A very basic ppt describing everything from Anatomy of physeal plate to treatment and complications of Physeal injuries

1. Physeal Injuries
Prepared by:
Dr. Gaurav Sahu
2nd Year Resident
Dept. of Orthopaedics
Lecture by:-
Dr. S. A. Mustafa
Professor
Dept. of Orthopaedics

2. ANATOMY OF LONG BONE:-

4. ANATOMY OF THE PHYSIS:-
 EPIPHYSEAL PLATE = GROWTH PLATE = PHYSIS
 THE PHYSIS IS A SLAB OF HYALINE CARTILAGE.
 LOCATED AT THE ENDS OF GROWING BONES BETWEEN
THE EPIPHYSES AND METAPHYSES.
 RESPONSIBLE FOR THE ‘LONGITUDINAL’ GROWTH OF
BONES.
 IT IS THE WEAKEST PART OF AN IMMATURE BONE.
 NORMAL WIDTH – 2 TO 4 MM.
 APPEARS RADIOLUCENT ON X-RAY.
 GRADUALLY OSSIFIES AND DISAPPEARS AT THE TIME
OF SKELETAL MATURITY.

6. HISTOLOGYOFTHEPHYSIS(4ZONES):-
 GERMINAL (RESTING) ZONE:
- CONTAINS CHONDROCYTES IN QUISENCE
- REPLENISHES PROLIFERATIVE ZONE
- INJURY CAUSES CESSATION OF GROWTH
 PROLIFERATIVE ZONE:
- CONTAINS CHONDROCYTES IN MITOSIS
- HAS ABUNDANT BLOOD SUPPLY
- RESPONSIBLE FOR INCREASE IN BONE LENGTH
- INJURY CAUSES CESSATION OF GROWTH
 HYPERTROPHIC (MATURATION) ZONE:
- CELLS ACCUMULATE GLYCOGEN/LIPIDS
- WEAKEST ZONE AND SITE OF PHYSEAL
FRACTURES
 ZONE OF CALCIFICATION:
- MINERALISATION OF MATRIX
- INFILTRATION BY METAPHYSEAL BLOOD VESSELS

7. PHYSEALINJURY:-
 FRACTURE THROUGH GROWTH PLATE.
 UNIQUE TO PAEDIATRIC PATIENTS.
 PREVALENCE – 10-30-% OF CHILDHOOD FRACTURES.
 AGE – BIMODAL PEAKS
INFANCY, 10-12 YEARS OF AGE
 SEX – MALES > FEMALES
 COMMONEST SITES – UPPER EXTREMITY>LOWER
EXTREMITY
DISTAL FEMUR
DISTAL TIBIA
PROXIMAL TIBIA/FIBULA
DISTAL RADIUS

8. Etiology
Trauma
Infection
Tumor
Vascular
Repetitive stress
Irradiation

9. CLINICAL PRESENTATION:-
 HISTORY:
- PAIN/SWELLING AROUND THE AFFECTED JOINT.
- UPPER LIMB - FUNCTION LIMITED BY PAIN.
- LOWER LIMB - INABILITY TO BEAR WEIGHT ON AFFECTED LIMB.
- HISTORY OF TRAUMA.
 ON EXAMINATION:
- SWELLING +
- DEFORMITY +/- (MINIMAL IF PRESENT)
- FOCAL TENDERNESS OVER PHYSIS +
- LIMITED RANGE OF MOTION OF JOINT

10. CLASSIFICATION:-
SALTER-HARRIS CLASSIFICATION
 TYPE I – TRANSVERSE FRACTURE THROUGH THE GROWTH
PLATE (6%)
 TYPE II – FRACTURE THROUGH THE GROWTH PLATE AND
METAPHYSIS, SPARING THE EPIPHYSIS (75%)
 TYPE III – FRACTURE THROUGH GROWTH-
PLATE AND EPIPHYSIS, SPARING THE METAPHYSIS (8%)
 TYPE IV – FRACTURE THROUGH GROWTH-PLATE, METAPHYSIS
AND EPIPHYSIS (10%)
 TYPE V – COMPRESSION FRACTURE OF THE GROWTH PLATE
(1%)

11.  MNEMONIC – S.A.L.T.E.R.

12. TYPE 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 WIDENING OF PHYSEAL PLATE.

14. TYPE 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.

17. TYPE 3:-
 FRACTURE THROUGH THE PHYSIS AND EPIPHYSIS, MATEPHYSIS IS
SPARED.
 PRONE TO CHRONIC DISABILITY, BECAUSE IT EXTENDS INTO THE
ARTICULAR SURFACE OF THE BONE.
 HOWEVER, RARELY RESULTS IN SIGNIFICANT DEFORMITY.
 ANATOMIC REDUCTION (USUALLY OPEN) AND STABILIZATION.

19. TYPE 4:-
 INVOLVES ALL 3 ELEMENTS OF THE BONE, PASSING
THROUGH THE EPIPHYSIS, PHYSIS, AND METAPHYSIS.
 AN INTRA-ARTICULAR FRACTURE; THUS, IT CAN RESULT IN
CHRONIC DISABILITY.
 INTERFERE WITH THE GROWING LAYER OF CARTILAGE CELLS.
 CAN CAUSE PREMATURE FOCAL FUSION OF THE INVOLVED
BONE LEADING TO DEFORMITY OF THE JOINT.
 FREQUENT AROUND THE MEDIAL MALLEOLUS, LATERAL
CONDYLAR.
 ANATOMIC REDUCTION AND ADEQUATE STABILIZATION.

21. TYPE 5:-
 A COMPRESSION OR CRUSH INJURY OF THE PHYSIS,
WITH NO ASSOCIATED EPIPHYSEAL OR METAPHYSEAL
FRACTURE.
 THE CLINICAL HISTORY IS OF PARAMOUNT
IMPORTANCE. 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

23. HOW WILL YOU MANAGE PHYSEAL INJURIES ?

24. MANAGEMENT:-
 AFTER THOROUGH HISTORY AND CLINICAL EXAMINATION.
 X-RAY:
IT IS DIFFICULT TO ASSESS AS THE PHYSIS IS RADIOLUCENT AND THE EPIPHYSIS IS
INCOMPLETELY OSSIFIED. ON X-RAY:-
1. THE PHYSEAL WIDENING OF THE GAP
2. TILTING OF THE EPIPHYSIS
3. COMPARE THE INJURED SIDE WITH THE NORMAL
4. REPEATING X RAY WITHIN FEW DAYS

25. MANAGEMENT CONTD…
 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
- IDENTIFIES FORMATION OF BONY BRIDGE EARLIER THAN X-RAYS

26.  FACTORS THAT AFFECT TREATMENT DECISIONS INCLUDE THE FOLLOWING:
1) SEVERITY OF THE INJURY
2) ANATOMIC LOCATION OF THE INJURY
3) CLASSIFICATION OF THE FRACTURE
4) PLANE OF THE DEFORMITY
5) PATIENT AGE
6) GROWTH POTENTIAL OF THE INVOLVED PHYSIS

27. TREATMENT:-
• FOR TYPES 1 & 2:
CLOSED REDUCTION AND IMMOBILIZATION IN CAST WILL USUALLY
SUFFICE
GENTLE REDUCTION. NEVER FORCEFUL AND REPEATED. REDUCE ASAP.
ACUTE INJURIES MUST BE IMMOBILISED IN A SLAB, SO AS TO ALLOW
SOME SWELLING FROM THE FRACTURE.
REPEAT RADIOGRAPHS AT WEEKLY INTERVALS TO DOCUMENT
MAINTENANCE OF ACCEPTABLE POSITION UNTIL EARLY BONE HEALING.

28. • FOR TYPES 3 & 4:
REQUIRE ANATOMICAL REALIGNMENT VIA O.R.I.F.
O.R.I.F. CAN BE WITH LAG SCREWS OR KIRSCHNER WIRES RUNNING
PARALLEL TO PHYSIS
• FOR TYPES 5:
USUALLY DIAGNOSED RETROSPECTIVELY
HOWEVER HIGH INDEX OF SUSPICION MUST BE MAINTAINED IN HIGH
RISK INJURIES

30. SURGICAL METHODS:-
1) BONE BRIDGE RESECTION WITH FAT INTERPOSITION.
- BONE BRIDGE LEADS TO ANGULAR DEFORMITY.
- INTERPOSITION OF FAT PREVENTS BONE BRIDGE FORMATION.
2) IPSILATERAL COMPLETION OF ARREST
3) CONTRALATERAL EPIPHYSIODESIS
4) LIMB LENGTHENING
5) CORRECTIVE OSTEOTOMY

31. BONE-BRIDGE RESECTION
WITH FAT INTERPOSITION:-
 TYPE V FRACTURES ARE RARELY DIAGNOSED
ACUTELY, AND UNFORTUNATELY, TREATMENT IS
OFTEN DELAYED UNTIL THE FORMATION OF A
BONY BAR ACROSS THE PHYSIS IS EVIDENT.
 SAUCER AND CUP APPEARANCE.
 ANGULAR DEFORMITY.

32. MATERIALS USED FOR INTERPOSITION:
a) FAT
b) BONE WAX
c) SILICON RUBBER
d) POLYMETHYLMETHACRYLATE

33. EPIPHYSIODESIS:-

34. LIMB LENGTHENING:-

35. CORRECTIVE OSTEOTOMY:-

36. FOLLOW UP:-
 CHECK X-RAY POST-REDUCTION.
 RE-EVALUATED IN THE SHORT TERM (7-10 DAYS) TO ENSURE MAINTENANCE OF
REDUCTION.
 WEEKLY FOLLOW-UP TILL CALLUS APPEARS ON X-RAY.
 AFTER INITIAL FRACTURE HEALING HAS OCCURRED, PHYSEAL FRACTURES REQUIRE
ADDITIONAL FOLLOW-UP X-RAYS 6 MONTHS AND 12 MONTHS AFTER INJURY TO
ASSESS FOR GROWTH DISTURBANCE.
 MAY BE EXTENDED UP TO 2 YEARS.
 2 PHASES:
A) ENSURING BONE HEALING
B) MONITORING GROWTH

37. REHABILITATION:-
 TYPES 1 & 2 FRACTURES ARE IMMOBILIZED FOR 3 - 6 WEEKS
 TYPES 3 & 4 FRACTURES ARE IMMOBILIZED FOR 4 - 8 WEEKS
 PATIENT RESUMES UNRESTRICTED PHYSICAL ACTIVITIES 4 - 6 WEEKS FOLLOWING
REMOVAL OF IMPLANTS FOR FRACTURES THAT REQUIRED OPERATIVE FIXATION.
 THEN GRADUALLY, ROM EXERCISES ARE STARTED.

38. PROGNOSIS:-
• SEVERITY OF THE INJURY
• AGE OF PATIENT AT TIME OF INJURY
• TYPE OF FRACTURE

39. COMPLICATIONS:-
 GROWTH ARREST:
• DUE TO DISRUPTION OF PHYSEAL BLOOD SUPPLY OR
BONE BRIDGE FORMATION.
1) COMPLETE ARREST LEADS TO SHORTENING/LLD.
2) PARTIAL ARREST LEADS TO ANGULATION
 GROWTH ACCELERATION
 SECONDARY OSTEOARTHRITIS (SH III AND IV)

42. ALSO NOTE:-

43. HARRIS LINES:-
 TRANSVERSELY ORIENTED
CONDENSATIONS OF NORMAL BONE
(THIN, WHITE LINES ON X-RAY)
 REPRESENT SLOWING OR CESSATION OF
GROWTH
 APPEAR AFTER RESTORATION OF
GROWTH FOLLOWING A PHYSEAL
INJURY
 MIGRATE TOWARDS DIAPHYSIS WITH
GROWTH
 MAY DISAPPEAR WITH AGE

44. GROWING ENDS OF LONG BONES:-
 THE DIRECTION OF NUTRIENT ARTERY:
“TOWARDS THE ELBOW WE GO,
AWAY FROM KNEE WE FLEE.”
 REVERSE IS TRUE FOR THE GROWING ENDS OF LONG BONES.

45. CAN YOU CLASSIFY THESE INJURIES ???

55. WHAT HAVE WE LEARNT TODAY…
 DIFFERENTIATE A PHYSIS FROM A FRACTURE.
 PHYSEAL INJURIES MAY NOT BE OBVIOUS ON X-RAY.
 TYPE II IS MOST COMMON .
 TYPES III & IV ARE MORE PRONE TO CHRONIC DISABILITY.
 TYPE V IS USUALLY ASSOCIATED WITH GROWTH DISTURBANCES AND HAS A POOR
FUNCTIONAL PROGNOSIS. USUALLY DIAGNOSED RETROSPECTIVELY.
 ONLY 2% OF SALTER-HARRIS FRACTURES RESULT IN A SIGNIFICANT FUNCTIONAL
DISTURBANCE IF TREATED PROPERLY.
 ANATOMICAL REDUCTION IS THE KEY TO SUCCESSFUL OUTCOME.
 A HIGH INDEX OF SUSPICION DURING EVALUATION, TREATMENT AND FOLLOW-UP IS
OF THE ESSENCE TO PREVENT FUTURE COMPLICATIONS.