7 physeal injuries prinicples of mangement kaye
-
Upload
krishna-mohan-reddy -
Category
Documents
-
view
749 -
download
1
Transcript of 7 physeal injuries prinicples of mangement kaye
Physeal injuries Principles of management
The Statistics
• Phalanges 37%
• Distal Radius 18%
• Distal Tibia 11%
• Distal Fibula 7%
• Metacarpal 6%
Distal Femur is < 2%
Average of six combined series= 21%
Classifications- Are They Helpful ??
OGDEN Two ComplicatedPETERSON: Probably the best for prognosis
The Salter- HarrisClassification
HasStood The
Test Of Time!!
Descriptive more than Prognostic
Major Contribution of Peterson’s Types
Callous and fracture lines Extend to the physis
Peterson Type I
Cast Removal19 mo. post- fracture
Beware!!
Unique Physeal Anatomy
Blood supply
Growth
Maturation
OssificationRemodeling
Transformation
Blood Supply
Dangerous Side
Safe Side
Safe Side -Effects
Factors Contributing to Physeal Failure
1.Torsion > Tension
Most Occur at End of Growth
2.Weakened Perichondral Ring
3.Increased Skeletal Mass -- KE=MV2
Distal Femur
Thus high rate of growth arrest in this area
SHEAR
Physeal ArrestBasic Pathology
Fracture Line Through Zone of Hypertrophy
Can be Anywhere
Resting Cells
Basic Pathology
Physeal Bar
Sclerotic Bone On X-Ray Cortical Bone From Tension Forces
Patterns of Arrest (Peterson)
Central
Asymmetrical Harris- Park Migration
Central
Perirheral Physis Remains Intact
Central
PeripheralIpsilateral
distal femoral
Ipsilateral proximal tibial
Linear
D O I 1 Yr. P.I.Asymmetrical Harris- Park Migration
LinearUsually associated withType IV S-H Injuries
X- Ray criteria
Physeal Narrowing
Sclerotic Bone
Absent Harris-Park Migration
Angular Deformity
Making the diagnosis
C-T Scans
Other imaging studies more helpful
Good polytomography can be useful
M R Imaging
TheGold Standard
M R Imaging
May be too sensitive
Location Affects:
1. Type of Deformity
2. Surgical Approach
3. Success Of Resection
Location affects Deformity
• Central Volcano Effect
• Peripheral Severe Angulation
• Longitudinal AngulationShortening
Location affects Success of Resection
Central Linear
Physis-Bridge-PhysisSymetrical Growth
Peripheral Physis-Bridge
Asymetrical Growth
Expected results
Not 100% Successful
Three Series = 64 Cases
Excellent: 23 (36%)
Good: 16 (25%)
Fair/Poor: 24 (24%)
Factors Contributing To Success
1. Size
2. Age
3. Duration Since Injury
4. Etiology
1. 30%
2. Younger The Better > 2 yrs Growth Left
3. > 2 yrs---Poor
4. Trauma= GoodInfection,Irradiation= Poor
Will Resection Help ?
1. Young
2. Small Bridge
3. Trauma Origin
4. Recent Onset
5. Central or Linear Bridge
1. Older
2. Large Bridge
3. Infectious or Irradiation Origin
4. Peripheral Bridge
2.Poor Candidate1. Ideal Candidate
Location affects Surgical Approach
Central
LargeMetaphyseal Window
Peripheral
Direct Approach
Metaphysis
Epiphysis
Physis
Location affects Surgical Approach
Osseous Tunnel
Cortex to Cortex
Linear Bridge
Technical Points Location Of Bridge
Must Be Perpendicular To The Physis
Need to see 3600
Not Perpendicular To The Physis
Easier, less vital structures
Close to Perpendicular to The Physis
OK
More dangerous structures
To Serve As A Barrier To Bridge Reformation
Peripheral Bridge
Sclerotic bridge
remains
Grey physis now
visible
Physis now in profile
Cranioplastspacer
Cranioplastspacer
Metal marker for growth
Technical PointsUse Dental Mirror toVisualize Proximal Physeal Border
Can usean arthroscope as well
Technical Points Remove All Sclerotic Bone
Interposed Material
Autogenous Fat
Cranioplast ( Methymethacrolate
with out barium)
Silastic (no longer available in US)
Illustrative Cases
D P 6 y.o.Injury x-ray
S-H IV injury 1 yr. P. I.
Longitudinal bridge
D.P. Cont. 4 mo. p.o. bridge resection Silastic Insertion
Migration of
growth arrest lines begins
Osseous bridge
Silastic spacer
D.P. Cont.3 yrs. P.O.
Despite Proximal Migration of Silastic, Normal Growth Re-established
Alternatives to resection
11 y.o. 5 yrs p.i.
Poorly Defined Bridge
Problems ?
1.Physeal bar
2.Angulation Shortening
Close to End of GrowthSolution ??
Physeal Distraction
Alignment corrected
Will It Grow?
2 years post op.
Growth arrest lines have
migrated 2 cm.
What If The Arrest Recurs ?
OK to Re-Resect if Criteria Met
3 y.o. Injury at 18 m.o.
Central Bridge
Following three resections over 8 years
Radio-Ulnar Relationships Re-established
Normal Side
So What Have Learned ??
To Have Good Results One Needs to Have
• Knowledge of the Physeal Anatomy
• Understanding of Physeal Arrest Patterns
• What Cases Can Benefit From Resection
• How To Effectively Pre-Operative Plan
• Technical Aspects of The Resection Proceedure
• Alternatives to Resection
• How to Manage Recurrences
Thank you