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PHYSEAL FRACTURES Manoj Ramachandran

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PHYSEAL FRACTURES Manoj Ramachandran

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    1. PHYSEAL FRACTURES Manoj Ramachandran

    2. STRUCTURE OF THE GROWTH PLATE

    3. CLASSIFICATION Salter and Harris JBJS 45A:587 1963 Ogden Peterson Many more

    4. SALTeR AND HARRIS

    5. PATHOPHYSIOLOGY Anatomy of the physis is of 3 or 4 orders of interdigitation Anisotropic, nonhomogenous and viscoelastic Salter & Harris thought fracture through hypertrophic zone - ?true

    6. PATHOPHYSIOLOGY WHAT FRACTURES? In vitro isolated growth plate specimens

    7. ANATOMY Structure / Strength Perichondrial ring Macroscopic Undulations Microscopic Mamillary processes

    8. INCIDENCE Incidence - 15-30% of childhood fractures Age Commoner in older children (10-17) Peak 9-12 F and 12-15 M Sex - M>F Upper limb: lower limb = 3:1 92.5% nonoperative management

    9. INCIDENCE SH Mizuta Peterson 1- 8.5% 13.2% 2- 73% 69.1% 3- 6.5% 10.9% 4- 12% 6.5% 5- rare rare

    10. INCIDENCE Growth arrest (Peterson JPO 14 1994) Complete 3.9% Partial 2.5% Bar excision 0.3%

    11. SITE Phalanges 37% Distal radius 18% Distal tibia 11% Distal fibula 7% Distal femur 2-5%

    12. DIAGNOSIS History and examination X-ray stress views CT MRI

    13. TREATMENT Stability Joint congruency Risk of physeal arrest Site Distal femur Dale and Harris - Type A epiphyseal blood supply to proximal femur and proximal radius SH classification Delay to treatment Rang, Salter leave type I or II if more than 2/52

    14. SURGICAL PRINCIPLES Take care of the soft tissues Perichondrial ring and periosteum Use instruments carefully Smooth pins inserted once only! Screw threads should not cross the physis Small cannulated screw system

    15. PHYSEAL ARREST CAUSES Trauma 3 months to years after injury 1-10% of physeal fractures Infection- may not present for years Iatrogenic Drugs - chemotherapy Tumour Irradiation- >1500 rads Thermal

    16. PHYSEAL ARREST Energy of fracture Anatomical site Distal femur/ proximal tibia (3% of # but 55% of arrests) Large, complex contour, rate of growth SH 3 and 4 Formation of vascular anastomoses between epiphseal and metaphyseal vessels

    17. CLASSIFICATION Partial / complete Peripheral / central / combined - Bright Peripheral angular +/- longitudinal Central longitudinal deformity +/- angular

    18. ASSESSMENT Plain films Physis and Harris line converge CT MRI Also bone age and limb length

    19. TREATMENT Offer if At least 1 year of growth remaining (Langenskiold) At least 2 years of growth remaining (Birch) At least 2.5 cm of growth remaining (Kasser)

    20. OPTIONS Shoe raise Osteotomy Stapling Epiphysiodesis Epiphysiolysis Ilizarov

    21. EPIPHYSIOLYSIS Langenskiold 1967 Excise bar Preserve as much viable physis as possible Plan approach Interpose a spacer

    22. SURGICAL APPROACH PERIPHERAL (A) Directly Excise with wide margin of periosteum CENTRAL (B and C) Via metaphysis or osteotomy ?fiberoptic lighting/dental mirrors ANGULAR DEFORMITY If >20 degrees will need osteotomy

    23. SPACER MATERIAL Fat (local or distant e.g. buttock) Methylmethacrylate Silastic Cartilage

    24. RESULTS Better if bar less than 50% of physeal area Physis at other end of bone can accelerate Recurrent bridge can be re-excised If premature arrest, then can arrest other side

    25. SUMMARY Less than 5% of physeal fractures result in growth disturbance Certain sites more prone to growth disturbance e.g. knee

    26. SUMMARY Always warn parents of possibility of arrest Effective treatment available for arrest Physeal bar resection Deformity correction and lengthening

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