Epiphyseal injury

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  • In 1989, Siliski, Mahring, and Hofer evaluated 52 intercondylar femoral fractures (AO type C) treated predominantly with blade plates. Three quarters of the fractures were caused by high-energy mechanisms, and 39% were open fractures. Overall, good or excellent results were obtained in 81% of fractures, and range of motion averaged 107 degrees. Results were better in type C1 fractures (92% good or excellent results) than in type C2 and type C3 fractures (77% good or excellent results). Only three (5.8%) fractures had malalignment in the sagittal plane; however, shortening of 1 to 3 cm occurred in 15 patients. Shortening was intentional to improve stability in 11 older patients (average age 60 years), but it was unintentional in four younger patients (average age 30 years). Infection occurred in four patients (7.7%) and accounted for three of the four poor results. Two fractures complicated by infection required amputation, and one required arthrodesis to treat the infection. Perioperative antibiotics were not used in closed and type I open fractures.
  • Epiphyseal injury

    1. 1. Seminar on “ Fracture Healing and Epiphyseal injuries” 13 – 10 - 2011 Moderator: Presenter: Dr. C B Patil Dr Professor Graduate VIMS & RC. Post Somnath Machani VIMS & RC .
    2. 2. Bone healing in adults  Fracture healing can be divided in to two types  Primary- direct healing by internal remodelling  Secondary- Indirect healing by callus  Stages − − − − Inflamation Soft callus Hard callus remodelling
    3. 3.  Stage of inflamation   1 to 7 days Hematoma, inflamatory exudates  Cytokines role  Collagen formation  Necrotic bone removal
    4. 4.  Soft callus formation  2- 3 weeks  Decreased pain and swelling  Prone to angulation   Progenitor cells in cambium layer Hematoma replaced
    5. 5.  Hard callus formation  3 to 4 months  Firmly united by new bone  Enchondral ossification   Bone callus begins at the periphery of the fracture sitelow strain Initial bone bridge forms externally of within medullary canal and later joins original cortex
    6. 6.  Remodelling   Woven bone replaced by lamellar bone. Few months to years till the meduallary canal is replaced
    7. 7. Difference  Cancellous  Less formation of significant external callus  After inflamatory stage – intramembranous ossification  In unusual cases interfragmentary motion leads to intermediary soft tissue formation and soon replaced by bone
    8. 8. Need to study child fracture healing  Changing structure and function  Different failure pattern  Fracture after insignificant trauma  15% of childhood fractures are physeal injuries  Physis has longitudinal and diametric growth  Salter harris type 1 MC in infants  Salter harris type 2 to 4 when 2 nd ary ossification centre enlarges
    9. 9. Anatomic regions of child bone  Epiphysis  Physis  Metaphysis  Diaphysis
    10. 10. Epiphysis     @ birth except distal femur Cartilagenous chondroepiphysis 2nd ary ossification centre enlarges until replaced by bone Lucent physeal lines
    11. 11.    External surface has perichondrium or articualar cartilage Pericondrium has ligament and muscle attachmentscentrifugal enlargement of the epiphysis Thick perichondriummechanical strength to zone of Ranvier
    12. 12. Physis / growth plate    Rapid longitudinal and diametric growth Appreciated by growth of the secondary centre Epiphyseal blood vessels penetrate to reach physis(fig 2)
    13. 13.  Vessel damage leads to uneven growth Patterns of response to ischemia of the epiphyseal (A, B) versus metaphyseal (C, D) circulatory systems. Metaphyseal ischemia is usually transient; epiphyseal ischemia is usually severe and permanent. Histologic section showing an area of central ischemic growth arrest (arrow). The infarcted area of cartilage is left behind as the rest of the physis continues longitudinal growth.
    14. 14. Metaphysis    Contoured flare at the end of diaphysis Less cortical and more trabecular bone Te99m scan shows increased bone turnover Cortical fenestration (solid arrows) of a metaphysis. Note the interdigitation of periosteal (Ps) tissue with the fenestrations. The periosteum blends into the perichondrium (Pc). Extensive vascularity is often present in this region (open arrows). (E, epiphysis; P, physis; Z, zone of Ranvier; L, ring of Lacroix.)
    15. 15.  Fibrovascular connections is the cause for torus or buckle fractures Extensive modeling and remodeling of the medial (M) versus the lateral (L) cortex of the distal femur may create irregularities that have been misinterpreted as fracture, stress fracture, infection, and tumor. Note the well-formed subchondral bone at the periphery of the epiphyseal ossification center.
    16. 16.  Transverse lines of park and harris Histologic section (A) and x-ray study (B) of a distal femur showing a typical Harris line (arrows). This formed during an acute illness and chemotherapy for leukemia. The child then resumed a more normal pattern of growth until her death from leukemia about 14 months later.
    17. 17. Diaphysis    Extremely vascualar Periosteum- thicker in child and easily elevated Greater osteogenic potential and less likely to injure periosteum Simulated type 1 epiphyseal (E) displacement from the metaphysis (M). Note the thick periosteum (arrow) and its contiguity with the cartilage of the epiphysis (radiopaque here because of the cartilage and air contrast). In the body, however, the similar soft-tissue radiodensities of cartilage, ligament, muscle, and so forth blend together, making them radiolucent.
    18. 18. Composition of bone
    19. 19. Composition of Cartilage
    20. 20. Zones of physis
    21. 21. Factors influencing bone growth
    22. 22. Fracture healing in children    Usually associated with ligament and soft tissue injury Physis and epiphysis don't heal by callus formation Phases  Inflamatory  Reparative  remodelling
    23. 23. Inflamatory phase    Hematoma and local necrosis Bleeding from periosteum and bone Dissects along diaphysis upto the zone of ranvierPDGF, VGEF, TGF beta promote osteoblast recruitment and activation
    24. 24.     Local necrosis- supply is disrupted for a few mm on either side Necrosis also releases growth factors Initial matrix contains type 1,3,5 collagen Promotes mineralization and primary callus
    25. 25. Reparative phase      Osteogenic cells proliferate from the external callus 10-14 days thick fracture callus enveloping mass of peripheral osteogenic tissue BMP family- mesenchymal cell differenciation Till healing goes thro final stages- fracture is still biologically plastic Clinical union
    26. 26. Remodelling     Resorption of unnecessary and in efficient callus Trabecular orientation Cancellous bone- the cells are never far away from the blood vessels Replacement of bone occur in the trabeculae
    27. 27. Physeal healing  Limted ability to repair  Primarily heals by increased endochondral bone  3 types of chondro osseous healing  I- # thro columns  II - # thro transition zone  III - # injury to all layers of the physis
    28. 28. Mechanism of bone bridge formation Intramembranous ossification mechanism for bone bridge formation at the growth plate injury site. Histologically (Barbara's histology stain), bony bridge trabeculae start to appear on day 7 postinjury (A), and become well-constructed on day 14 with marrow (B). Prior to and during physeal bar formation, there is no new cartilage formation, no collagen-X synthesis (as examined by immunostaining) at the injury site (C), and no expansion of chondrocyte proliferation (as examined by BrdU labeling) from adjacent physeal cartilage (D).
    29. 29. Starting from day 3 (E) until day 14, there is infiltration of marrow-derived fibroblast-like mesenchymal cells (as examined by vimentin immunostaining), some of which are osteoblast precursor cells displaying positive immunostaining for bone cell differentiation transcription factor cbf-a1 (F) and osteoblast/osteoprogenitor maturation marker alkaline phosphatase (G). During bone bridge formation, bone matrix protein osteocalcin is produced by osteoblasts on bone bridge trabeculae (immunostaining) (H). *, injury site; block arrow, pointing to adjacent growth plate cartilage; small arrow, pointing to bone bridge trabeculae or immunostained positive cells.
    30. 30. Etiology of Physeal injuries  Infection Standing anteroposterior lower extremity x-ray of a 12-year-old boy with multifocal physeal disturbance from purpura fulminans associated with meningococcemia. X-ray abnormalities are present in the left proximal femur; both distal femoral epiphyses, including partial arrest of the left distal femoral physis; and both distal tibial epiphyses. The patient also has digital amputations and
    31. 31.  Tumours Valgus deformity of the distal femur associated with the presence of an enchondroma of the distal lateral femur involving the lateral physis.
    32. 32.  Vascular insult A. The patient's leg was caught under heavy pipes rolling off a rack, resulting in stripping of the soft tissues from the distal thigh, open comminuted fracture of the distal femur, and popliteal artery injury. B. In follow-up, after arterial and soft tissue reconstruction, the patient has physeal growth arrests of the distal femur and proximal tibia. The mechanism of injury to the proximal tibial physis was presumed to be vascular, because of the associated femoral artery injury.
    33. 33.  Repetitive stress  Distal radius in gymnast  Proximal tibia in soccer
    34. 34. Classification of epiphyseal injuries  Salter Harris- 1963  Poland 1898  Aitken 1936  Petersons 1970
    35. 35. Salter Harris  Type 1 transphyseal plane  X ray only shows soft tissue swelling  Diagnosis by MRI and USG  Avoid stress x ray  # line in zone of hypertrophy  Minimal growth disturbance
    36. 36.     Type II Metaphyseal and physeal component Thurston holland fragment sign Growth disturbance uncommon
    37. 37.  Metaphyseal spike may damage physis 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 x-ray evidence of physeal arrest formation in the distal radial physis.
    38. 38. Type III  Begins in the epiphysis as a fracture thro the articular surface  2 fragments- small portion of epiphysis and physis large with long bone  Type 3 fracture fixed with screw 
    39. 39.      Type IV Veritical shear Disrrupt articular cartilage Metaphyseal and epiphyseal cross union is common Reduction and stabilization
    40. 40.  Type V  Unrecognized compression  Normal x ray show a premature physeal closure later
    41. 41. Poland classification Poland type I, epiphyseal separation without metaphyseal fragment, or extension into the epiphysis. Poland type II, physeal fracture line extends into the metaphysis. Poland type III fracture extends from the articular surface to the physis and continues peripherally through the physis. Poland type IV, T-condylar fracture of the epiphysis and physis.
    42. 42. Aitken classification    Type 1 – SH2 Type 2 – SH 3 Type 3 – SH 4
    43. 43. Petersons Classification  Does not accept SH 5  Peterson 2 to 5 like SH 1 to 4   Peterson 1- transverse metaphyseal fracture with longitudinal extension into physis Peterson 6- partial physeal loss
    44. 44. Evaluation of physeal injury  Xray  CT  MRI  USG  Arthorgraphy to assess the congrugency of articular surface
    45. 45. Treatment  Stabilize first  General principles  Children # heal rapidly  Cast immobilization  Accurate reduction  Complication – growth disturbance, neurovascular compromise
    46. 46. Physeal growth disturbance  Etiology    Blounts disease   Peterson type 6, Infection, Cyst Purpura fulminans Evaluation- serial x rays Loss of physeal contour, radiolucency between physeal and metaphyseal bone Asymmetric growth arrest line that does not taper to the physis is a strong indication of the presence of physeal growth disturbance without frank physeal arrest. In this case, the asymmetric growth arrest line is noted in the proximal tibial metaphysis on computed tomography scan.
    47. 47. Harris growth arrest line tapering to the physis at the level of the growth arrest can serve as an excellent x-ray confirmation of the presence of the true growth arrest. Although most commonly noted on plain x-rays, these arrest lines can be seen on computed tomography (CT) scans and magnetic resonance images as well. A. Anteroposterior x-ray of the distal tibia after Salter-Harris type IV fracture demonstrates a Harris growth arrest line tapering to the medial distal tibial physis, where a partial physeal arrest has formed. B. Harris growth arrest line as noted on CT. CT scans with coronal (C) and sagittal (D) reconstructions corrected for bone distortion provide excellent images of the location and size of arrest.
    48. 48. Magnetic resonance imaging scan of a patient with traumatic lateral distal femoral partial growth arrest. Note Harris arrest line tapering to the site of the arrest.
    49. 49. Magnetic resonance imaging scan (threedimensional spoiled recalled gradient echo images with fat saturation) provides excellent visualization of the affected area and some sense of the integrity of the residual physis. This patient has infantile Blount disease.
    50. 50. Physeal arrests Potential Causes Traumatic vascular disruption Transphyseal infection Vascular collapse associated with infection (purpura fulminans) Infantile Blount's disease Irradiation Unicameral bone cyst Enchondroma limb shortening, angular deformity, and epiphyseal distortion, depending on the duration of the arrest, the physis affected, and the size of the arrest. A long, standing film of the lower extremities with the hip, knee, and ankle joints included provides an overall assessment of angular deformity and shortening.
    51. 51. Classification of physeal arrests 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.
    52. 52. Management    Prevention of arrest formation Gentle anatomic and secure reduction Fat grafting NSIAD's ??
    53. 53. Physiolysis   Partial physeal arrest resection Principle- to remove bone between metaphysis and physis and fill defect with bone reformation retardant
    54. 54. Physeal distraction    External fixator is used to span the arrest . Gradual distraction until arrest separates Distraction injury may cause complete cessation of normal physeal growth
    55. 55. Repeated osteotomies   Corrective osteotomy of adjacent metaphysis to correct angular deformity Completion of epiphysisodesis and management of resulting limb length discrepancy  Epiphysiodesis prevents angular deformtiy  Limb lengthening can be considered
    56. 56. Physeal arrest resection  Etiology- trauma/ blounts- good prognosis infection / tumour- unlikely to show growth    Central and linear arrest regrowth more likely Proximal humeral and femoral leisions more difficult to exposeadequate resection unlikely Arrests affecting >25% of total surface area are unlikely to grow
    57. 57. Preoperative planning extent and location of the arrest relative to the rest of the physis must be carefully documented evaluate an arrest is with reconstructed sagittal and coronal CT images to provide views orthogonal to the affected physis estimation of the affected surface area can be computed with the assistance of the radiologist using a modification of the method of Carlson and Wenger Reconstructed magnetic resonance images allow estimation of the percentage of surface area of the physis affected by a growth arrest. This workstation reconstruction delineates the perimeter of normal physis (border 2) and that of the physeal arrest (border 1). Surface area affected can be calculated from these reconstructions.
    58. 58. The arrest must be resected in a manner that minimizes trauma to the residual physis. Central lesions should be approached through either 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 Fluoroscopy is needed to keep the surgeon oriented properly to the arrest and the residual healthy physis.
    59. 59. A high-speed burr worked in a gentle to-andfro movement perpendicular to the physis usually is the most effective way to gradually remove the bone composing the arrest and expose the residual healthy physis
    60. 60. By the end of the resection, all of the bridging bone between the metaphysis and 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
    61. 61. Prevent Re-forming of Bridge between Metaphysis and Epiphysis A bone-growth retardant or a spacer material should be placed in the cavity created by the arrest resection to prevent re-forming of the bony bridge between the metaphysis and epiphysis. Four compounds have been used for this purpose either clinically or experimentally: autogenous fat , methylmethacrylate , silicone rubber , and autogenous cartilage. Silione and cartilage not used anymore Methlymethacrylate is inert but gives structural stability in large resection and in weight bearing areas (tibia in blounts disease)
    62. 62. Metallic markers should implanted in the epiphysis and metaphysis at the time of arrest resection to 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 Resumption of longitudinal growth may not occur despite technically adequate arrest resection in patients with good clinical indications. The treating surgeon be alert to those developments, so that proper intervention can be instituted promptly. Embedded metallic markers serve these purposes
    63. 63. Treatment recommendations On average, approximately 60% of physeal arrests demonstrate clear x-ray evidence of resumption of longitudinal growth of the affected physis after physeal arrest resection. There is a correlation between the amount of surface area of the physis affected and the prognosis for subsequent longitudinal growth after arrest resection. Physeal arrests affecting less than 10% of the surface area of the physis have a better prognosis than larger arrests. Langenskiod stage VI infantile Blount disease has results comparable to post-traumatic physeal arrests. Etiologies other than post-traumatic and infantile Blount disease have poor prognoses for subsequent growth. Central and peripheral arrests have equivalent prognoses with respect to resumption of growth. Early growth resumption may be followed by cessation of longitudinal growth before skeletal maturity. As a consequence, patients must be evaluated regularly until skeletal maturity with some reliable method (such as metaphyseal and epiphyseal x-ray markers) to detect such development as promptly as possible.
    64. 64. Growth Deceleration Without Arrest growth deceleration without frank cessation of growth is characterized by x-ray abnormality of the appearance of an injured physis clinical or x-ray deformity if the disturbance is severe and long-standing, but without complete cessation of growth in the affected area The concept of growth deceleration without arrest is most readily appreciated in patients with adolescent Blount disease and the milder stages of infantile Blount disease, infection and physeal fracture there is no sclerotic area of arrest on plain x-rays A growth arrest line, if present, may be asymmetric but will not taper to the physis, thereby suggesting growth asymmetry but not complete arrest.
    65. 65. Management The diagnosis of physeal growth disturbance usually is made incidentally by noting physeal abnormality on x-rays during physeal fracture follow-up or after a diagnosis of frank physeal arrest has been excluded during the evaluation of a patient with angular deformity and physeal abnormality on plain x-rays. Assess extent of limb length inequality and the calculated amount of potential growth remaining for the affected physis. If angular deformity is present or progressive, treatment options include hemiepiphysiodesis or stapling and corrective osteotomy, with or without completion of the epiphysiodesis.
    66. 66. Hemiepiphysiodesis or stapling of the affected physis on the convex side of the deformity may result in gradual correction of the deformity. If correction occurs, options include completion of the epiphysiodesis (with contralateral epiphysiodesis if necessary to prevent the development of significant leg length deformity) or removal of staples with careful longitudinal observation for recurrence or overcorrection of deformity. Corrective osteotomy is the other option for the management of growth disturbance with established angular deformity. Treating surgeon must decide whether to perform epiphysiodesis of the affected physis (with contralateral epiphysiodesis, if appropriate) to prevent recurrence or to ensure careful longitudinal observation of the growth performance of the affected physis until skeletal maturity.
    67. 67. Conclusion Physeal injuries are common Gentle and expert management to maximize restoration of normal limb function and longitudinal growth Follow up with serial x rays to identify physeal arrest
    68. 68. References  Rockwood and wilkins fractures in children  AO trauma manual
    69. 69. Thankyou

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