detail presentation of physeal anatomy , classification , and treatment

1. Epiphyseal Injuries
Classification and
Management
MODERATOR – DR RATNAKAR AMBADE
PRESENTER - DR SIDDHARTH , DR KEVIN

2. Physeal Injuries Introduction
Physeal Injuries represent 15%-30% of all fractures in children
Incidence varies with Age but reported peak in Adolescence
Physeal Injuries involving the Phalanges fractures have been reported to account for over 30% of
all Physeal fractures
Physeal injuries common but deformity is rare .
Occur only in 1%-10%

3. Physeal Anatomy
Physis also referred to as epiphyseal plate / epiphyseal growth plate /epiphyseal cartilage
Physis is a made of Hyaline cartilage located at the end of growing bones between the epiphyses and
metaphysis .
Physis is responsible for the growth of bones .
Physis divided into 4 zones histologically
1. Germinal ( resting) zone
2. Proliferative zone
3. Hypertrophic ( Maturation) zone
4. Zone of Calcification

4. Zone of Ranvier –wedge shaped
group of germinal cells that is
continuous with the physis and
contributes to circumferential
growth of the physis
Consists three type of cells
-Osteoblasts :forms bony portion
of the perichondral at the
metaphysis
-Chondrocytes : contributes to
circumferential growth
- Fibroblasts circumscribe the zone
and anchor it to perichondrium
above and below the growth plate
The perichondral ring of Lacroix
is fibrous structure that
continuous with the fibroblasts
of the zone of ranvier and the
periosteum of the metaphysis
- Provides strong mechanical
support for the bone cartilage
junction of growth plate

5. Physis divided in 4 zones
1. Resting or germinal zone abundant extracellular matrix , and due
2. Proliferative zone mechanical integrity response to shear
forces
3. Zone of hypertrophy – contain less extracellular matrix and it is weakest area of physis , most
injuries occur in this area
4. Zone of enchondral ossification –continuous with metaphysis ,

6. The fact that fracture through the physis is through the hypertrophic zone implies that after
most injuries but due to intact of germinal layer of physis to the epiphysis which provide blood
supply of germinal layer help to development of a bone bridge across the injured physis and
normal growth should resume after an injury

7. Epiphseal blood supply
Two type defined by Dale and Harris
1. Type A – entirely covered by articular
cartilage , in these epiphyses the blood
supply enters the periphery after
traversing the metaphysis and may be
damaged on separation of the metaphysis
and epiphysis , only present in proximal
femur and proximal radius
2. Type B – Only partially covered by articular
cartilage , blood supply enters from the
epiphyseal side and is protected from
vascular injury during separation

8. CLASSIFICATION OF PHYSEAL INJURIES
SALTER HARRIS CLASSIFICATION ( 1963)
-Most widely used
Poland( 1898)
Aitken (1936 )
Petersons (1970 )

10. SALTER HARRIS CLASSFICATION
TYPE 1
-Separation of the epiphysis from metaphysis through the
physis
-rare and seen in most frequently in infants or in pathologic
fracture , such those secondary to rickets or scurvy
-as the germinal layer remains with the epiphysis , growth is
not disturbed , if blood supply is interrupted as frequently
occurs with traumatic separation of proximal femoral
epiphysis .

11. Salter-Harris Type I fracture of the distal tibia. The fracture is in the plane of the physis

12. TYPE -2
-The fracture extends along the hypertrophic zone of physis and at
some point exits through the metaphysis .
-The epiphyseal fragment contains the entire germinal layer as
well as a metaphyseal fragment of varying size , this fragment
known as
“Thurston Holland Sign “.
-growth disturbance is rare because the germinal layer remains
intact.

13. the fracture is from the lateral metaphysis to the medial physis . The resulting
metaphyseal Thurston-Holland fragment

14. TYPE 3
-The fracture extends along the hypertrophic zone until it
exits through the epiphysis
-Fractures cross the germinal layer and are usually
intraarticular
-If displaced , require an anatomic reduction by open
method

15. Salter-Harris Type III facture of the distal tibia. The fracture is intraarticular,
exiting through the epiphysis

16. Type 4
-injuries extend from the metaphysis across the physis and
into the epiphysis , thus the fractures crosses the germinal
layer of the physis and usually extends into a joint
Three components
1. Vertical component through the epiphysis
2. Horizontal component through the growth plate
3. Oblique component through the metaphysis
- In this type it is important to achieve an anatomic reduction
to prevent osseous bridging across the physis and restore the
articular surface

17. Salter-Harris Type IV fracture -traveling from the medial metaphysis to exit through the
epiphysis. The injury at the distal fibula is a Salter-Harris Type I fracture

18. TYPE -5
-In this type crushing to the physis from a pure compression force
disrupting germinal matrix , hypertrophic region and vascular
supply
-force is transmitted through the epiphysis and physis
-Rarest type
-Poor prognosis with an almost universal growth disturbance .
-- it can be radiographically occult , and radiograph may appear
normal ,
-This may be diagnosed retrospectively once growth arrest has
occurred
-Symptomatic child with a normal radiograph

19. Salter-Harris Type V fracture or crush injury to the physis of the proximal radius. The smaller
arrows show the path of the fracture while the larger arrows represent the compressive force
causing the injury.

20. There is type 6 physeal injury in
which injury to the perichondral
ring which is found by RANG
(salter’s colleague)

21. Other rare type
Type 7: isolated injury to the epiphyseal plate
Type 8 : isolated injury to the metaphysis, with a potential injury related to endochondral
ossification
•Type 9: injury to the periosteum that may interfere with membranous growth

22. Management of physeal Injuries
Goal in treating physeal fractures is to achieve reduction and maintain an acceptable reduction
without affecting the germinal layer of physis .
Factors must be considered when assessing a nonanatomic reduction
- amount of residual deformity
-Location of injury
-Age of the patient
-Amount of time since the injury
Location of injury and patient age determining factors in the bone remodeling potential

23. Salter-Harris types I and II fractures can be treated
nonoperatively With cast application , immobilization
Salter-Harris types III and IV fractures usually require
operative intervention
Most commonly open reduction and internal fixation because
of the intraarticular nature of the fracture and the potential for
posttraumatic arthritis with nonanatomic reduction.

24. Salter Harris type 1
This fracture may be treated nonoperatively if undisplaced and stable.
If displaced, anatomical reduction of the growth plate should be attempted. If further
stability is needed, K-wire fixation may be necessary.

25. Salter Harris type 2
Conservative treatment (immobilization without reduction or
fixation) is only recommended for minimally displaced, stable
factures (type 2). The amount of angulation that can be
accepted depends on the modeling capacity and therefore the
age of the child.

26. Salter Harris type 3
A simple SH III fracture may be fixed with one or two
screws through the epiphysis, parallel to the growth plate.
The main goals of treatment of these fractures are:
•Restore joint congruity
•Uncomplicated healing
•No secondary displacement
•Minimize injury to the growth plate

27. Multifragmentary fractures in young children Multifragmentary Fractures in older
children

28. Salter Harris type 4
A simple SH IV fracture may be fixed with a screw
through the epiphysis and one or two screws
through the metaphysis, each parallel to the growth
plate.
The main goals of treatment of these fractures are:
•Restore joint congruity
•Restore growth plate anatomy
•Reduce the metaphyseal fracture

29. Displaced fracture
Undisplaced fracture

30. multi fragmentary Severely unstable
fracture or in older children with
closed/closing growth plate

31. Implants crossing the physis should be avoided when possible
and when used should be smooth and the smallest diameter
possible, and should be removed as soon as the fracture stable

32. Most common complication in physeal fractures is growth arrest , which can result into a
shortening or angular deformity of both limb depending upon the size and location of the
growth arrest .
Growth arrest most commonly results from a bony bar that crosses the physis
Distal femoral and Distal tibial physeal fractures have higher rate of growth arrest and deformity
than others
Growth arrest can be complete or partial ( incomplete )
-: complete – premature closure of the entire growth plate
-: Partial – premature closure of the partial growth plate

33. Partial growth arrests can further classified
based on their anatomical position
1.Central – surrounded by a normal physis
-can cause tenting and or limb length
discrepancy
- if eccentric leads to angulation
2.Peripheral –cause angulation and shortening
3.Linear – surrounded by normal physis

34. Growth across the physis ceases symmetrically , such as with large central bars or with type v
fractures , main problem is Limb Shortening
Major growth centers in upper limb are proximal humerus , distal radius and ulna ,and in lower
limbs distal femur and proximal tibia and fibula
Shortening is better tolerated in upper limb then lower limbs

35. Patient with lower extremity leg length discrepancy at maturity
1. Up to 2 cm – treated with Shoe lift
2. 2 to 5 cm – contralateral epiphsiodesis
3. More then 5 cm – limb lengthening by intramedullary lengthening nails , external fixation
based lengthening techniques

36. THANK YOU …..