1) The patient is a 5 year 5 month old Thai boy who was brought in after a soccer goal post fell on his left knee. He reported pain, difficulty walking and bending his knee. 2) Examination found tenderness over the left knee with limited range of motion due to pain. X-rays revealed a Salter-Harris type II injury of the left proximal tibial epiphysis. 3) The diagnosis was an epiphyseal plate injury of the left proximal tibia (Salter-Harris type II). Treatment was with a posterior long leg slab.

1. Extern conference
7th June 2017
Ext. Thanawan Sitthikarnkha

2. Patient profile
Case ผู้ป่วยเด็กชายไทย อายุ 5 ปี 5 เดือน

3. Present illness
5 hr PTA ผู้ป่วยให้ประวัติว่าถูกเสาประตูฟุตซอล ล้ม
ทับบริเวณเข่าข้างซ้าย หลังจากนั้นผู้ป่วยมีอาการปวด เดินลง
น้าหนักไม่ได้ ,งอเข่าไม่ได้ , ไม่มีบาดแผลภายนอก ไม่ชา
สามารรถกระดกข้อเท้าได้ปกติดี

4. Physical Examination
Primary survey
A : Can talk , no tenderness at C-spine
B : Equal breath sound , SpO2 = 98%
C : BP 100/67 mmHg , PR 72 bpm , no external bleeding
D : E4V5M6 , pupil 3 mm RTLBE

5. Physical Examination
Vital signs :
BP 100/67 mmHg , PR 72 bpm (Full regular) ,
RR 20 /min , BT 36◦C
GA :
A Thai boy , good consciousness well co-operative
HEENT :
Mild pale conjunctivae , anicteric sclerae ,
lymph nodes not palpable , no thyroid gland enlargement

6. Physical Examination
CVS :
No active precordium , no heave , no thrill ,normal s1s2, no murmur
Respiratory :
No tachypnea , equal lung expansion , normal breath sound ,
no adventitious sound
Abdomen :
Abdomen soft , not tender , no hepatospleenomegaly

7. Physical Examination
Marked tender,
Limit ROM due to pain
Lt. leg

8. Radiographic findings

9. Lt.knee AP
Lt.knee Lat

10. Lt.knee Lat
Lt.knee AP
(Zoom)

11. Diagnosis

12. Epiphyseal plate of left
proximal tibia injury
(Salter-Harris type II )

13. Epiphyseal plate injury

14. Epiphyseal plate injury
• Epiphyseal plate = growth plate = physis
• Locate at the end of the long bone
• Responsible for longitudinal growth
• Is the weakest structure of the immature
bone

16. Epiphyseal plate injury
The classification of the injuries is
important, because it affects patient
treatment and provides clues to possible long-
term complications

17. Symptoms
• A growth plate fracture usually causes persistent
or severe pain. Other common symptoms
include:
• Visible deformity
• An inability to move or put pressure on the limb
• Swelling, warmth, and tenderness in the area
around the end of the bone, near the joint

18. Salter-Harris classification

19. Epiphyseal plate injury
Type 1- Physeal separation
Type 2- Fracture traverses physis and exits metaphysis
Type 3- Fracture traverses physis and exits epiphysis
Type 4- Fracture passes through epiphysis, physis and
metaphysis
Type 5- Crush injury to physis

20. Type 1
• Physeal separation
• Is a transverse fracture
through the hypertrophic
zone of the physis.
• The growing zone of the
physis usually is not injured,
and growth disturbance is
uncommon.

21. Type 2
• Fracture traverses physis
and exits metaphysis
(the epiphysis is not involved
in the injury)
• Is the most common type
• May cause minimal
shortening; however, the
injuries rarely result in
functional limitations

22. Type 3
• Fracture traverses physis and
exits epiphysis
• This type of fracture is prone
to chronic disability, because
by crossing the physis, the
fracture extends into the
articular surface of the bone.
• The treatment for type III
fractures is often surgical

23. Type 4
• Fracture passes through
epiphysis, physis,
metaphysis
• Similar to a type III fracture,
a type IV fracture is an
intra-articular fracture
• It can result in chronic
disability.

24. Type 5
• Is a compression or crush
injury of the epiphyseal
plate
• This fracture is associated
with growth disturbances
at the physis
• A typical history is that of
an axial load injury.
• Type 5 injuries have a
poor functional prognosis

25. Nonsurgical Treatment
Many growth plate fractures can heal
successfully when treated with immobilization: a cast
is applied to the injured area and the child limits some
types of activity.
Doctors most often use cast immobilization
when the broken fragments of bone are not
significantly out of place. A cast will protect the bones
and hold them in proper position while they heal

26. Surgical Treatment
If the bone fragments are displaced and the
fracture is unstable, surgery may be necessary
The most common operation used to treat
fractures is called open reduction and internal fixation.

27. Treatment

28. Complication
• Growth arrests
– complete arrest leads to shortening
– partial arrest leads to angulation

29. Epiphyseal plate of left
proximal tibia injury
(Salter-Harris type II )
Posterior long leg slab