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1 PHYSEAL INJURY 2006 년도소아정형외과학연수강좌인제대학교일산백병원주석규 2006 년 11 월 11 일

2 ANATOMY VASCULAR SUPPLY Epiphyseal a.: Main blood supply to epiphysis and physis 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 Vascular Supply Two types of Epiphyseal artery Intracapsular physis, extracapsular physis

5 ANATOMY Cartilagenous Component of physis Reserve(resting) ) Zone Proliferative Zone Hypertrophic Zone

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

7 ANATOMY Cartilagenous Component of physis Proliferative Zone Highest oxygen tension Matrix production and cellular division contribute to longitudinal growth

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

9 ANATOMY Groove of Ranvier: Responsible for the growth of the physis in width. Perichondral Ring of LaCroix: Provides support to the physis and resistance to seperation.

10 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

11 History of Growth Plate Fables of Amazon Hippocrates Ambroise Pare(1500): Earliest known reference of the growth plate. Severinus(1632) Malgaigne(1855) Poland(1898)

12 FRCTURE PLANE The weakest zone is provisional Cartilage zone Between calcified and uncalcified cartilage Proliferating cells remain with epiphysis. The plane is avascular, less bleeding and swelling

13 FRCTURE PLANE Fracture rarely limited to one plane. Younger the patient, more likely to limited to one plane. Older the patient more likely to involve proliferative zone and cause growth arrest

14 Classification Poland s s Classification(1898):

15 Classification Bergenfeldt(1933): First radiologic classification

16 Aitken(1936) Classification

17 Peterson(1994): Classification

18 Classifcation Salter and Harris(1963): Rang(1969):

19 Classification Salter-Harris Classification: Practical, easy to use. Guide to rational tx. Covers most fractures.

Classification Salter-Harris I: Complete separation of epiphysis The Germinal cells remain with the epiphysis -rate of load, maturity of physis,, type of

20 Classification Salter-Harris I: Complete separation of epiphysis The Germinal cells remain with the epiphysis -rate of load, maturity of physis,, type of joints X-ray may seem normal!!! Shearing, torsion or avulsion injury Scurvy, rickets, hormonal imbalance, infection Early healing Proximal and distal femur

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

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

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

24 Salter-Harris type IV

$Classification SALTER-HARRIS V: Crushing injury vs there is no fracture X-ray at the time of injury shows no abnormality Can longitudinal force$

25 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

26 SALTER-HARRIS VI: Classification Perichondral ring injury Lawn mower injury Skin loss, difficult skin coverage Often growth arrest

27 Epiphyseal fracture

28 EPIDEMIOLOGY 15-30% long bone fracture involve physis Growth disturbance in 10% of physeal injury Male:Female=2:1 Boys 14yrs old, girls 11 to 12 yrs old most common Uncommon in children less than 5 yrs old Growth arrest most likely in early adolescence Thin physis and weak cartilage Phalanges of fingers > distal radius Distal > Proximal

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

30 TREATMENT Gentle reduction Never forceful repeated reduction Reduce as soon as possible

31 PetersonType I: Least potential damage to physis Growth arrest 3.4% TREATMENT

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

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

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

35 TREATMENT Salter-Harris III: Needs anatomic reduction Epiphysis to epiphysis fixation Epiphysis to metaphysis with smooth wire

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

37 CONSIDERATIONS IN TREATMENT Reduce or not to reduce: 7-10 days?, 3weeks?, 3mths?...

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

39 PROGNOSIS Severity of the Injury Remaining growth potential Anatomic site(undulation, multiplanar physis) Type of Fracture Size of the injury

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

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

42 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

43 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

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

45 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 5 cm < lengthening

46 PHYSEAL ARREST Physeal bar: Formed by primary ossification along areas of vertical septa Indications of excision: < 50% of physis involved > 2 yrs of remaining growth Not all bar cause growth arrest Damage < 7% of the physis usually does not cause permanent physeal arrest

47 PHYSEAL ARREST

48 PHYSEAL ARREST 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

49 PHYSEAL ARREST BAR EXCISION Interposition material Polymethylmethacrylate : load sharing better for larger lesion

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

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

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

53 PHYSEAL ARREST Langenskiold s procedure Jackson s Modification approach

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

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

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

57 Results PHYSEAL ARREST 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

( ) Jkra076.hwp

( ) Jkra076.hwp Vol. 11, No. 4, December, 2004 Objective: Ultrasonography (USG) of joints has a unique position for the diagnosis of joint diseases. Bone surface, cartilage, periarticular soft tissue and their pathologic