Phenomenon's of bone growth

and their therapeutic use

Bone growth

• Some important parameters– Age of the patient– Participation of the growth plates in growth– Type of motion of the joints– Localisation of fractures in the skeleton

• Posttraumatic kinds of growth disturbances (GD) and “spontaneous” correction of deformities

• Integration into treatment– Primarily– Secondarily

Growth and „grow-out“

• Who is grown up can’t “grow-out” nothing

But only grow-at!

Growth of bone

• Long bones have two epiphyseal plates• Little bones (finger, tooth, metacarpalia and metatarsalia)

have only one epiphyseal plate

• The growth plates of long bones grow eccentrically• High per cent growth plates

are growing longer • Low per cent growth plates

are growing shorter

80%

80%

70%

50%

50%

20%

30%

Wachstum am Knochen

• For “spontaneous” correction of deformities the functional stimulus is very important • functionally• statically

• There is a great difference between • Upper E. / functionally• Lower E. / statically

Wachstum am Knochen –Wachstumsstörungen (WTS)

• For „growth disturbances“ the functional stimulus seems to be important???• functionally• statically

• Difference• Upper E. / (functionally)

• Lower E. / (statically)

Growth disturbances (GD)

Stimulativ

Arrestive

Stimulative GD

• Obligatory after all fractures in childhood

• Affected are– In most of all cases one ore more epiphyseal plates

around the fracture

– Rare are partial stimulations

• GD temporary till consolidation / end of remodelling

• Consequences – Most of all lengthening without axial deviation

– rare lengthening with axial deviation

Stimulative GD (growth plate at all) - character:stimulates the age-dependent condition of the plate

< 10. year > 10. year

: fracture

lengthening

shortening(„growth plate is burning out early“)

Partial stimulation

• Condylus radialis humeri

• Valgus fractures of the proximal and the distal tibia

Partial stimulation

• Condylus radialis humeri

• Valgus fractures of theproximal and the distal tibia

arrestive GD

• Facultative (between 5-50%)

• After fx nearby the growth plate (lower E. > upper E.)

– most of all partial arrest o the growth plate

– Rare total arrest of the growth plate

• GD permanent till end of growth

• Consequences – Most of all shortening with axial deviation

– Rare shortening without axial deviation

Arresting GD

Both GD s – growth with increasing deformity

• Difference between upper and lower E. (Zehnter et al 1990, Berson et al 2000, Lonjon et al 2012, von Laer et al 2013

etc.)

With weight bearing

Without weight bearing

Prognosis of growth: upper / lower E.

• upper E.

– Arrest GD < 5%

– Stimulative GD > 70%

After extraarticular Fx

After intraarticular Fx

Prognosis of growth: upper / lower E.

• Lower E.

– Arrest GD > 20 %

– Stimulative GD < 5%

Knee: up to 50% premature arrest (physiological arrest

of the growth plate: around 15 y)

Ankle joint: up to 20% prmature arrest (physiological arrest

of the growth plate around 12 y)

After extra- andintraarticular Fx

After extraarticular Fx

Classification - Prognosis of growth?

• Arresting GD

– Salter and Harris (and others) would induce epiphyseal separations do have a better prognosis of growth than epiphyseal fractures – and classified

Classification

• Aitken classified the distal femur• Salter und Harris classified the distal tibia

• Epiphyseal separations do have the peak of age around the puberty– The growth plates around the knee will close

physiologically between14-16 Years – after the begin of puberty

– The growth plates around the distal tibia will close physiologically around 12 Years – before the begin of puberty

Prognosis of growthepiphyseal separations

• Arresting GD

– Bad for the fractures around the knee (ca 50%)

– better for the fractures of the distal tibia (10-20%)

– Good for the upper E. (< 5%)

4

1

Stimulation or arrest?

Arrest should shorten

Stimulation should lengthen

Lit. talks about a partial arrest: OSG: Berson et al 2000, Baramada et al 2003, Rohmiller et al. 2006,

Cottalorda et al. 2008, Leary et al, 2009, Schurz et al. 2010: right or wrong?

Wich deformity? Valgus

Deformities of the distal tibia - cause

• Valgus

– Partial stimulation (temporary)

– Shortening of the fibula caused by an exostosis: increasing valgus deformity (no

arrest but retardation)

• Varus

– Arrest (partial closure of the growth plate) after epiphyseal fractures and separations

classification

Should be addressed to the kind of treatment and not to the prognosis of growth

GelenkFugengelenkfrakturen

SchaftFugenschaftfrakturen

„Spontaneous Corrections“

In all planes of the space

„Spontaneous Corrections“

• Possible in all planes (Frontal-,

Sagittal- und Transversal plane as wellas shortening)

– But by different mechanismen

Schema of “spontaneous corrections“

Correction of axial deviations

Epiphysis: asymmetric growth

+

Shaft:periostal-endostaladditional growth

Aimed correction with two components

Correction of rotational deformities

Unaimed correction

In the frame ofPhysiological detorsions

• Physiological detorsion will be found in all bones• At different point of growth• With different duration

A rotational defomrity nearby hinge joints could not be compensated by the joint in contrary by a multidimensional movable joint

Correction of rotational deformities -duration

Over years!

Therefore it must be compensable functionally

• Functional compensable• Humerus and femur

• Not compensable• Lower leg• Fingers and toes• Metacarpus and metatarsus• Forearm???

Korrektur Längendifferenz

Ungezielt indirekt

• Belassene Verkürzung: meist überschießende „Korrektur“• Belassene Verlängerung: keinerlei Korrektur (Verstärkung)

Integration into treatment

primarily

secondarily

Integration of corrections primarily

Leave a deformity primarily

• Ist the deformity clinically visible? (neighbour!)

• Reasonable???

Extent of treatment?• Reduction or• Redression (plaster wedging)?

Growth of bones - corrections

Upper E.: high percentage plates nearby multidimensional movable joints (shoulder and wrist)

• High functional stimulus! / no static stimulus!

• Lower E.: high percentage plates nearby monofunctional joints (knee

und ankle joint)

• Low functional stimulus (only in the sagittal plane) / high static stimulus

Spontaneous correction=Longer stiumlation=Increased lengtheninngor shortening

Integration of spontaneous corrections primarily

• Only at upper E.

– Reasonable (clinically no visible deformity)

– Reliable (age of the patient and localisation in the skeleton)

• Humerus proximal

• Neck of the radius

• Distal humerus in the sagittal plane in spite of functional disorder up to the age of 6 y

• Forearm distal

Integration of spontaneous corrections primarily

• Exception: – Neck of the radius: excellent

spontaneous correction• 20% participation of growth

• Functional mix of the elbow (F/E; Pro/Sup)

• Danger of necrosis with functional disorder caused by several traumatizations(accident, Reduction, operation aftertreatment etc.)

• Danger of chronicalepiphyseolysis (hopeless situation)

7 8 Wo

8 nach Unfall

Integration of spontaneous corrections secondarily

Is it reasonable to leave the situation?:Ask the patient

• Control the further growth• Find a perfect appointment

for controlling the situation! Depending from the patience and the agressivity of the parents:

Integration of spontaneous corrections secondarily

• At all localisations of the skeleton

– Reasonable (no functional or cosmetically strain)

– Reasonable and wise point to control the influence of growth to the situation

• If it becomes worse an operation should be necessary

• If it becomes better you can wait further on

• First think and wait! It is always enough time for activities!

DRG= indicative spanner in the works

Thanks!