This document discusses epiphyseal injuries in children. It notes that growth disturbance is the most common complication if not properly diagnosed and managed. It describes the two types of epiphysis - pressure and traction - and provides examples. It also details the Salter-Harris classification system for epiphyseal injuries. Key factors in prognosis include the type and location of injury, the child's age, degree of displacement, and whether the blood supply is disrupted. Early closed reduction within 10 days of injury generally leads to the best outcomes.

1. Epiphyseal injury

2. Importance
• The most predictable complication of epiphyseal injury is growth
disturbance
• And so could be prevented if diagnosed properly and managed
accordingly

3. • Each epiphysis has its own epiphysial plate through which skeletal
growth occurs
• So it is important that a distinction be made between the epiphysis
and epiphysial plate

4. Types of epiphysis
• Two types
• Pressure epiphysis
• Traction epiphysis
• Pressure epiphysis
• Location – at the end of a long bone
• Subjected to pressure transmitted through the joint
• Could be considered articular epiphysis
• Provides longitudinal growth of long bone
• Pressure epiphysis itself could be divided into two depending on whether
their nutrient vessels enter epiphysis directly like lower femoral epiphysis or
indirectly like upper femoral epiphysis

5. • Traction epiphysis
• Location – site of origin or insertion of major muscles or muscles group
• Subjected to traction rather than pressure
• Does not enter into joint formation , so extra articular
• Does not contribute to longitudinal growth of long bone
• Examples : trochanters of femur

8. • Normal epiphysial plate has four distinct layers
• Resting cells
• Proliferating cells
• Layer of hypertrophy
• Endochondral ossification
Space between cells filled with cartilage matrix ( intercellular substance)
Made up of collagen embedded with chondroitin sulphate
It is the inter cellular substance which provides strength to epiphysial plate

9. • Collagen fibres are arranged longitudinally in the matrix
• First two layers , matrix is abundant and the plate is strong
• In third layer ( hypertrophy layer ) matrix is scanty and so plate is
weak.
• It is layer of hypertrophy which is a commen site of epiphysial injury

10. Mechanism of nutrition in epiphysial plates
• Two separate systems of blood vessels
• Epiphysial system
• Metaphyseal system
•
• Epiphyseal system – vessels penetrate the plate of epiphysis and end in
capillary tufts or loops in a layer of resting cells
• Metaphyseal system – arises in marrow of shaft and ends in loops in layer
of endochondral ossification
• So the epiphysial system is responsible for nutrition of proliferating cells
• And metaphysial system is responsible for nutrition of endochondral
ossification

12. Etiology
• Trauma ( shearing / avulsion / crushing )
• Pathological separation of epiphysis ( rickets , scurvy , osteomyelitis )
• Iatrogenic damage to epiphysial plates

13. • Epiphysial injury mainly divided into two groups
• Fracture that cross the epiphysial plate
• Epiphysial separation
• Fracture crossing the epiphysial plate
• With or without longitudinal displacement
• When there is no displacement of fragment but fracture crossing the plate
will lead to premature closure of epiphysis and ultimately leads to shortening
• When displacement is present it will be combined with shortening and
angular deformity

14. • Epiphysial separation :
• Healing of epiphysis separation is rapid if there is no vascular damage
• Prognosis is not good if it damages nutrient vessels to epiphysis
• Such as avascular necrosis of femoral head in slipped capital femoral epiphysis

15. Classification of epiphysial plate injuries
• Salter Harris classification
• Type 1 : complete separation of epiphysis from metaphysis
• More common in birth injuries or pathological separation as in scurvy, rickets
• Type 2 : commonest type of epiphysial plate injuries
• Line of separation extends along the epiphyseal plate to a variable distance
and then out through a metaphysis
• Producing a triangular shaped metaphyseal fragment called Thurston Holland
sign

17. • Type 3: fracture which is intra articular extends from the joint surface to
the weak zone of epiphyseal plate and then extends along the plate to its
periphery
• Type 4 : fracture which is intra articular extends from the joint surface
through epiphysis across ful thickness of epiphyseal plate and through a
portion of metaphysis
• Producing a complete split
• Commonest example of this type is fracture of lateral condyle humerus

18. • Type 5
• Relatively uncommon injury
• Occurs due to severe crushing force applied through epiphysis to epiphyseal
plate
• More common in ankle and knee
• Injury might be misdiagnosed on xray

19. • Type 6 Injury by RANG
• Injury to perichondrial ring
• Type 7 Ogden – isolated epiphysis injury
• Type 8 – isolated injury to metaphysis
• Type 9 – avulsion injury to periosteum

20. Factors in prognosis
• Type of injury
• Type 1,2,3 have a good prognosis provided the intact blood supply
• Type 4 has a bad prognosis unless the plate is completely realigned
• Type 5 has the worst prognosis
• Age of the child
• Depends on the amount of growth expected in particular epiphyseal plate for
the remaining years of growth
• Younger the child , poor the prognosis

21. • Blood supply
• Examples femoral head necrosis
• Method of reduction :
• Undue forceful manipulation further damages the plate
• Mostly carried out after tenth day of injury
• Damage by instruments
• Screws or wires traversing the plate

22. • Open or closed injury :
• Open injuries of epiphysis uncommon
• But when associated , outcome is worst

23. Principles of treatment
• Time of reduction :
• Best time to reduce an epiphyseal plate injury is the day of injury
• Reduction becomes progressively more difficult with each passing day
• After 10 days , forceful manipulation is required and which may Further
damage the plate and so should be avoided
• And wiser to accept an imperfect reduction than to risk the danger of either
forceful manipulation or open reduction

24. • Method of reduction
• Closed or open
• Majority type 1&2 reduced by closed means
• Type 3 may require open reduction to obtain smooth joint surface
• Type 4 mostly requires open reduction always
•
• Follow up : growth disturbance may be delayed and so minimum of
one year follow up is must

26. • Common type of injury at upper radial epiphysis is type 2
• Produced by valgus force on the elbow , resulting in angulation of
radial head
• Reduction can be achieved by holding the extended elbow in varus
and directly pressing over the radial head
• If angulation is > 15° after closed reduction , supination – pronation
may get affected and open reduction is indicated
• Radial head should not be excised in children , if done loss of radius
growth wll produce progressive radial deviation at the wrist joint and
valgus deformity at the elbow

28. • Fracture of lateral condyle humerus (capitellum ) is type 4 injury
• Weekly x-rays needed to check the alignment
• When it’s displaced , open reduction is must
• Elbow is immobilised for 3 weeks in 90° flexion
• If not reduced properly – may lead to over growth of radial head /
valgus deformity / tardy ulnar nerve palsy

30. • Largest of pressure epiphysis – lower femoral epiphysis
• Serious injury of lower femur epiphysis is hyper extension type with
forward displacement of epiphysis
• Posterior corner of metaphysis may injur popliteal vessels
• Reduction is achieved by traction on semibent knee , pushing the
proximal fragment forward and then flexing the knee
• Reduction is most stable in 90° knee flexion
• Total period of immobilisation 3 weeks

31. Traction epiphysis injuries
• Medial epicondyle humerus injury : common flexor muscles avulsion
• Severe valgus injury
• Tibial tubercle : traction epiphysis of quadriceps
• Lesser trochanter : iliopsoas inserted to lesser tubercle
• Sudden abduction and extension of hip may result in lesser trochanteric
avulsion
• Anterior superior iliac spine – traction epiphysis of sartorius
• Anterior inferior iliac spine – traction epiphysis of rectus femoris

32. Thank you