epihyseal injuries Rockwood

1. EPIPHYSEAL INJURIES
MODERATOR- Dr. MAHESH
PRESENTER- Dr. KARTHIK M V

2. INTRODUCTION
• One of the unique aspect of paediatric orthopaedics is the presence
of physis (or growth plate) providing longitudinal growth of children’s
long bones.
• Physeal fractures make up to 15-30% of all long bone fractures in
children.

3. Epiphysis (EPI- upon, PHYSIS- Growth)
• It refers to the bulbous end of a long bone
incorporating the growth plate (or) physis and
secondary ossification center
• It takes part in the formation of joints & also acts as
an attachment for muscles and tendons.

4. EPIPHYSIS
• The ends of a long bone which ossify from secondary centers are
called epiphyses.
• Lies B/W Physis & Articular cartilage
• Usually Intra articular (joint formation)
• The periosteum in intra articular layer lacks Cambium layer that has
totipotent cell rests.

5. • Types of Epiphysis
1. Pressure epiphysis – transmission of the weight
Ex-head of femur
2. Traction epiphysis – provides attachment to tendons which exerts a
traction on the epiphysis. Ex- trochanters of femur.
3. Atavistic epiphysis – phylogenetically an independent bone, which
fuses to another bone. Ex-coracoid process of scapula.
4. Aberrant epiphysis – not always present. Ex- head of the 1st
metacarpal and base of other metacarpal.

7. Physeal anatomy
• During growth, the epiphyseal and metaphyseal are separated by the
cartilaginous physis, which is the major contributor to longitudinal growth
of the bone.
• The long bones has physis at both the ends.
• The smaller tubular bones has physis at only one end.
• At birth, with the exception of the distal femur and occasionally the
proximal tibia, all of the epiphyses which are mentioned above are purely
cartilaginous

8. • PHYSIS LAYERS
Reserve Zone :- cells store lipids, glycogen
Proliferative Zone :- proliferation of Chondrocytes
Hypertrophic Zone :- a) Maturation zone
b) Degenerative zone
c) zone of provisional Calcification
Primary Spongiosa
Secondary Spongiosa

10. • Zone (or groove) of Ranvier
- A triangular microscopic structure at the periphery of the, containing
fibroblasts, chondroblasts, and osteoblasts.
- It is responsible for peripheral growth of the physis.
• Perichondral ring of LaCroix
- Fibrous structure overlying the zone of Ranvier, connecting the
metaphyseal periosteum and cartilaginous epiphysis
- Mechanical function of stabilizing the epiphysis to the metaphysis

11. Blood supply
• Epiphyseal vessels – supply the germinal layer of physis
• Periosteal vessels- nourishes the perichondrial ring & peripheral part
of physis
• Nutrient artery- supplies majority of metaphyseal side of physis.

12. DALE & HARRIS Classification of epiphyseal
blood supply

13. Etiology of physeal injuries
• FRACTURE (most frequent mechanism of injury)
• Infection
• Tumour
• Repetitive stress
• Vascular insult
• Miscellaneous

14. Infection
• Long bone osteomyelitis or septic arthritis can cause physeal damage
resulting in either physeal growth disturbance or frank growth arrest.
Tumour
• Benign tumors and tumor-like conditions can result in destruction of
all or part of a physis.
• Growth disturbance as a consequence of physeal damage from these
disorders generally cannot be corrected by surgical physeal arrest
resection

15. Repetitive stress
• Repetitious physical activities in skeletally immature individuals
• most common location are
- distal radius or ulna, as seen in competitive gymnasts
- proximal tibia, as in running and kicking sports such as soccer
- proximal humerus, as in baseball pitchers
• managed by rest, judicious resumption of activities, longitudinal
observation to monitor for potential physeal growth disturbance.

16. • Miscellaneous
- Irradiation
- Electric shocks
- Thermal injuries
- Vascular insult

17. Physeal Biomechanics
• Growth in length of bone occurs by proliferation of chondrocytes in
the epiphyseal plate
• At same time, chondrocytes in diaphyseal site of plate hypertrophy,
matrix become calcified and cells die.
• Because of the rates of these opposing forces namely
PROLIFERATION and DESTRUCTION are approximately equal
• The epiphyseal plate doesn’t change in thickness but gets displaced
away from the diaphysis, resulting in bone growth.

18. • Within physiological range, increasing tension or compression can
accelerate growth, but beyond physiological limits growth may be
significantly decreased or even stopped.
• These principles are often referred to HUETER-VOLKMANN LAW

19. SALTER-HARRIS CLASSIFICATION

21. Salter-Harris 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.
• Produced by shearing force
• Radiographs of undisplaced type I physeal fractures, therefore,
are normal except for associated soft tissue swelling
• Diagnosed by MRI and USG
• Minimal growth disturbance

23. SALTER HARRIS TYPE 2
• Physeal and metaphyseal components
• Line of separation extends along epiphyseal
plate to a variable distance & then out through
a diaphysis.
• Producing a triangular shaped metaphyseal
fragment called THURSTON HOLLAND SIGN
• Growth disturbance is uncommon

25. SALTER HARRIS TYPE 3
• Fracture line begins from the epiphysis, as fracture through
articular surface, and extend vertically through physis.
• Articular surfaces are involved
• Fracture involves germinal and proliferative areas of growth
plate
• High velocity or compressive injuries
• Risk of subsequent growth disturbance
• Partial growth arrest when the physis is not anatomically
reduced
• Prognosis is good- anatomical alignment of physis and no
impaired blood supply to separated epiphyseal fragment

27. SALTER HARRIS TYPE 4
• Fracture through the metaphysis, physis and epiphysis
• With possible joint incongruity
• M/c medial malleoli, lateral condylar fractures of
humerus
• Requires open reduction and internal fixation
• Growth disturbance is present

29. SALTER HARRIS TYPE 5
• Compression fracture of physis producing
permanent damage
• Prognosis is poor as premature growth arrest
occurs

30. Polland Classification

31. Aitken classification

32. Peterson Classification

34. Evaluation of physeal fractures
• Plain radiography – preffered modality for initial assessment
• CT scans - provides excellent definition for bony anatomy, help in
assessing joint congruity, complex or communited fractures.
• Ultrasound – occasionally used in infants for diagnostic purpose to
identify epiphyseal separation in infants
• MRI – excellent for soft tissue lesions and minor soft tissue injuries

35. TREATMENT
• Immediate Primary anatomical reduction
- Perform gently
- Prevent damage to physeal cartilage
- Avoid forcefull and repeated manipulation
- Avoid putting direct pressure over physis using instruments
- Must be performed early, delay everyday makes reduction more
difficult

36. • SALTER HARRIS TYPE 1
- Closed reduction whenever possible
- Internal fixation when closed reduction not possible
- Immobilization with cast for 3-4 weeks
• SALTER HARRIS TYPE 2
- Usually reduces easily with closed reduction
- Internal fixation is not necessary

39. • SALTER HARRIS TYPE 4
- Open reduction and internal fixation is usually required
- Minimally displaced- closed reduction with percutaneous pinning
- Major displacement- ORIF
• PETERSON TYPE 1
- Closed reduction and casting
- Immobilize for 3 weeks
- Follow up to ensure normal growth
• PETERSON TYPE 6
- Initial debridement & wound packing with secondary closure, skin
graft
- Regular follow up till maturity as shortening and deformity is common

40. Complication of physeal injuries
• Growth disturbances
- Angular deformity
- Limb length inequality
- Epiphyseal distortion
• Neurovascular compromise
• Non union, malunion
• Avascular necrosis
• Physeal arrest

41. • Physeal arrest
- Partial arrest can cause angular deformity, joint distortion, limb length
inequality
- Complete arrest
• Bone bridge
- Bridge of bone forms from metaphysis to epiphysis crossing physis
- Tethers the growth

44. • Central arrest
- A central arrest is surrounded by a perimeter of normal physis, like an
island within the remaining physis.
• Peripheral arrest
- A peripheral arrest is located at the perimeter of the affected physis.
- Progressive angular deformity and variable shortening
• Linear arrest
- A linear arrest is a “through-and-through” lesion
- specifically, the affected area starts at the perimeter of the physis and
extends centrally with normal physis on either side of the affected area.

46. General principles of fracture treatment in childrens
• Don’t think that all fractures in children will remodel completely that
adequate reduction is unnecessary
• If open reduction is necessary, reposition the fragments as
anatomically as possible, or it may lead joint incongruity.
• Use fixation that can be easily removed
• Use smooth rather than threaded pins
• Avoid pin penetration into joints
• Try not to cross the physis, but rather parallel into the epiphysis

47. • Avoid unnecessary drill holes
• Immobilize the noncompliant child adequately
• Warn the parents about complications
- Angular deformity
- Limb length inequality
- Avascular necrosis
• Use of adequate fixation but keeping in mind that early mobilization is
necessary

48. Prevention of Arrest formation
• Damaged, exposed physis should be protected by immediate fat
grafting
• Used in open reduction of medial malleoli fractures, where
comminution or partial arrest is identified after resection.

49. Partial physis arrest resection
• Surgical resection of a physeal arrest (physiolysis or epiphysiolysis)
restoring normal growth of the affected physis is the ideal treatment
for this condition.
• Principle is to remove the bony tether between the metaphysis and
the physis
• Fill the physeal defect with a bone reformation retardant,
anticipating that the residual healthy physis will resume normal
longitudinal growth

50. • Physeal distraction
- External fixator spanning the arrest and gradual distraction until the
arrest separates
- Angular deformity correction and lengthening can be accomplished
after separation as well.
• Repeated Osteotomies during Growth
- correct angular deformity associated with physeal arrests is corrective
osteotomy in the adjacent metaphysis

51. PHYSEAL ARREST RESECTION
• ETIOLOGY
- Arrest caused by trauma has good prognosis
- Secondary to infection, tumours, irradiation has bad prognosis.
• ANATOMIC TYPE
- Central and linear arrests are more likely to demonstrate resumption of
growth
• EXTENT OF ARREST
- > 25 % of affected area of physis- unlikely to grow after resection

52. • Pre operative planning
- Sagittal and coronal CT
- MRI identifying and quantifying physeal arrests
- CT images shows precise delineation of bony margins, and cheaper
than MRI
• Minimize Trauma
- Central lesions should be approached through either metaphyseal
window or intramedullary canal
- Peripheral lesions approached directly by resecting overlying
periosteum
- Arthroscope can be inserted into metaphyseal cavity circumferential
view of area of resection
- High speed burr to and fro motion

54. Prevent bone bridge formation
• A bone growth retardant or spacer material should be placed in the
cavity created after resection to prevent bone bridge formation
• 4 compounds used are
- Autogenous fat
- Methylmethacrylate
- Silicon rubber
- Autogenous cartilage

55. Marker Implantation
• Metallic markers should be implanted in the epiphysis and metaphysis
at the time of arrest resection to allow reasonably accurate
estimation of the amount of longitudinal growth
• Initially resumption of growth may not occur despite adequate
resection and good clinical indication
• Perhaps resumption of normal or accelerated growth may be
followed by late deceleration or cessation of growth.

58. Management of partial physeal arrest
• Shoe lift – LLD less than 2.5cm and no angular deformity
• Wedge osteotomy to correct angular deformity
• Lengthening of ipsilateral bone
• Shortening of contralateral bone
• Excision of physeal bar and insertion of interposition material
• Breaking of physeal bar by distraction.

59. Management of Complete arrest
• Shoe lift ( for limb length discrepancy)
• Physeal arrest – contralateral bone
• Ipsilateral bone lengthening
• Contralateral bone shortening

60. THANK YOU