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PHYSEAL INJURIES & GROWTH DISTURBANCE. Dr.Ghaznavi Pediatric Orthopedic Fellowship TUMS. 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. Classification. Mercer Rang. - PowerPoint PPT Presentation
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PHYSEAL INJURIES & GROWTH DISTURBANCE
Dr.Ghaznavi Pediatric Orthopedic Fellowship
TUMS
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.
Physeal injuries
Obvious
Subtle
Etiology
Trauma
Infection
Tumor
Vascular
Repitative stress
Irradiation
Classification
Poland1898
Aitken1936
Salter-Harris1963
Peterson1994
Mercer Rang
Peterson
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
Type 2
• limited propensity to subsequent growth disturbance
• (the Thurston-Holland fragment or sign).
• Hypertrophic zone
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
Type 4• vertical shear fractures• metaphyseal-epiphyseal
cross-union• subsequent growth
disturbance.• Frequent around the medial
malleolus, Lateral condylar• anatomic reduction and
adequate stabilization
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
Salter-Harris classification remains aneasily recognized and recalled classification
SH
Prognostic
Tx. guidline
20%to 30% of all childhood fractures were physeal injuries.
Study between 1979 and 1988, in Olmstead County, Minnesota. 951 physeal Fx 1979-1988
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
Treatment
Open physeal injuries
N.V compromise
Compartment synd.Emer
gent
SH 1,2Minimal risk of
growth retardationExcept distal femur &
proximal tibia
Excellent remodeling potential
not to create physeal injury by excessively forceful or invasive reductions.
SH 3,4Anatomic reduction
Restore articular surface
Prevent epiphyseal-metaphyseal crossunion
HARRIS GROWTH ARREST LINES
• 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
PHYSEAL GROWTH DISTURBANCE
EtiologyPeterson
6
disruption architecture & function
bony bridges or physeal
bars.
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
MRI scan (three-dimensional spoiled recalled gradient echo images with fat saturation)Alignment view
Scanogeram
Classification
Angular DeformityLLD
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
Prevention
treatment principles
Gentle
Anatomic
Secure fixation
immediate fat grafting
NSAID
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
Pre Op. planning
Extent & Location
CT ,MRI
Minimize trauma
Metaphyseal windowFluoroscopyBriliant light sourceMagnifictionDry surgical fieldArthroscopeHigh speed burr
Prevent reforming of bridge
Autogenous fatMethylmethacrylateSilicone rubberAutogenous cartilage
Marker implantation
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