Large head Pliable rib cage, exposed liver and spleen Unprotected bowels Distended bladder avove pelvis. Open physeal plate and thick periosteum

Transcription

1 PHYSEAL INJURY 2008 년도소아정형외과학연수강좌인제대학교일산백병원주석규 2008년 11월 9일

2 Children and Adult Large head Pliable rib cage, exposed liver and spleen Unprotected bowels Distended bladder avove pelvis Open physeal plate and thick periosteum

3 Pediatric Fractures Plastic deformation Buckle fracture Greenstick fracture Complete fracture Physeal Injuries

4 Physis Traction epiphysis(apophysis) Subject to tensile force Contribute to shape of the bone Tibial tubercle, medial epicondyle, iliac crest Pressure epiphysis End of long bones, subjected to compressive forces Between epiphysis and metaphysis, undergoes endochondral ossification Responsible for longitudinal growth

5 Epiphyseal a.: Supplies proliferative zone chondrocytes Main blood supply Nutrient a. Capillary loops ends at the bone-cartilage interface of the growth plate Metaphyseal a. and periosteal a. Collateral supply Perichondral a. Supplies perichondral ring of LaCroix Vascular Supply

6 Vascular Supply By Dale and Harris

7 Cartilagenous Components Germinal Zone Proliferative Zone Hypertrophic Zone Zone of endochondral ossification

8 Cartilagenous Components Cellular Proliferation: at germinal and proliferative zone Matrix production, cellular hypertrophy, apoptosis, matrix calcification: at hypertrophic and provisional calcification zone

9 Germinal Zone(resting Z) Chondrocytes produce cartilagenous matrix. Inactive in cell or matrix turnover Not participate in longtitudinal growth but provides some matrix production and storage function Diastrophic Dwarfism, Pseudoachondroplasia

10 Proliferative Zone Highest oxygen tension Matrix production, and cellular division longitudinal growth Achondroplasia, gigantism

11 Hypertrophic Zone 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 Mucopolysaccharidosis i

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

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

14 FRCTURE PLANE The weakest is z of provisional calcification Between calcified and uncalcified cartilage Proliferating cells remain with epiphysis. The plane is avascular, less bleeding and swelling

15 Classification Poland s Classification(1898):

16 Classification Bergenfeldt(1933): First radiologic classification

17 Classification Aitken(1936)

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

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

20 Classification Peterson(1994):

21 PetersonType I: Vertical line to physis Least potential damage to physis Classification

22 Classification Salter-Harris I: Complete separation of epiphysis The Germinal cells remain with the epiphysis -rate of fl load, -maturity of physis, -type of joints X-ray may seem normal!!! US, MRI, arthrogram

23 Classification Salter-Harris I: Shearing, torsion or avulsion injury Scurvy, rickets, hormonal imbalance, infection Early healing M/C in phalnges, metacarpals, In infants: Proximal and distal femur

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

25 Classification Salter-Harris II: Fracture through the plate, then angles through metaphysis. Most common physeal injury(>50%)

26 Salter-Harris II: Classification -Thurston Thurston-Holland Fragment -Irreducible; shaft of the bone trapped in the buttonhole tear of periosteum

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

28 Classification Salter-Harris III: Vertical intraarticular fracture and transverse fracture of physis M/C in partially closed physis

29 TREATMENT Salter-Harris III: Needs anatomic reduction Epiphysis to epiphysis fixation Epiphysis to metaphysis with smooth wire Mostly physis which h are in process of closing!

30 Salter-Harris IV: Classification Vertical shear fracture from articular surface to metaphysis Involves all layers of physis

31 Classification Salter-Harris IV: Lateral condyle fx, med malleolar fx. Neglected: loss of position, nonunion, growth arrest

32 Salter-Harris type IV

33 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

34 Classification SALTER-HARRIS V: Mechanism of injury may be in dispute but delayed d physeal closure does occur

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

36 EPIDEMIOLOGY 20-30% long bone fracture involve physis 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

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

38 TREATMENT Acceptable reduction: Fracture pattern Remodeling potential Prognosis: Severity of injury Remaining of growth potential Anatomic Site Type of fracture Size of Injury

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

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

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

42 CONSIDERATIONS IN TREATMENT Distal Femur High energy trauma High complication rate (40%) Displaced fracture, Fracture fixed by epiphysis to metaphysis (Arkader et al, JPO, 2007) High complication rate of S-H II Injury (70%) Metaphyseal h l comminunition i i as well as Initial displacement, important factor (Ilharreborde et al JPO-B B, 2006)

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

44 PHYSEAL ARREST Ei Etiology Physeal fx: at the time of injury, during reduction, internal fixation Vascular injury, Transphyseal infection Infantile blount s ds

45 PHYSEAL ARREST Management Prevention: gentle, anatomic secure reduction Partial physeal arrest resection Physeal distraction Repeated osteotomies during growth Epiphysiodesis and management of resulting LLD

46 PHYSEAL ARREST Management U/E: 10cm > may not need treatment L/E: 2.5cm > : shoe lift 2.5cm 25 to 5cm contralateral t l shortening Only in femur, Tibia muscle weakness 5cm < : lengthening

47 PHYSEAL ARREST Prognosis Trauma and Infantile Blount s ds better prognosis Central and linear arrest? Distal femur poor prognosis Distal tibia good prognosis Prox humerus and prox femur technically difficult >25% lesion less likely to grow

48 PHYSEAL ARREST Study: Skeletal age Leg length measurement X-ray: growth line Localization of bar; Tomography, CT, scintigraphy, MRI

49 PHYSEAL BAR EXCISION Physeal bar: Starts to form 1 to 2 months after injury Distal femur and prox tibia < 3 % of physeal fx > 50 % of all physeal bridge resection 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

50 12/F acute osteomyelitis

51 PHYSEAL ARREST Classification Peripheral: approach directly Excise the periosteum instead of suture Elongated: common after S-H IV Central: approach through metaphysis

52 PHYSEAL ARREST Langenskiold s procedure Jackson s Modification approach

53 PHYSEAL ARREST Technique Burr and dental mirror Flat and smooth cavity Do not weaken the epiphysis

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

55 PHYSEAL BAR EXCISION Interposition material Fat, PMMA, bone wax, cartilage, muscle, silicon To prevent blood from occupying the cavity, organizing, and re-formation of a bone bar PMMA: cement should be anchored to the epiphysis and minimal amount used in metaphysis Autogenous fat: lacks hemostasis, may float out of cavity Cartilage: apophysis of iliac crest, cultured autogenous chondrocytes

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

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

58 PHYSEAL ARREST Results Avg growth: 84 % of opposite side Distal tibia > prox tibia > distal femur Distal femur more large lesion(?) poorer result