physeal injury 2005 년도 소아정형외과학 연수강좌 인제대학교 일산 백병원 주...

PHYSEAL INJURYPHYSEAL INJURY

2005 년도 소아정형외과학 연수강좌인제대학교 일산 백병원

주 석규2005 년 11 월 12 일

ANATOMYANATOMY

• VASCULAR SUPPLY– Epiphyseal a.:

Supplies proliferative zone chondrocytes

– Nutrient a.Capillary loops ends at the bone-cartilage interface of the growth plateAvascular lower proliferative and hyprtrophic zone

ANATOMYANATOMY

•VASCULAR SUPPLY– Metaphyseal a. and periosteal a.

Collateral supply

– Perichondral a.Supplies perichondral ring of LaCroix

ANATOMYANATOMY

• Cartilagenous Component

– Reserve Zone– Proliferative Zone– Hypertrophic Zon

e

ANATOMYANATOMY

• Cartilagenous Component

– Reserve Zone•Chondrocytes produce cartilagenous matrix.•Inactive in cell or matrix turnover•Low oxygen tension lowest calcium content•Not participate in longtitudinal growth

ANATOMYANATOMY

• Cartilagenous Component

– Proliferative Zone•Highest oxygen tension•Matrix production and cellular division contribute to longitudinal growth

ANATOMYANATOMY

• Cartilagenous Component

– Hypertrophic Zone•Weakest region within the growth plate(low matrix volume, high cellular volume)•Ultimate fate of the hypertrophic zone cell is cell death•Avascular and low oxygen tension•Zone of provisional calcification

Cause of Physeal InjuryCause of Physeal Injury

Fracture, disuse, radiation, infection,

tumor, vascular impairment, neural

involvement, metabolic abnormality,

frostbite, burns, electric burns, laser

injuries, chronic stress, iatrogenic injury

PHYSEAL FRACTURESPHYSEAL FRACTURES

• History– Fables of Amazon– Hippocrates– Severinus(1632)– Malgaigne(1855)– Poland(1898)

FRCTURE PLANEFRCTURE PLANE

-Between calcified and uncalcified cartilage-Proliferating cells remain with epiphysis.-The plane is avascular, less bleeding and swelling

ClassificationClassification

•Poland’s Classification(1898):

ClassificationClassification

Bergenfeldt(1933): First radiologic classification

ClassificationClassification

Aitken(1936)

ClassificationClassification

Peterson(1994):

ClassifcationClassifcation

Salter and Harris(1963):

Rang(1969):

ClassificationClassificationSalter-Harris Classification

Practical, easy to useGuide to rational treatmentCovers most fractures

ClassificationClassification

Salter-Harris I:Complete separation of epiphysis

The Germinal cells remain with the epiphysisX-ray may seem normalShearing, torsion or avulsion injuryScurvy, rickets, hormonal imbalance, infectionEarly healingProximal and distal femur

ClassificationClassificationSalter-Harris II:

Thurston-Holland FragmentEasy reductionOver reduction prevented by periosteum

Irreducible; shaft of the bone trapped in the buttonhole tear of periosteum

ClassificationClassification

Salter-Harris III:M/C in partially closed physisOften requires open reduction

ClassificationClassificationSalter-Harris IV:

Lateral condyle fx, med malleolar fx.Neglected: loss of position, nonunion,

growth arrestNot all type IV injuries are the same

Salter-Harris type IVSalter-Harris type IV

ClassificationClassification• 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

ClassificationClassification• SALTER-HARRIS VI:

–Peichondral ring injury–Lawn mower injury–Skin loss, difficult skin coverage–Often growth arrest

EPIDEMIOLOGYEPIDEMIOLOGY

• Male:Female=2:1

• Boys 14yrs old, girls 11 to 12 yrs old most

common

• Phalanges of fingers > distal radius

• Distal > Proximal

EVALUATIONEVALUATION

• 2 Plane radiograph

• Stress view

• Tomogram

• Arthrograms

• CT scans

• MRI

• Ultra Sound

TREATMENTTREATMENT

• Gentle reduction

• Never forceful repeated reduction

• Reduce as soon as possible

TREATMENTTREATMENT

• PetersonType I:-Least potential damage to physis -Growth arrest 3.4%

TREATMENTTREATMENT•Salter-Harris I:

– Growth arrest :•Type I > type II

– Distal femur: frequent growth arrest– Proximal tibia:

Vascular injury

TREATMENTTREATMENT

• Salter-Harris II:– Scraping of the physis

•Relaxed by anesthesia

– Metaphyseal fragment prevents overreduction•Periosteum intact on the metaphyseal fragment side

– Periosteum impingement•Open reduction

– Intact proliferative layer

TREATMENTTREATMENTImpinged Periosteum (Gruber, JPO, 2002)

-Intact physis:Degradation of periosteumPeriostum pushed away

-Ablation of Physeal cartilage:Dramatic injury, growth arrest

TREATMENTTREATMENT•Salter-Harris III:

– Needs anatomic reduction– Epiphysis to epiphysis fixation

CONSIDERATIONS IN TREATMENTCONSIDERATIONS IN TREATMENT

Accurate diagnosis:CT, MRI, Stress view, arthrogram

CONSIDERATIONS IN TREATMENTCONSIDERATIONS IN TREATMENT

Reduce or not to reduce:

7-10 days?

CONSIDERATIONS IN TREATMENTCONSIDERATIONS IN TREATMENT

OR or CR:-Malreduction of Type I, II vs III,IV-Impinged periosteum

Immobilization period:

PROGNOSISPROGNOSIS

•SEVERITY OF THE INJURY

•AGE

•TYPE OF FRACTURE

COMPLICATIONSCOMPLICATIONS

• Sepsis

• Overgrowth

• Malunion

• Delayed or nonunion

• Compartment syndrome

• AVN: proximal femur

• Premature Growth Arrest

PHYSEAL ARRESTPHYSEAL ARREST

• Occur at the time of injury, during reduction, or internal fixation

• Study:– Skeletal age

– Leg length measurement

– Localization of bar;• Tomography, CT, scintigraphy, MRI

PHYSEAL ARRESTPHYSEAL ARREST• MRI

- Preop: for mapping the lesion-Early postop: to detect incomplete resection

-6mths postop: to detect bridge recurrence, migration and necrosis of the interpositional material

PHYSEAL ARRESTPHYSEAL ARREST

• Management

– Complete arrest vs partial arrest

–Cessation of growth without angular deformity

• U/E physis;– 10 cm > no treatment

• L/E physis;– Pelvic tilt and spine curvature

Low back pain

PHYSEAL ARRESTPHYSEAL ARREST

• Management–Osteotomy–Bar excision–Arrest of remaining physis–Shoe lift–Lengthening, –Contralateral shortening, –Physeal distraction,–Transplantation of epiphysis and physis

PHYSEAL ARRESTPHYSEAL ARREST

• Management– Leg length discrepancy;

• 2.5 cm > shoe lift

• 2.5 cm to 5 cm contralateral shortening– Only for femur

– Tibia muscle weakness

• 5 cm < lengthening

PHYSEAL BAR EXCISIONPHYSEAL BAR EXCISION

Physeal bar: Formed by primary ossification along areas of vertical septa

Indications of excision:< 50% of physis involved> 2 yrs of remaining growth

PHYSEAL BAR EXCISIONPHYSEAL BAR EXCISION

Interposition materialTo prevent blood from occupying the cavity, orga

nizing, and re-formation of a bone bar

-Bone wax

– Autogenous fat: lacks hemostasis function

– Cartilage: apophysis of iliac crest

– Silicone rubber: commercially not available

PHYSEAL ARRESTPHYSEAL ARREST• BAR EXCISION

– Interposition materialPolymethylmethacrylate: load sharing

better for large lesion

PHYSEAL BAR EXCISIONPHYSEAL BAR EXCISION

Animal Study-Cultured chondrocytes

(E.H. Lee)-Mesenchymal stem cell with TGF beta

(J.I. Ahn)

PHYSEAL ARRESTPHYSEAL ARREST• Classification

– Peripheral: approach directly– Elongated: common after S-H IV

– Central: approach through metaphysis

PHYSEAL ARRESTPHYSEAL ARREST•Classification

– Peripheral: approach directly

– Elongated: common after S-H IV– Central: approach through metaphysis

PHYSEAL ARRESTPHYSEAL ARREST

•Technique– Burr and dental mirror– Flat and smooth cavity– Do not weaken the epiphysis– Oreo cookie like

PHYSEAL ARRESTPHYSEAL ARREST

• Technique– Do not undermine epiphysis and metaphysis– Metal marker – Angular deformity > 20 degrees

Combine with osteotomy

PHYSEAL ARRESTPHYSEAL ARREST

•Results– Operated physis may close earlier– Bar 50% < usually fail– Bar 50% < excision should be tried in young children

PHYSEAL ARRESTPHYSEAL ARREST

• Results–Only 2.2% of all physeal injuries are at the knee–50% of bar excision are at the knee– Avg growth: 84 % of opposite side

• Distal tibia > prox tibia > distal femur

– Distal femur more large lesion

poorer result