PHYSEAL INJURIES

1. PHYSEAL INJURIES
Presenter :- Dr CHETAN M N
Moderator :- Dr Vinay B Patil

2. Topics:-
Introduction Anatomy Etiology
Clinical
features
Classification Diagnosis Treatment Complications

3. 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.

4. • Physeal injuries are unique to the pediatric patients.
• Prevalence – 10 – 30 % of all childhood fractures
• AGE :- Bimodal peaks
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.

5. Anatomy:-

6. • Histologically, the physis is divided into four zones oriented from the
epiphysis to the metaphysis:
 Germinal (reserve) zone:-
Contains chondrocytes in quiescent stage.
Replenishes proliferative zone
Injury causes cessation of growth
 Zone of proliferation:-
Contains chondrocytes in mitotic stage
Number of cells in this layer shows activity of Physeal plate
Injury causes cessation of growth
 Zone of Hypertrophy(Maturation):-
Weakest zone and site of Physeal fractures.
 Zone of provisional calcification (or endochondral ossification):-
Mineralization of chondroid matrix.

7. The peripheral margin of the physis comprises two
specialized areas :-
• The zone (or groove) of Ranvier :- is a triangular
microscopic structure at the periphery of the physis,
containing fibroblasts, chondroblasts, and osteoblasts.
It is responsible for peripheral growth of the physis.
• The perichondral ring of LaCroix :- is a fibrous structure
overlying the zone of Ranvier, connecting the
metaphyseal periosteum and cartilaginous epiphysis,
and has the important mechanical function of
stabilizing the epiphysis to the metaphysis.

8. 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.

9. Etiology:-
• The most frequent mechanism of injury is fracture.
• Most commonly, physeal injury is direct, with a fracture involving the physis itself. Occasionally, physeal
injury from trauma is associated with a fracture elsewhere in the limb segment, so the injury would be
as a result of ischemia or perhaps compression.
• 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]

10. 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

11. Classifications of physeal injury :-
• POLAND
• AITKEN
• SALTER AND HARRIS (m/c used)
• OGDEN
• PETERSON

12. Salter and Harris classification:-

13. 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.
• Radiographs of undisplaced type I physeal fractures, therefore, are
normal except for associated soft tissue swelling.
• type I fractures occurred most frequently in the phalanges,
metacarpals, distal tibia, and distal ulna.
• Because the hypertrophic zone is the weakest zone structurally,
separation should occur at this level. studies have confirmed that
the fracture plane is more complex than this concept and
frequently involves other physeal zones as well.
• Because the articular surface and, at least in theory, the germinal
and proliferative layers of the physis are not displaced, the general
principles of management here are to secure a gentle and
adequate reduction and stabilize the fragments as needed.

15. Type 2
• Type II injuries have physeal and metaphyseal components; the
fracture line extends from the physeal margin peripherally across a
variable portion of the physis and exits into the metaphysis at the
opposite end of the fracture .
• The epiphyseal fragment thus comprises all of the epiphysis and some
portion of the peripheral metaphysis (the Thurston Holland fragment
or sign).
• The physeal portion of this fracture has microscopic characteristics
similar to those of type I injuries, but 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.
• However, the metaphyseal “spike” fragment may be driven into the
physis of the epiphyseal fragment, which can damage the physis .
• Similar to type I injuries, the articular surface is not affected and the
general principles of fracture management are effectively the same.

17. • A: Dorsally displaced type II
fracture of the distal radius.
Note the evidence of
impaction of the epiphyseal
fragment (with the physis) by
the dorsal margin of the
proximal fragment
metaphysis.
• B: One year later, there is
radiographic evidence of
physeal arrest formation in
the distal radial physis

18. Type 3
• Salter–Harris type III fractures begin in the epiphysis as a fracture
through the articular surface and extend vertically toward the physis.
The fracture then courses peripherally through the physis .
• 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.
• This fracture pattern is important for two main reasons: the articular
surface is involved and the fracture line involves the germinal and
proliferative layers of the physis. So, higher risk of subsequent growth
disturbance.
• Anatomic reduction (usually open reduction) and stabilization are
required to restore the articular surface and to minimize the potential
for growth disturbance.

20. 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, and, with displacement, may
result in metaphyseal–epiphyseal cross union
which almost invariably results in subsequent
growth disturbance.
• This fracture pattern is frequent around the
medial malleolus ,lateral condyle of humerus.

22. • In type 4, treatment principles
include obtaining anatomic
reduction and adequate
stabilization to restore the
articular surface and prevent
metaphyseal–epiphyseal cross
union , to prevent subsequent
growth disturbances.

23. Type 5
• It is a relatively uncommon type of
injury caused by a severe crushing
force applied through the epiphysis
to one area of the physeal plate.
• Mechanism of this injury is by
longitudinal compression, which
damages the germinal layer of
physeal cells.
• The radiograph taken at the time of
injury is normal (as there is no
fracture) and growth-arrest is
discovered only in retrospect.
• This type of injury cannot be
diagnosed radiologically at the time
of trauma.
• The prognosis for growth is poor, and
there is a likelihood of premature
growth cessation

25. Type 6
(Modification
by Ogden &
Rang)
• This type of injury was described by Rang as a
perichondrial injury, which may result from burn/ a blow
to the surface of the extremity or in run-over injury.
• The epiphysis is undisplaced in this form of injury, but it
may lead to rapid development of an angular deformity.

26. Ogden added 3 more as :-
Type 7, 8 and 9

27. Peterson classification:-
• Type 1 (transverse fracture of the
metaphysis with fracture line extending to
the physis)
• Type 2 to 5 is similar to Salter & Harris
classification.
• Type 6 (Fracture in which part of physis has
been removed or is missing. This occurs
only with open or compound fractures. The
common mechanisms of injury are from
lawn mowers , farm machinery and
gunshot wounds).

28. Evaluation:-
• Radiographic Assessment:-
• Physeal injuries are three-dimensional problems and X-rays only give us a two-
dimensional picture of the injury. So, Anteroposterior and lateral views helps in diagnosis
a lot.
• Comparative views of the normal opposite limb should be obtained in doubtful cases.
• Stress views are useful in identifying cases where spontaneous reduction has occurred
after the injury.
• Tomograms
• Arthrograms
• Ultrasonography  to identify epiphyseal separation in infants.
• MRI
• CT scans are helpful in difficult situations,
e.g. triplane epiphyseal injury of the ankle.

29. X ray:-
• WIDENING OF PHYSEAL GAP
• JOINT INCONGRUITY
• TILTING OF EPIPHYSIS
• PRESENCE OF DISPLACEMENT MAKES DIAGNOSIS MORE OBVIOUS
• TYPES 5 & 6 INJURIES ARE USUALLY DIAGNOSED later
RETROSPECTIVELY

30. CT scan:-
• TO VISUALISE FRACTURE ANATOMY IN SEVERELY COMMINUTED
FRACTURES OF EPIPHYSIS AND METAPHYSIS.
MRI:-
• MOST ACCURATE FOR FRACTURE ANATOMY IF DONE IN ACUTE
PERIOD.
• Useful to identify soft tissue lesions and bony bruises
• IDENTIFIES FORMATION OF BONY BRIDGE EARLIER THAN X-RAYS.

31. 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).

32. • 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.

33. 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 injuries require anatomic reduction. In types I
and II anatomically perfect reduction, although desirable, is not absolutely
essential.
• Type III and IV:
• Might need open reduction to obtain anatomical reduction. Maintenance
of reduction, if needed, is with smooth Kirschner wires, and they are
removed as soon as the injury heals. Threaded screws or wires should not
be inserted across the physis. Biodegradable smooth pins are now
available.
• Because of the intra-articular component, displaced type III and IV injuries
must be reduced usually by open method regardless of the time that has
elapsed.

34. • Caution must always be exercised during open
reductions to prevent injury to the circulation
entering the epiphysis. Excessive stripping of the
already damaged periosteum and
perichondrium should be avoided. Soft tissue
attachments are carefully preserved.
• 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.

37. • Period of immobilization and follow-up:
Type IV injuries need the same time of immobilization as that needed
for a metaphyseal fracture of the same bone in a child of the same age.
In type I, II and III injuries, immobilization is only needed for half this
time.
• 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

38. Factors Affecting the Prognosis for Future Growth Disturbance:
Types of Injury
• In type III and IV, complications rate is higher.
Types of injury Prognosis
I, II and III Good
IV Bad
V Worst
Age at the time of injury:
The younger the age at the time of injury, the more serious the
likelihood of growth disturbance. However, in younger patient remodeling
capacity is more.
Blood supply to the epiphysis:
Interferences with the blood supply to the epiphysis will lead to
a poor result, as in femoral and radial head epiphyseal injuries.

39. Severity of the injury:
High-velocity injuries like automobile accidents carry a poor prognosis
because of the associated crushing of the physis.
Method of reduction:
Forceful manipulation open or closed, excessive soft tissue dissection and
penetration of the physis by screws, nails or threaded wires may predispose
to physeal damage.
Closed or open injury:
Open injuries, which are uncommon, have a poor prognosis, and if
infection sets in, chondrolysis destroys the physis.
Interval elapsed since injury:
Delay in treatment causes difficulty in reduction. Further damage may
occur to growth plate during reduction.

40. Complications of Physeal Injuries:-
•Growth Acceleration
•Malunion
Angular malunion might correct spontaneously. Malunion of type III
and IV physeal injuries of the distal tibial physis might result in
secondary osteoarthrosis and premature cessation of growth
respectively.
•Nonunion
Nonunion is the most common in type IV injury of the lateral
condyle of the humerus. Hence, this fracture is best treated by open
reduction and internal fixation (ORIF) to prevent malunion, nonunion,
lateral instability of the elbow and tardy ulnar nerve palsy.

41. •Osteomyelitis
In open injuries, infection of bone might result in chondrolysis and
premature cessation of growth. Acute osteomyelitis may involve the growth
plate causing partial or complete destruction. This results in shortening of
the limb or angular deformity, which is treated by limb lengthening or
corrective osteotomy respectively.
•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.

42. •Growth Arrest
• Although most physeal injuries are free of serious acute and chronic
complications, in some partial or total growth arrest may subsequently occur.
Incidence of physeal growth damage after a distal radial physeal fracture is
10% proximal tibia, and distal femur represents only 3%.
• A complication unique to physeal fractures is growth disturbance, trauma is
the most common cause of growth disturbance, and most important is the
severity of the injury to the physis.
• Osteomyelitis is a common cause of growth disturbance and resultant
deformity. Total destruction causes shortening of the limb and partial
destruction causes angular deformities near the joint.
• Growth arrests due to trauma. Growth arrest may be immediate or growth
may continue at a retarded rate for a period of time before it ceases
completely. Growth disturbance, from a physeal fracture is usually evident 2–
6 months after the injury, but it may not become evident for up to a year.
• Growth disturbance is usually the result of the development of a bony
bridge/bony bar, across the physeal cartilage. This produces a tethering
effect.

43. • A 7-year-old girl presented
with an ankle deformity
after a trampoline injury 7
months prior.
• MRI showing bony bars and
tethering of epiphysis and
metaphysis

44. • CT is the modality most commonly used today to detect bony bar.
• Growth arrest could be of two types:
1. Complete growth arrest: This will result in progressive limb
length discrepancy.
2. Partial growth arrest: It may be of three types
CENTRAL
PERIPHERAL
LINEAR
Central arrests are surrounded by a perimeter of normal physis. Peripheral
arrests are located at the perimeter of the physis. Linear arrests are
“through-and-through” lesions with normal physis on either side of the
arrest area

45. • Central arrests are characterized by tenting of the articular surface.

46. MANAGEMENT of complications of physeal arrest:
1. Prevention of arrest formation
2. Physeal distraction (using external fixators)
3. Osteotomies ( to correct angular deformities)
4. Completion of Epiphysiodesis (to prevent recurrent angular
deformity)
5. Management of LLD (simultaneous or subsequent lengthening of the
affected limb segment or contralateral epiphysiodesis if the
existing discrepancy is tolerable and lengthening is not desired)
6. PHYSEAL ARREST (BONY BAR resection) RESECTION.

47. PHYSEAL ARREST RESECTION:- (physiolysis or epiphysiolysis)
• surgical resection of a physeal arrest restoring normal growth of the
affected physis is the ideal treatment.
• The principle is to remove the bony tether between the metaphysis
and the physis and fill the physeal defect with a bone reformation
retardant, anticipating that the residual healthy physis will resume
normal longitudinal growth.
• Based on skeletal age determination and the amount of growth
remaining in the physis (minimum of 2 yrs of growth
remaining),arrest resection is considered.

48. • Procedure:-
After careful planning, with the help of MRI for the location & extent of
bony bar relative to the surrounding normal physis ,procedure is
started.

49. • The arrest must be resected in a manner that minimizes trauma to
the residual physis.
• Central lesions should be approached either through a
metaphyseal window or through the intramedullary canal after a
metaphyseal osteotomy.
• Peripheral lesions are approached directly, resecting the overlying
periosteum to help prevent reformation of the arrest.
• A high-speed burr worked in a gentle to-and-fro movement
perpendicular to the physis is usually the most effective way to
gradually remove the bony bridge and expose the residual healthy
physis .By the end of the resection, all of the bridging bone
between the metaphysis and the epiphysis should be removed,
leaving a void in the physis where the arrest had been, and the
perimeter of the healthy residual physis should be visible
circumferentially at the margins of the surgically created cavity.

50. • After the bar is resected, metallic markers are inserted in the
epiphysis and metaphysis.
• Prevent Reforming of Bridge Between Metaphysis and Epiphysis by
using “ bone growth retardant “ or “ spacer ” material in the void
created after resection like:
1.Autogenous Fat
2.Methyl-methacrylate
3.Silicone rubber
4.Autogenous cartilage

51. • Currently, only autogenous fat graft, harvested either locally or from
the buttock, and methyl methacrylate are used clinically. Autogenous
fat has at least a theoretic advantage of the ability to hypertrophy and
migrate with longitudinal and interstitial growth.Methyl methacrylate
is inert, but provides some immediate structural stability.

52. • These metallic markers allow reasonably accurate estimation of
the amount of longitudinal growth that occurs across the
operated physis, as well as to identify the deceleration or
cessation of that growth.

53. Harris lines or park
lines:
• Growth arrest lines, also known as growth resumption
lines, Harris lines or Park lines, are alternating transverse
rings of sclerosis at the metaphysis of a long bone.
• Pathology
The radiographic finding occurs from alternating cycles of
osseous growth arrest and growth resumption. This appears to
result from pathologic levels of stress during bone development
(e.g. disease, malnutrition).
• Histology
Three histological characteristics :
• non-lamellar appearance on histology
• a complete lack of osteocyte lacunae
• presence of irregularly distributed tubular structures

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