Injuries in Sport Unit 306. Learning Outcomes Football Injuries.
Physeal injuries
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Transcript of Physeal injuries
PHYSEAL INJURIES
Dr . LOKESH SHAROFFOrthopaedic surgeon, mumbai, india
ANATOMY OF PHYSIS GERMINAL LAYER ZONE OF PROLIFERATING
CARTILAGE ZONE OF HYPERTROPHIC CELLS ZONE OF PROVISIONAL
CALCIFICATION ZONE OF ENCHONDRAL
OSSIFICATION
CLASSIFICATIONS
AITKENS (1936) SALTER&HARRIS(1963) OGDEN(1981) PETERSON(1994)
SH TYPE 1 Complete seperation of
epiphysis without true # through bone with or without displacement
From shearng/torsion/avulsion
No findings on x-ray Good prognosis
SH TYPE 2 # seperation line traverses along
physis to a variable distance & then out through a portion of triangular shaped metaphyseal fragment(Thurstan-Holland sign)
Intact periosteum on the side of metaphyseal fragment
Prognosis-good
SH TYPE 3 Vertical split from joint
surface to physis & then along physis to periphery(intra-articular)
Uncommon Lower tibial epiphysis Prognosis-good
SH TYPE 4
Intra-articular # extending from joint surface through epiphysis,entire physis & a portion of metaphysis-Lateral condyle of humerus Prognosis-bad
S H TYPE5
Severe crushing force applied through epiphysis damaging the germinal layer of physis
No osseous injury-diagnosed in retrospect
S H TYPE 6 Perichondrial injury as described
by Mercer Rang(1969) Rare injury Blow to periosteum/perichondrial
ring
scarring tethering and bony bar formation can occur
OGDEN 7
INTRA-ARTICULAR OSTEOCHONDRAL FRACTURE
OGDEN 8 AND 9
METAPHYSEAL AND DIAPHYSEAL #S RESPECTIVELY BUT SEEN TO STIMULATE THE LONGITUDINAL GROWTH OF THAT BONE.
PETERSON
He described 2 new types of fractures ..1st and 5th in his classification
PETERSON TYPE1 Transverse # of metaphysis
with # line extending to physis
Comminution-common MOI:longitudinal compression Sites:distal radius,finger
phalanges,MC Prognosis:good
PETERSON TYPE 2
Seperation of physis with a portion of metaphysis attached to epiphysis (THURSTAN-HOLLAND sign)
Most common type Site:finger phalanges
PETERSON TYPE 3
Seperation of metaphyis from epiphysis through the physis disrupting the physis
Site:distal fibula
PETERSON TYPE 4 # of epiphysis extending to &
along the physis May be comminuted/double Common in older children Premature growth arrest
common Sites:finger phalanges,distal
tibia(medial malleolus0
PETERSON TYPE 5 # that traverses the
metaphysis,physis,epiphysis & atricular cartilage
Tri-plane # Comminution & open# common Premature growth arrest occurs sites: lateral condyle humerus,
distal tibia
PETERSON TYPE 6 # in which part of
metaphysis,physis & epiphysis is removed/ missing
Found in open # Premature closure of
epiphysis occurs
PROGNOSIS
Severity of injury Age of the child Site of injury Amount of physis injured
TREATMENT
To obtain & maintain reduction by closed/open means
To maintain function & normal growth
PRINCIPLES OF TREATMENT Physeal # should be reduced
immediately All reductions open/closed
should be gentle Forceful repeated manipulations
should be avoided During open reduction pressure
on physis should be avoided
PETERSON TYPE 1
CMR & casting Immobilisation for 3-4 weeks
Follow up to ensure normal growth
P TYPE 2/S H TYPE 2 CMR & casting under GA/block Metaphyseal fragment & intact
periosteum provide stability Surgical intervention 1.periosteal impingement 2.unstable fragment ? Bio-degradable pins
P TYPE 3/S H TYPE 1
CMR & casting
P TYPE 4/S H TYPE 3 Anatomical reduction of physeal &
articular cartilage by ORIF
P TYPE 5/S H TYPE 4
OR & IF
P TYPE 6
Initial debridement followed by reconstructive surgery later on
COMPLICATIONS Premature growth arrest 1.length discrepancy 2.angular deformity Compartment syndrome/arterial
occlusion Neurological complications sepsis & osteomyelitis Overgrowth & hypoplasia Malunion/delayed union/non union
HARRIS GROWTH ARREST LINES Symmetrical, thin white lines Perpendicular to long axis of bone Metaphyseal at first Most marked in rapidly growing ends of
bones, e.g. distal femur and proximal tibia
They migrate towards the diaphysis with further growth and may disappear
HARRIS GROWTH ARREST LINES Denote activity of physeal plate If asymmetric , denotes partial
arrest If lines are absent , denotes growth
arrest