Physeal Fractures and Growth Arrest
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1 Physeal Fractures and Growth Arrest Raymond W. Liu, M.D. Victor M. Goldberg Master Clinician-Scientist in Orthopaedics Rainbow Babies and Children s Hospital Case Western Reserve University
2 Outline General Distal Femur Proximal Tibia Distal Tibia Growth Arrest Reconstruction
3 General Concepts
4 Physeal Fractures 15-30% of all childhood fractures Uncommon under 5 years Peaks at years
5 I II III IV V
6 Histology Plane of fracture on the diaphyseal side along the zone of hypertrophy Epiphysis Metaphysis
7 SH I distal tibia fracture in an amputated limb, 9 yo M Growth Plate Fracture
8 Distal Femur
9 11 Year Old Male
10 Distal Femur SH II
11 7 Year Old Female
12 Distal Femur SH I
13 Antegrade Pinning
14 16 yo M
15 SH IV, CRPP
16 Undulating physis Bony Anatomy
17 Bony Anatomy 26 distal femoral physes 12 bilateral Ages 3-18 years Liu et al, J Pediatr Orthop 2013
18 Liu et al, J Pediatr Orthop 2013 Bony Anatomy
19 Casting versus skeletal traction 7/10 lost reduction 9 with growth arrest
20 30 fractures 43% reductions treated with cast displaced None with internal fixation displaced Long leg cast
21 151 fractures 30/82 LLC versus 3/29 hip spica lost reduction
22 34 fractures, 19 SHII 13/28 LLD 1cm 11/33 5 degree angulation Higher incidence: Displaced fractures Poorly-reduced fractures
23 Distal Femur Physeal Fx SH I Nondisplaced: cast, consider spica Displaced: closed reduction under anesthesia, smooth pins SHII Closed reduction and cannulated screws Low threshold for open reduction SH III/IV Consider percutaneous screws if non-displaced Open reduction and cannulated screws otherwise
24 Proximal Tibia
25 16 yo M, attempted jump over marble table, direct blow
26 CRPP
27 7 months later, basketball
28 Purposeful Overcorrection
29 28 fractures 2 popliteal artery occlusions
30 28 fractures 3 SH I, 9 II, 6 III, 8 IV, 2 V Sports/MVA/law n mower Corrective surgery in 9 growth disturbances
31 14 yo M, hurdles
32 3 ½ months postop
33 Classification: Watson- Jones, modified by Ogden
34 2 cases of compartment syndrome
35 15 fractures 9 preexisting Osgood Schlatter Type I usually can extend knee
36 Priority is Articular Reduction
37 Proximal Tibial Physeal Fx Proximal tibia Nondisplaced: LLC, careful observation especially in type III/IV Displaced: closed reduction if possible, smooth pins for type I and type II with small metaphyseal pieces, else cannulated screws Tibial tubercle Casting for type 1A ORIF for remaining types Okay to cross physis with screws Consider prophylactic anterior fasciotomy
38 Distal Tibia
39 12 yo male, fell dancing
40 Closed Reduction ED Reduction F/U 3 days out Comparison View
41 ORIF Distal Proximal
42 124 fractures 12% growth arrest Risk factors High energy Initial displacement SH II 32% of total fractures 10/15 growth arrest in SH II
43 14 yo F
44 CT
45 CRPP
46 6 months
47 Tillaux Fracture from: Rang s Children s Fractures 3rd ed., eds Rang, MR, DR Wenger and ME Pring: Philadelphia, Lippincott, Williams and Wilkins, 2005.
48 12 yo F, playing/sliding
49 Closed Reduction
50 CT Scan
51 Percutaneous Screws
52 4 Months Postop
53 237 fractures, 15 triplanes Described two-part triplane Tomograms in 5 patients confirmed 3 with PPC, minimal deformity 3 had 5-10 o ER deformity, rec IR in cast
54
55 Signs of two part Medial malleolus continuous with tibial shaft No anterior displacement of lateral epiphysis
56 23 fractures 20/23 asymptomatic at months 8/15 asymptomatic at 38 months to 13 years 2mm articular step off: poor 5/5 Recommend CT to evaluate for stepoff
57 Analyzed 184 of 237 closed fractures 89 low risk (6.7% complications) SH I/II distal fibula, SH I distal tibia SH III/IV with <2mm displ 28 high risk (32% complications) SH III/IV with >2mm displ Tilliaux, triplane Comminute type V 66 unpredictable (16.7% complications): SH II distal tibia
58
59 12 year old male, trampoline
60 ORIF
61 2 months postop
62 Triplanes excluded 32 distal tibia arrests 28/32 SH III/IV 28/32 treated closed 33 acute fractures 19/20 SH III/IV treated open without arrest 5/9 treated closed with arrest Growth arrests 18 months to 4 yrs
63
64 Distal Tibia Physeal Fx SH I/II Closed reduction and casting in IR ORIF if persistent gap, deformity Transitional Percutaneous/ORIF unless minimally displaced Less concern of physeal arrest SH IV medial malleolus ORIF unless minimally displaced
65 Growth Arrest
66 Physeal Injuries 1-10% of physeal fractures with growth disturbance Most in adolescents Bar can resolve on their own Worst sites Distal femur Distal tibia Proximal tibia
67 Low Risk Growth Disturbance Upper extremity Tibial tubercle fractures Transitional fractures ankle
68 Fixator Across Physis Smooth is better than threaded Duration Location Obliquity
69 Distal Radius Arrest Original Injury Refracture
70 Comparison Images
71 CT Scan
72 Pathoanatomy Etiology Bony bridge Compromised vascularity Damage to germinal cells 7% of physis Peripheral injuries worse
73 12 year old male
74 10 weeks postop, full ROM
75 2 ½ years, contralateral wrist pain
76 Screening Harris growth arrest lines Remodeling of fracture Comparison views
77 Diagnosis Recognized at a few months, up to 2 years Sclerotic bone bridge or blurring Oblique growth arrest line MRI/CT to clarify Lovell and Winters, 6 th Edition
78 Growth Disturbance Types Complete: LLD Partial LLD Angular deformity Joint incongruity Lovell and Winters, 6 th Edition
79 7 yo F, Pedestrian Struck
80 CT Scan
81 8 weeks, free flap
82 2 years out
83 Reconstruction
84 Treatment Complete arrest <2cm: observe 2-5cm: contralateral epiphyseodesis >5cm: limb lengthening
85 13 yo F, snowboarding
86 6 months postop
87 CT, Bone Age years
88 Epiphyseodesis
89 Treatment Partial arrest Early recognition is key Completion of epiphyseodesis Contralateral epiphyseodesis Reconstruction Osteotomy ± contralateral epiphyseodesis Lengthening and deformity correction Physeal bar excision
90 Fell one year ago, initial radiographs negative 11 yo F
91 CT scan
92 Advanced Bone Age
93 Osteotomy with Contralateral Epiphyseodesis
94 Follow Up
95 3 years s/p knee injury, now knee popping 16 yo M
96 Comparison
97 Comparison
98
99 7 Months s/p Frame Placement
100 Follow Up
101 10 yo F, Trampoline Injury
102 CRPP
103 Growth Disturbance 25 mm LLD, procurvatum, bone age yrs
104 Correction Varus
105 Correction Procurvatum
106
107 8 weeks postop
108 4 months postop
109 15 yo F R distal femur fracture age 7 Lost to follow up after screw removal 7cm LLD
110 Ex-fix for Lengthening
111 Ex-fix for Lengthening
112 Went into Varus
113 Went into Varus
114 Went into Varus
115 Follow Up
116 Bar Excision <50% of physis, better if <25% 2 years of growth remaining 2 cm growth remaining Earlier resection tends to do better Central lesions tend to do better Circumvent osteotomy if <20 degrees CT or MRI to map physis
117 13 Year Old Female
118 7 Weeks
119 Simplest treatment Early detection Epiphyseodesis (unilateral/bilateral) Complete Arrest Epiphyseodesis if time Internal lengthening nails Partial Arrest Epiphyseodesis to stop Osteotomy if minimal LLD Ex-fix versus internal lengthening nail Growth Disturbance Summary
120 Thank You
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