,proximal
tibia/fibula.

4. Epiphyseal blood supply according to Dale &
Harris
• TYPE A: Type A epiphyses are nearly completely covered by
articular cartilage. Therefore, most of the blood supply to the
epiphysis must enter from the perichondrium in a distal to proximal
direction . This blood supply is susceptible to disruption by
epiphyseal separation. The proximal femur and proximal humerus
are examples of type A epiphyses.
• TYPE B: Type B epiphyses are only partially covered by articular
cartilage. Such epiphyses are more resistant to blood supply
impairment by epiphyseal separation. The distal femur, proximal
and distal tibia, and distal radius are clinical examples of type B
epiphyses.

5. Etiology:-
• The most frequent mechanism of injury is fracture.
• Other mechanisms of injuries to the physis include :-
infection [Septic arthritis or metaphyseal osteomyelitis]
tumor
cysts
vascular insult
Repetitive stress injury [Gymnasts]
Irradiation
Neural involvement [in polio & Cerebral palsy]
iatrogenic causes [surgical insults]
Metabolic abnormalities [vit C def]

6. Clinical Presentation:-
• HISTORY :-
- Pain / Swelling around the affected joint.
- UPPER LIMB  Function limited by pain.
- LOWER LIMB  Inability to bear weight.
- History of trauma
• ON EXAMINATION :-
- swelling +
- Deformity +/- (minimal if present)
- Focal tenderness over physis +
- Limited ROM

7. Salter and Harris classification:-

8. Type 1
• Salter–Harris type I injuries are characterized by a transphyseal
plane of injury, with no bony fracture line through either the
metaphysis or the epiphysis.
• type I fractures occurred most frequently in the phalanges,
metacarpals, distal tibia, and distal ulna.

10. Type 2
• Type II injuries have physeal and metaphyseal components;
the fracture line exits the physis to enter the metaphysis (i.e., away
from the germinal and proliferative layers) at one margin. Similar to
type I injuries, these fractures should have a limited propensity to
growth disturbances.

12. Type 3
There are two fracture fragments:
a small fragment consisting of a portion of the epiphysis and physis, and
a large fragment consisting the remaining epiphysis and long bone.
. higher risk of subsequent growth disturbance.
• Anatomic reduction (usually open reduction) and stabilization are
required

14. Type 4
• Type IV fractures are effectively vertical shear fractures,
extending from the articular surface to the metaphysis.
• These fractures are important because
• they disrupt the articular surface,
• violate all the physeal layers in crossing from the epiphysis to
the metaphysis
• may result in metaphyseal–epiphyseal cross union which
almost invariably results in subsequent growth disturbance.
frequent around the medial malleolus ,lateral condyle of
humerus.

16. • In type 4, treatment principles
include obtaining
• anatomic reduction
• adequate stabilization

17. Type 5
.
• Mechanism of this injury is by
longitudinal compression, which
damages the germinal layer of
physeal cells.
• The prognosis for growth is poor, and
there is a likelihood of premature
growth cessation

19. General Principle of Treatment in Acute Physeal Injuries :-
• All reductions must be done with utmost gentleness to prevent further
damage to the physis. Direct pressure on the physis by instruments
must be avoided during open reduction.
• Microvascular disruption also plays a significant role to produce growth
arrest.so,rather than trying multiple reductions ,more deformity after
the # can be accepted, if the potential to remodel is high.
• Because of the intra-articular component, displaced type III and IV
injuries must be reduced regardless of the time that has elapsed since
the injury.
• Percutaneous pinning is often sufficient to stabilize the fragment.
Cancellous cannulated screws of appropriate size may be used. Joystick
method may be used to reduce the type III and IV fractures, to avoid
open reduction (if possible).

20. • Reduction:-
• The reduction maneuver must be performed as early as possible to
prevent damage to the physis in the process of reduction.
• Each day of delay makes the reduction more difficult, especially in
infants and younger child.

21. Methods of Reduction:-
• Type I and II:
• Injuries can be managed by closed reduction, as these cause less damage
to the physis.
• Type III and IV:
• Might need open reduction to obtain anatomical reduction.

22. • Caution must always be exercised during open
reductions to prevent injury to the circulation
entering the epiphysis.
• In Infants and newborns—any swelling near a
joint, growth plate injury should be inspected
unless otherwise proved by CT scans and MRI.
• The most desirable internal fixation is epiphysis
to epiphysis and metaphysis to metaphysis if
possible, especially in young children.

25. • Period of immobilization and follow-up:
• Fracture is immobilized for at least 3–4 weeks.
• No activities or play is allowed for at least 4–6 weeks after removal
of cast.
• Follow-up will be needed for at least 1 yr to 2 yrs after the treatment,
and comparative radiographs of the contralateral limb should be
taken

26. Complications of Physeal Injuries:-
•Growth Acceleration
•Malunion
•Nonunion
•Growth Arrest

27. •Osteomyelitis
•Neurological Complications
Median nerve compression in unreduced type II injury of distal radial
epiphysis is known.
•Vascular Complications
The popliteal artery is at risk in the physeal injuries around the knee
following hyperextension injuries. Unrecognize damage or disruptions of
the artery might lead to gangrene.
•Avascular Necrosis of Epiphysis
Completely displaced type I physeal injuries of the femoral and radial
head carry a high-risk of this complication. It results in cessation of growth.

28. THANK YOU