physeal injuries physeal fractures PAEDIATRIC FRACTURES INVOLVING THE PHYSIS. CLASSIFICQTION BASED ON SALTER HARRIS.

1. Discuss the pathology and management
of Physeal fractures
Dr PJ Shindang
Orthopedic Dept
NHA

2. Outline
• Introduction
• Definition
• Epidemiology
• Mechanism of injury
• Anatomy of the physis
• Pathology of the physis
• Classification
• Management
• Resuscitation
• History
• Physical examination
• Investigation
• Treatment
• Complication
• follow up/rehabilitation
• Prognosis
• Current trend
• Conclusion

3. Introduction
• Physeal injury is a disruption in the cartilaginous physis of bones
with or without the involvement of the epiphysis and or
metaphysis.
• The physis is weaker than the surrounding ligament or bone and,
therefore, it is more susceptible to disruption.
• Early commencement of appropriate management is necessary to
prevent complications such as growth arrest and progressive
angular deformities.

4. Epidemiology
• 18% to 30% of pediatric fractures involve the physis
• M: F – 2:1
• Peak age 12- 16yrs in males; 10-12yrs in females
• The upper limbs tend to be more commonly injured than the lower
limbs.
• The most common site is
• Phalanges of the fingers (~40%)
• Distal radius (18%)
• Distal Tibia (11%)
• Distal Fibula (7%)

5. Mechanism of injury
• Etiology
• Road traffic accident
• Falls (FOOSH)
• Sports
• Domestic abuse
• Iatrogenic injury
• Biomechanics
• Compression
• Shear
• Tension
• Fracture configuration usually transverse

6. Anatomy of the physis
• Physis is made up of hyaline cartilage
• Responsible for the longitudinal growth
of bones
• Located at the ends of growing bones
between the epiphyses and
metaphyses.
• It is the weakest part of an immature
bone.
• Normal width; 2 - 4 mm.
• Appears radiolucent on x-ray.
• Gradually ossifies and disappears at the
time of skeletal maturity

7. Anatomy: Histology(4 zones)
• Germinal (resting) zone:
• Contains chondrocytes in the quiescence phase
• Replenishes proliferative zone
• Proliferative zone:
• Contains chondrocytes in mitosis
• Has an abundant blood supply
• Responsible for the increase in bone length
• Hypertrophic (maturation) zone:
• Chondrocytes accumulate glycogen/lipids,
undergo hypertrophy then apoptosis.
• Weakest zone and site of physeal fractures
• Zone of calcification:
• Mineralisation of matrix
• Infiltration by metaphyseal blood vessels

8. Anatomy: Blood supply To physis
• Epiphyseal vessels (supply
germinal layer)
• Metaphyseal vessels
(supply central ¾ of physis)
• Periosteal vessels.

9. Relative contribution to growth by various
physis

10. Classification of physeal injury
• Several classification systems have been described for physeal
fractures.
• Salter-Harris system described in 1963 is the most widely used classification.
• Others
• Poland
• Foucher
• Aitken
• Ogden and Rang modification of Salter-Harris
• Peterson

11. Salter Harris classification
5% 75% 10% 10% <1%
Frequency

12. Salter-Harris 1
• A transverse fracture through the
physis.
• Physeal separation without any
bony injury:
• The growing zone is not injured,
so growth disturbance is
uncommon.
Clinically - point tenderness over
the epiphyseal plate with
swelling.
• X-ray is normal, except for
widening of physeal plate

13. Salter-Harris 2
• The most common type
• Fracture occurs through the
physis and metaphysis;
epiphysis is spared.
• The metaphyseal fragment is
sometimes called the
'Thurston-holland fragment’.
• Limited growth disturbance;
may cause minimal shortening.

14. Salter-Harris 3
• Fracture through the physis
and epiphysis
• Prone to chronic disability,
because it extends into the
articular surface of the bone.
• However, rarely results in
significant deformity.

15. Salter-Harris 4
• Involves the epiphysis, physis,
and metaphysis.
• An intra-articular fracture;
thus, it can result in chronic
disability.
• Interfere with the growing
layer of cartilage cells. Leading
to premature focal fusion with
deformity.
• Frequent around the medial
malleolus and lateral condylar.

16. Salter-Harris 5
• Compression or crush injury of
the physis, with no associated
epiphyseal or metaphyseal
fracture
• A typical history of an axial load
injury.
• X-ray at the time of injury shows
no abnormality. Usually
diagnosed retrospectively.
(Minimum 6 months)
• worst prognosis

17. Rare types of Salter-Harris
• Include the following:
• Type VI - Injury to the perichondral structures
• Type VII - Isolated injury to the epiphyseal plate
• Type VIII - Isolated injury to the metaphysis, with a potential
injury related to endochondral ossification
• Type IX - Injury to the periosteum that may interfere with
membranous growth

19. Management
• Resuscitation using the ATLS protocol
• History:
• Pain/swelling around the affected joint.
• Upper limb - function limited by pain.
• Lower limb - inability to bear weight on the affected limb.
• History of trauma.
• On examination:
• Swelling
• Deformity +/- (minimal if present)
• Focal tenderness over physis
• Limited range of motion of the joint

20. Imaging
• Xrays
• First line imaging approach
• Cost effective, available
• Features
• Physis appears radiolucent
• Physeal widening
• Epiphyseal displacement of physis,
fragmentaion
• CT Scan
• Offers more detailed analysis
than radiographs
• Further detail on fracture extent
and alignment esspecially when
exvaluating intra-articular
fractures
• unable to directly image the
physis

21. Imaging
• MRI
• Can demonstrate location ,
morphology, presise size of
physeal injury
• Show subtle physeal widening
and irregularities
• Metaphyseal intrusion of physeal
cartillage

22. Diff diagnosis
• ligamentous sprain
• A ligamentous sprain may have a similar presentation and the patient may be
unable to bear weight. However, the patient should not have bony point
tenderness.
• Acute osteomyelitis
• A patient who has osteomyelitis may have other symptoms such as fever,
swelling, and elevated ESR, FBC, or C-reactive protein.
• Torus fracture.

23. Principles: treatment
• Displaced physeal fracture should be reduced with sustained traction and
gentle manipulation.
• Forceful reduction maneuvers, repeated attempts of reduction
or insertion of instruments into the physis to manipulate fracture fragments
should be avoided.
• Intra-articular displaced physeal fractures (SH 3 and 4) should be reduced
anatomically and stabilized by internal fixation, irrespective of their time of
presentation.
• Implants used for internal fixation should be placed in a physical-respecting
manner.

24. Salter Harris type 1
• non-displaced SH1
• Non-operative with
Casting/immobilizati
on
•
• displaced SH1
• Closed reduction and
casting favored
• Reduces risk of
iatrogenic physeal
injury

25. Salter-Harris type 2
• Nonoperative
• indications
• non-displaced (< 2mm) fractures
• stable Salter-Harris type II fractures
• Closed reduction and
Immobilization in cast for 6 weeks
• Operative
• Indication
• unstable Salter-Harris type II fractures
• Re-displacement following closed
treatment
• Closed reduction and
percutaneous screw or wire
fixation Screw for larger
metaphyseal fragment

26. Salter Harris 2
• ORIF
• crossed smooth pins
• Trans-physeal if Salter-Harris type II with small Thurston-Holland fragment
• cannulated compression screws parallel to physis for Salter-Harris type II with
large Thurston-Holland fragment
• POST OP
• cast in for 4-6 weeks

27. Salter Harris type 3 & 4
• Non operative
• Indication:
• < 2mm displacement
• Cast applied for 6-8 weeks
• Follow-up early with radiographs to assess for displacement

28. Salter Harris type 3 & 4
• Operative fixation
• indications
• Irreducible fractures usually due to diaphyseal periosteal flap blocking reduction
• Displaced (> 2mm) type IV fractures
• Vascular injury
• ORIF with screws or Kwire
• ORIF with plates and screws

29. SH type 3

30. Salter Harris type 5
Crush injury to entire physis
• Very difficult initial diagnosis as minimal displacement
• Initial nonoperative treatment
• Late diagnosis after complication of physeal arrest and deformity has
occurred

31. Follow-up and Rehabilitation
• SH 1 and 2 should be immobilized for 3–6 weeks
• SH 3 and 4 should be immobilized for 4–8 weeks.
• A patient can start unrestricted physical activities only after 4–6
weeks of implant removal.
• Follow-up radiographs are done at 6 months and 12 months
(which may be done at 2 years as well).

32. Prognosis
• It is multifactorial.
• initial fracture type
• location, time to treatment
• quality of reduction, and subsequent orthopedic follow-up.
• Generally, the prognosis for pediatric physeal fractures is good.
Most cases heal with good alignment with closed treatment.
• Inappropriate initial management increases the risk of growth
arrest, malalignment, and lifelong difficulty for the patient

33. Recent advances
• Use of gene therapy and tissue engineering to regenerate
articular cartilage
• Growth plate transplantations
• Physis distractions
• Some studies are being conducted to study the role of physeal distraction in
stimulating physis in physeal fractures.

34. Complications
• Growth arrest
• Malunion
• Iatrogenic injury of physis
• Joint stiffness
• Secondary posttraumatic arthritis of the joint can occur.
• Hardware-related complications
• Compartment syndrome
• Neurovascular complication

35. 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 essential in preventing
complications

36. Thank you

37. References
• Singh A, Mahajan P, Ruffin J, Galwankar S, Kirkland C. Approach to Suspected
Physeal Fractures in the Emergency Department. J Emerg Trauma Shock.
2021 Oct 1;14(4):222.
• Nayagam S. Principles of Fractures. In: Solomon L, Warwick D, Nayagam S.
Apley's System of Orthopedics & 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.
• Google images