1. 2005년도 소아정형외과학 연수강좌 인제대학교 일산 백병원 주 석규 2005년 11월 12일
PHYSEAL INJURY
2005년도 소아정형외과학 연수강좌
인제대학교 일산 백병원
주 석규
2005년 11월 12일

2. ANATOMY VASCULAR SUPPLY Epiphyseal a.: Nutrient a.
Supplies proliferative zone chondrocytes
Nutrient a.
Capillary loops ends at the bone-cartilage interface of the growth plate
Avascular lower proliferative and hyprtrophic zone

3. ANATOMY VASCULAR SUPPLY Metaphyseal a. and periosteal a.
Collateral supply
Perichondral a.
Supplies perichondral ring of LaCroix

4. ANATOMY Cartilagenous Component Reserve Zone Proliferative Zone
Hypertrophic Zone

5. ANATOMY Cartilagenous Component Reserve Zone
Chondrocytes produce cartilagenous matrix.
Inactive in cell or matrix turnover
Low oxygen tension lowest calcium content
Not participate in longtitudinal growth

6. ANATOMY Cartilagenous Component Proliferative Zone
Highest oxygen tension
Matrix production and cellular division contribute to longitudinal growth

7. ANATOMY Cartilagenous Component Hypertrophic Zone
Weakest region within the growth plate(low matrix volume, high cellular volume)
Ultimate fate of the hypertrophic zone cell is cell death
Avascular and low oxygen tension
Zone of provisional calcification

8. Cause of Physeal Injury
Fracture, disuse, radiation, infection, tumor, vascular impairment, neural involvement, metabolic abnormality, frostbite, burns, electric burns, laser injuries, chronic stress, iatrogenic injury

9. PHYSEAL FRACTURES History Fables of Amazon Hippocrates Severinus(1632)
Malgaigne(1855)
Poland(1898)

10. FRCTURE PLANE -Between calcified and uncalcified cartilage
-Proliferating cells remain with epiphysis.
-The plane is avascular, less bleeding and swelling

11. Classification
Poland’s Classification(1898):

12. Classification
Bergenfeldt(1933): First radiologic classification

13. Classification
Aitken(1936)

14. Classification
Peterson(1994):

15. Classifcation
Salter and Harris(1963):
Rang(1969):

16. Classification Salter-Harris Classification Practical, easy to use
Guide to rational treatment
Covers most fractures

17. Classification Salter-Harris I: Complete separation of epiphysis
The Germinal cells remain with the epiphysis
X-ray may seem normal
Shearing, torsion or avulsion injury
Scurvy, rickets, hormonal imbalance, infection
Early healing
Proximal and distal femur

18. Classification Salter-Harris II: Thurston-Holland Fragment
Easy reduction
Over reduction prevented by periosteum
Irreducible; shaft of the bone trapped in the buttonhole tear of periosteum

19. Classification Salter-Harris III: M/C in partially closed physis
Often requires open reduction

20. Classification Salter-Harris IV: Lateral condyle fx, med malleolar fx.
Neglected: loss of position, nonunion,
growth arrest
Not all type IV injuries are the same

21. Salter-Harris type IV

22. Classification SALTER-HARRIS V:
Crushing injury vs there is no fracture
X-ray at the time of injury shows no abnormality
Can longitudinal force compress the physis enough to kill cells without causing any fracture?
Possibility of disuse or arterial insufficiency
In association with long bone fracture

23. Classification SALTER-HARRIS VI: Peichondral ring injury
Lawn mower injury
Skin loss, difficult skin coverage
Often growth arrest

24. EPIDEMIOLOGY Male:Female=2:1
Boys 14yrs old, girls 11 to 12 yrs old most
common
Phalanges of fingers > distal radius
Distal > Proximal

25. EVALUATION 2 Plane radiograph Stress view Tomogram Arthrograms
CT scans
MRI
Ultra Sound

26. TREATMENT Gentle reduction Never forceful repeated reduction
Reduce as soon as possible

27. TREATMENT PetersonType I: -Least potential damage to physis
-Growth arrest 3.4%

28. TREATMENT Growth arrest : Distal femur: frequent growth arrest
Salter-Harris I:
Growth arrest :
Type I > type II
Distal femur: frequent growth arrest
Proximal tibia:
Vascular injury

29. TREATMENT Salter-Harris II: Scraping of the physis
Relaxed by anesthesia
Metaphyseal fragment prevents overreduction
Periosteum intact on the metaphyseal fragment side
Periosteum impingement
Open reduction
Intact proliferative layer

30. TREATMENT Impinged Periosteum (Gruber, JPO, 2002) -Intact physis:
Degradation of periosteum
Periostum pushed away
-Ablation of Physeal cartilage:
Dramatic injury, growth arrest

31. TREATMENT Salter-Harris III: Needs anatomic reduction
Epiphysis to epiphysis fixation

32. CONSIDERATIONS IN TREATMENT
Accurate diagnosis:
CT, MRI,
Stress view,
arthrogram

33. CONSIDERATIONS IN TREATMENT
Reduce or not to reduce:
7-10 days?

34. CONSIDERATIONS IN TREATMENT
OR or CR:
-Malreduction of Type I, II vs III,IV
-Impinged periosteum
Immobilization period:

35. PROGNOSIS
SEVERITY OF THE INJURY
AGE
TYPE OF FRACTURE

36. COMPLICATIONS Sepsis Overgrowth Malunion Delayed or nonunion
Compartment syndrome
AVN: proximal femur
Premature Growth Arrest

37. PHYSEAL ARREST Occur at the time of injury, during reduction, or
internal fixation
Study:
Skeletal age
Leg length measurement
Localization of bar;
Tomography, CT, scintigraphy, MRI

38. PHYSEAL ARREST MRI - Preop: for mapping the lesion
-Early postop: to detect incomplete resection
-6mths postop: to detect bridge recurrence, migration and necrosis of the interpositional material

39. PHYSEAL ARREST Management Complete arrest vs partial arrest
Cessation of growth without angular deformity
U/E physis;
10 cm > no treatment
L/E physis;
Pelvic tilt and spine curvature
 Low back pain

40. PHYSEAL ARREST Management Osteotomy Bar excision
Arrest of remaining physis
Shoe lift
Lengthening,
Contralateral shortening,
Physeal distraction,
Transplantation of epiphysis and physis

41. PHYSEAL ARREST Management Leg length discrepancy;
2.5 cm > shoe lift
2.5 cm to 5 cm contralateral shortening
Only for femur
Tibia  muscle weakness
5 cm < lengthening

42. PHYSEAL BAR EXCISION Physeal bar: Formed by primary ossification
along areas of vertical septa
Indications of excision:
< 50% of physis involved
> 2 yrs of remaining growth

43. PHYSEAL BAR EXCISION Interposition material
To prevent blood from occupying the cavity, organizing, and re-formation of a bone bar
-Bone wax
Autogenous fat: lacks hemostasis function
Cartilage: apophysis of iliac crest
Silicone rubber: commercially not available

44. PHYSEAL ARREST BAR EXCISION Interposition material
Polymethylmethacrylate: load sharing
better for large lesion

45. PHYSEAL BAR EXCISION Animal Study -Cultured chondrocytes (E.H. Lee)
-Mesenchymal stem cell with TGF beta
(J.I. Ahn)

46. PHYSEAL ARREST Classification Peripheral: approach directly
Elongated: common after S-H IV
Central: approach through metaphysis

47. PHYSEAL ARREST Classification Peripheral: approach directly
Elongated: common after S-H IV
Central: approach through metaphysis

48. PHYSEAL ARREST Technique Burr and dental mirror Flat and smooth cavity
Do not weaken the epiphysis
Oreo cookie like

49. PHYSEAL ARREST Technique Do not undermine epiphysis and metaphysis
Metal marker
Angular deformity > 20 degrees
 Combine with osteotomy

50. PHYSEAL ARREST Results Operated physis may close earlier
Bar 50% < usually fail
Bar 50% < excision should be tried in young children

51. PHYSEAL ARREST Results
Only 2.2% of all physeal injuries are at the knee
50% of bar excision are at the knee
Avg growth: 84 % of opposite side
Distal tibia > prox tibia > distal femur
Distal femur
 more large lesion
poorer result