PHYSEAL FRACTURES Manoj Ramachandran

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PHYSEAL FRACTURES Manoj Ramachandran
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STRUCTURE OF THE GROWTH PLATE
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CLASSIFICATION

• Salter and Harris JBJS 45A587 1963
• Ogden
• Peterson
• Many more

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SALTeR AND HARRIS
Separation
Above
Lower
Through
Reduced
Thurston Holland fragment (British radiologist
1929)
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PATHOPHYSIOLOGY

• Anatomy of the physis is of 3 or 4 orders of
  interdigitation
• Anisotropic, nonhomogenous and viscoelastic
• Salter Harris thought fracture through
  hypertrophic zone - ?true

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PATHOPHYSIOLOGY

• WHAT FRACTURES?
• In vitro isolated growth plate specimens

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ANATOMY

• Structure / Strength
• Perichondrial ring
• Macroscopic
• Undulations
• Microscopic
• Mamillary processes

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INCIDENCE

• Incidence - 15-30 of childhood fractures
• Age
• Commoner in older children (10-17)
• Peak 9-12 F and 12-15 M
• Sex - MgtF
• Upper limb lower limb 31
• 92.5 nonoperative management

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INCIDENCE

• SH Mizuta Peterson
• 1- 8.5 13.2
• 2- 73 69.1
• 3- 6.5 10.9
• 4- 12 6.5
• 5- rare rare

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INCIDENCE

• Growth arrest (Peterson JPO 14 1994)
• Complete 3.9
• Partial 2.5
• Bar excision 0.3

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SITE

• Phalanges 37
• Distal radius 18
• Distal tibia 11
• Distal fibula 7
• Distal femur 2-5

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DIAGNOSIS

• History and examination
• X-ray
• stress views
• CT
• MRI

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TREATMENT

• Stability
• Joint congruency
• Risk of physeal arrest
• Site
• Distal femur
• Dale and Harris - Type A epiphyseal blood supply
  to proximal femur and proximal radius
• SH classification
• Delay to treatment
• Rang, Salter leave type I or II if more than
  2/52

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SURGICAL PRINCIPLES

• Take care of the soft tissues
• Perichondrial ring and periosteum
• Use instruments carefully
• Smooth pins inserted once only!
• Screw threads should not cross the physis
• Small cannulated screw system

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PHYSEAL ARREST

• CAUSES
• Trauma
• 3 months to years after injury
• 1-10 of physeal fractures
• Infection- may not present for years
• Iatrogenic
• Drugs - chemotherapy
• Tumour
• Irradiation- gt1500 rads
• Thermal

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PHYSEAL ARREST

• Energy of fracture
• Anatomical site
• Distal femur/ proximal tibia (3 of but 55 of
  arrests)
• Large, complex contour, rate of growth
• SH 3 and 4
• Formation of vascular anastomoses between
  epiphseal and metaphyseal vessels

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CLASSIFICATION

• Partial / complete
• Peripheral / central / combined - Bright
• Peripheral
• angular
• /- longitudinal
• Central
• longitudinal deformity
• /- angular

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ASSESSMENT

• Plain films
• Physis and Harris line converge
• CT
• MRI
• Also bone age and limb length

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TREATMENT

• Offer if
• At least 1 year of growth remaining
  (Langenskiold)
• At least 2 years of growth remaining (Birch)
• At least 2.5 cm of growth remaining (Kasser)

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OPTIONS

• Shoe raise
• Osteotomy
• Stapling
• Epiphysiodesis
• Epiphysiolysis
• Ilizarov

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EPIPHYSIOLYSIS

• Langenskiold 1967
• Excise bar
• Preserve as much viable physis as possible
• Plan approach
• Interpose a spacer

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SURGICAL APPROACH

• PERIPHERAL (A)
• Directly
• Excise with wide margin of periosteum
• CENTRAL (B and C)
• Via metaphysis or osteotomy
• ?fiberoptic lighting/dental mirrors
• ANGULAR DEFORMITY
• If gt20 degrees will need osteotomy

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SPACER MATERIAL

• Fat (local or distant e.g. buttock)
• Methylmethacrylate
• Silastic
• Cartilage

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RESULTS

• Better if bar less than 50 of physeal area
• Physis at other end of bone can accelerate
• Recurrent bridge can be re-excised
• If premature arrest, then can arrest other side

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SUMMARY

• Less than 5 of physeal fractures result in
  growth disturbance
• Certain sites more prone to growth disturbance
  e.g. knee

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SUMMARY

• Always warn parents of possibility of arrest
• Effective treatment available for arrest
• Physeal bar resection
• Deformity correction and lengthening