Transcription
Gross plate injuries review. The fisis is the growth plate; it lies between the metaphysis and the epiphysis. The epiphysis is a secondary ossification center located between the growth plate and the articular cartilage. The metaphysis is the bone on the other side of the fisis; it is away from the joint.
Growth plates are layers. The reserve zone is minimally active and allows for matrix production. The chondrocytes are few and lie parallel to the surface. The proliferative zone is where cellular proliferation and linear growth occur. This zone determines if the person will be tall or short. Then, the hypertrophic zone involves maturation, degeneration, and provisional calcification. The chondrocytes accumulate and release calcium. This is the weakest zone.
The majority of growth plate injuries occur in the hypertrophic zone. We need to be familiar with the Salter-Harris classification of growth plate injuries. There are five types:
Type one is a fracture through the growth plate; there may not be obvious displacement.
Type two is a fracture through the growth plate and the metaphysis that spares the epiphysis. Type one and type two usually have a good result.
Type three is a fracture through the growth plate and the epiphysis, sparing the metaphysis.
Type four is a fracture through the three elements of the bone: the growth plate, the metaphysis, and the epiphysis. Type three and four usually involve the joint. Usually, type three and four require surgery, and the outcome is worse than for type one and two.
Type five has the worst prognosis; it is a compression fracture of the growth plate and is usually very difficult to diagnose. The diagnosis is usually late. Growth plate fractures have different characteristics according to the site of injury.
Now we move on to clavicle fractures. Proximal physis fracture injury: the secondary center of ossification at the proximal end of the clavicle appears at the age of 17 to 18 and fuses with the shaft at the age of 22 to 25. Fractures of the medial clavicle occur in children with an open fisis. You suspect an injury to the medial clavicle growth plate in patients with immediate clavicle injury who are less than 25 years of age. It is usually a growth plate injury and not a sternoclavicular injury.
Most of these injuries are classified as Salter one or Salter two, and the CT scan may be helpful for the diagnosis. Treatment is observation if asymptomatic. You reduce the fracture; you may need a thoracic surgeon backup for the posterior injury.
Now, the distal clavicle physis injury is a rare injury. It's an equivalent to AC separation. It looks like an AC separation but really isn't. So, when the fracture occurs in the distal third, the distal clavicle is usually stripped away from the physis and the periosteal sleeve, and it is called a sleeve fracture. The injury is usually treated by a sling.
Then we move on to the proximal humerus. Eighty percent of the longitudinal growth of the humerus occurs in the proximal physis. The injuries are usually type one or type two in a young child. The proximal humerus fracture allows for significant remodeling following injury of the proximal physis, even if the fracture is significantly displaced. Therefore, in young children with a fracture of the proximal humerus, we treat them conservatively with a sling.
The Little League shoulder is a widened growth plate of the proximal humerus. It is considered a stress fracture from overuse. The treatment will be cessation of throwing and a period of rest.
Then we move on to the distal humerus. Trans-epiphyseal separation of the distal humerus has two types: one that occurs in the newborn and the other that occurs in an older child. In this type of injury, consider child abuse. Usually, the fall separation of the distal humerus occurs in a younger child. The diagnosis is usually difficult; it may be missed.
This separation should be highly suspected with elbow injuries before the age of one year old and should be differentiated from an elbow dislocation. The distal fragment usually moves posteriorly and medially. It looks like it is a posteromedial displacement of the distal fragment of the forearm. However, the radiocapitellar relationship remains the same. If the fracture is displaced, treat the fracture by closed reduction and pinning.
Child abuse should be suspected and considered if the patient has multiple fractures at different stages of healing: coronal fractures, posterior fractures, or fractures of the femur before the walking age. Lateral condyle fracture is considered a type four Salter-Harris fracture. This is an important fracture. Internal rotation view will show you the fracture displacement; the fracture could be missed or unappreciated.
There are two classification systems used for this fracture: the MCH classification and the Jacob classification.
Type one fracture: the fracture line is lateral to the trochlear groove.
Type two: the fracture line goes into the trochlear groove.
Jacob types are three types: the first type, the articular surface is intact; the second type, the fracture goes into the joint but no fracture fragment rotation; the third type, the fracture fragment is rotated and displaced.
Treatment for non-displaced fractures requires a long arm cast for four to six weeks and close follow-up in the first two weeks. If it is displaced, or if we rarely do arthrograms, we rarely do closed reduction percutaneous pinning. However, in some cases, you may need to do that.
Complications of nonunion will give you cubitus valgus and tardy ulnar nerve palsy. There can be growth arrest, which can also lead to AVN from interruption of the posterior blood supply, especially if you do surgery.
Then we go to the elbow. The olecranon fracture can be confused with a growth plate and vice versa. The olecranon ossification center appears at nine and fuses at the age of 16. The patient may not be able to extend the elbow; they may be associated with osteogenesis imperfecta.
As I said before, the fracture and the secondary ossification center can be confused with each other. You have to know when the ossification centers appear around the elbow and what is the order of this appearance. We use the mnemonic "CRITOE." The ossification centers appear at 1, 3, 5, 7, 9, 11, and you will notice there are two years in between each.
Fractures of the radial head and neck are not common in children. The proximal radius gives about 25% of growth of the entire radius. The fracture can be nondisplaced, displaced, tilted, or translocated. These types of fractures are rare and usually occur around nine years of age, usually due to a valgus force.
The fracture may involve the physis; the fracture usually is altered too, but it may involve the radial neck at the metaphysis. An AP and lateral view of the elbow that includes the forearm should be taken. The radial head and the capitellum should be aligned in all views. Try to remember how you can get the radial head capitellum view; it may be helpful. The beam is directed 45 degrees approximately.
Treatment usually involves immobilization if the fracture is not displaced. That immobilization is used if the angulation is less than 30 degrees; up to 30 degrees of angulation is acceptable. Closed reduction is used if angulation is greater than 30 degrees. Open reduction is done if more than 45 degrees of residual angulation persists after failure of closed reduction or by a percutaneous method.
How about the distal radius? The fracture occurs with a low risk of growth arrest. The most common Salter-Harris fracture occurs in the distal radius, usually type one or type two. It may require oblique views in order to see the metaphyseal fracture. If the fracture occurs in the distal ulna, there's a chance of a 50% rate of growth arrest. This growth arrest will lead to a shortened ulna.
Now we go to the lower extremity. The proximal femur ossification center of the femoral head appears at about six months. In the case of trans-physeal separation of the femoral head with dislocation, the rate of avascular necrosis is almost 100%.
Distal femoral growth plate injuries have a high incidence of growth arrest that leads to growth arrest and deformity. The more displacement, the more likely that the patient will have growth arrest. Fracture of the distal femoral growth plate is unpredictable in its behavior. If the fracture is displaced, the growth risk is usually about 65%. The prognosis may not correlate with Salter types; in some cases, we need an ankle brachial index evaluation.
Now we move to the proximal tibia. Proximal tibial physis injury is a dangerous injury. It usually results from high-energy trauma, and there is a traumatic separation of the growth plate at the knee. The physis is at the level of the trifurcation of vessels. If fracture displacement may injure the vessels, we will reduce and fix that fracture.
Tibial tuberosity fracture: there are several types, but type three will go into the proximal tibial growth plate. Tibial tuberosity injury may be involved in compartment syndrome due to injury of the anterior tibial recurrent artery. When this fracture is displaced, it usually involves the joint and probably needs to be reduced and fixed surgically.
Sleeve fracture of the patella: the sleeve fracture occurs between the cartilage sleeve and the main part of the patella. It can easily be missed because of a small amount of bone and a large amount of cartilage. The sleeve fracture of the patella will require surgery with a tension band or a modified tension band technique. Just remember, sleeve fracture of the clavicle does not need surgery.
Distal tibial and ankle physis injury: the distal tibial growth plate contributes about 40% of the tibial growth, or about 5 mm per year. There are some injuries around the ankle joint. One of them is the Tillaux fracture, which is the lateral portion of the growth plate. The plate is open, and when an avulsion fracture of the anterior inferior tibiofibular ligament occurs, the condition is called Tillaux fracture.
There is a low risk of growth arrest if there's a displacement of more than 2 mm. You will do surgery; get a CT scan if you are not sure of the amount of displacement before you decide if you're going to do surgery or not.
Another one is the triplane fracture, which is Salter three in an AP view and Salter two in the lateral view. It is usually a Salter four fracture involving the growth plate, the metaphysis, and the epiphysis. CT scan is usually very helpful. The treatment is usually surgical if it is displaced.
Another entity called distal tibial physis injury may give rotational deformity. X-ray will show mild physis widening that will lead to a change in the foot progression angle with an increased external rotation of the foot.
Ankle fractures in general will show growth arrest, which will occur with fractures around the medial malleolus, which is a Salter four fracture. If the medial distal tibial growth arrest occurs, that will result in varus, and if the distal fibular growth arrest occurs, that will result in valgus.
Growth plate fractures usually occur in the zone of hypertrophy. The zone of hypertrophy is a weak zone; it may be difficult to see the fracture and assess the amount of displacement. If you are concerned, get different X-ray views, compare with the other side, or dig deeper and get a CT scan or an MRI.
Treatment: avoid repeated forceful manipulation. Three attempts will close the physis in about 50% of the cases. No manipulation after seven days. Usually, you reduce the growth plate injury by traction and very little translation.
You need to know the difference between fisis, epiphysis, and apophysis. Here is the fisis; here is the epiphysis. The epiphysis is usually near the joint, and here the apophysis is usually attached to a tendon or to a ligament. The fisis is the growth plate.
Physis fractures heal in roughly half the time required by an equivalent-sized bone. This video is for educational purposes only; please consult your doctor before you make any decision about your medical care.