1. Dr.Ghaznavi Pediatric Orthopedic Fellowship TUMS

2. One of the unique aspects of pediatric orthopaedics is the presence of the physis (or growth plate), which provides longitudinal growth of children's long bones.

3. Physeal injuries ObviousSubtle

4. Etiology Trauma Infection Tumor VascularRepitative stress Irradiation

5. Classification

6. Mercer Rang

7. Peterson

8. Type 1 Transphyseal plane of injury soft tissue swelling, making careful patient examination phalanges, metacarpals, distal tibia, and distal ulna. Ultrasound,MRI,Arthtography Stress Radiography unnecessary fracture line in zone of Hypertrophy subsequent growth disturbance is relatively uncommon

9. Type 2 limited propensity to subsequent growth disturbance (the Thurston-Holland fragment or sign). Hypertrophic zone

10. Type 3 through the articular surface and extend vertically toward the physis Germinal and proliferative high-energy or compression higher risk of subsequent growth disturbance. Anatomic reduction (usually open) and stabilization

11. Type 4 vertical shear fractures metaphyseal-epiphyseal cross-union subsequent growth disturbance. Frequent around the medial malleolus, Lateral condylar anatomic reduction and adequate stabilization

12. Type 5 Unrecognized compression injuries with normal initial radiographs later produced premature physeal closure. most common example of such an injury is closure of the tibial tubercle

13. Salter-Harris classification remains an easily recognized and recalled classification Salter-Harris classification remains an easily recognized and recalled classification

14. 20%to 30% of all childhood fractures were physeal injuries. Study between 1979 and 1988, in Olmstead County, Minnesota. 951 physeal Fx 1979-1988

15. The phalanges represent the most common location Next most common site the distal radius peak incidence at age 14 in boys and 11to 12 in girls 2: 1 male to female ratio

16. Treatment Open physeal injuries N.V compromise Compartment synd. Emergent

18. SH 3,4 Restore articular surface Prevent epiphyseal- metaphyseal crossunion Anatomic reduction

19. Transversely oriented condensations of normal bone represent slowing or cessation of growth effective representation of the health of the physis If transverse and parallel, growing normally If partial injury, the growth arrest line will be asymmetric

20. Etiology Peterson 6 disruption architectur e & function bony bridges or physeal bars.

21. Evaluation plain radiography CT scanning with sagittal & coronal reconstructions hallmark of plain radiographic loss of normal physeal contour Frank physeal arrests Sclerosis in the region of the arrest

22. MRI scan (three-dimensional spoiled recalled gradient echo images with fat saturation) Alignment view Scanogeram

23. Classification Angular Deformity LLD

24. Management Prevention of Arrest Formation. Partial Physeal Arrest Resection. Physeal Distraction Repeated Osteotomies during Growth Completion of Epiphysiodesis and Management of Resulting Limb Length Discrepancy

25. Prevention treatment principles GentleAnatomic Secure fixation immediate fat grafting NSAID

26. Physeal Arrest Resection Factors should be consider Etiology Anatomic type Physis Extent of arrest Amount of growth remaining Good prognosis Poor prognosis Trauma,ITV Infection;Tumor; Irradiation Central, Linear, Better prognosis Good prognosis Poor prognosis Distal Femur Distal tibia 25% >2y

27. Extent & Location CT,MRI Minimize trauma Metaphyseal window Fluoroscopy Briliant light source Magnifiction Dry surgical field Arthroscope High speed b urr

28. Prevent reforming of bridge Autogenous fat Methylmethacrylate Silicone rubber Autogenous cartilage Marker implantation

30. زندگي زيباست اي زيبا پسند زنده انديشان به زيبايي رسند آنقدر زيباست اين بي بازگشت كز برايش مي توان از جان گذشت باغ ها را گرچه ديوار و درست از هواشان راه با يکديگر است شاخه ها را از جدايي گر غم است ريشه هاشان دست در دست هم است زندگي زيباست اي زيبا پسند زنده انديشان به زيبايي رسند آنقدر زيباست اين بي بازگشت كز برايش مي توان از جان گذشت باغ ها را گرچه ديوار و درست از هواشان راه با يکديگر است شاخه ها را از جدايي گر غم است ريشه هاشان دست در دست هم است

31. Thank you