A broad overview of injuries to the physis. It would be of particular interest/use to trainee Orthopaedic surgeons.

1. PHYSEAL INJURIES
DR. BASSEY, A E
ORTHOPAEDIC & TRAUMA SURGERY
U.A.T.H, ABUJA

2. OUTLINE
• INTRODUCTION
 DEFINITION
 STATEMENT OF IMPORTANCE
 EPIDEMIOLOGY
• ANATOMY OF THE PHYSIS
• AETIOPATHOGENESIS OF PHYSEAL INJURIES
• CLASSIFICATION
• MANAGEMENT
 HISTORY
 EXAMINATION
 INVESTIGATION
 TREATMENT
• COMPLICATIONS
• FOLLOW-UP/REHABILITATION
• PROGNOSIS
• CURRENT TRENDS
• CONCLUSION

3. INTRODUCTION
• DEFINITION - PHYSEAL INJURY IS A
DISRUPTION IN THE CARTILAGINOUS PHYSIS
OF LONG BONES THAT MAY INVOLVE
EPIPHYSEAL AND/OR METAPHYSEAL BONE
• IT IS A FAIRLY COMMON INJURY WITH A
PROPENSITY FOR LIFELONG DIMINUTION OF
PRODUCTIVITY AND QUALITY OF LIFE. IT IS
THEREFORE IMPERATIVE FOR TODAY’S
SURGEON TO HAVE ADEQUATE KNOWLEDGE
AND SKILL IN ORDER TO DIAGNOSE THIS
CONDITION EARLY AND INSTITUTE
APPROPRIATE TREATMENT EXPEDITIOUSLY.

4. EPIDEMIOLOGY
• PREVALENCE: 10 – 30% OF CHILDHOOD
FRACTURES
• AGE: BIMODAL PEAKS AT INFANCY & 10 – 12
YEARS
• SEX: M>F
• COMMONEST SITES:
 UPPER EXTREMITY>LOWER EXTREMITY
 DISTAL RADIUS DECREASING
 DISTAL HUMERUS FREQUENCY
 PROXIMAL TIBIA/FIBULA

5. ANATOMY OF THE PHYSIS
• THE PHYSIS IS A SLAB OF HYALINE
CARTILAGE LOCATED AT THE ENDS OF
GROWING BONES BETWEEN THE
EPIPHYSES AND METAPHYSES AND WHICH
ARE RESPONSIBLE FOR THE GROWTH OF
SUCH BONES
• IT IS DIVIDED INTO 4 DISTINCT ZONES
HISTOLOGICALLY:
 GERMINAL (RESTING) ZONE
 PROLIFERATIVE ZONE
 HYPERTROPHIC (MATURATION) ZONE
 ZONE OF CALCIFICATION

6. ANATOMY OF THE PHYSIS
• GERMINAL ZONE
 CONTAINS CHONDROCYTES IN QUISENCE
 REPLENISHES PROLIFERATIVE ZONE
 INJURY CESSATION OF GROWTH
• PROLIFERATIVE ZONE
 CONTAINS CHONDROCYTES IN MITOSIS
 RESPONSIBLE FOR INCREASE IN BONE LENGTH
 INJURY CESSATION OF GROWTH
• HYPERTROPHIC ZONE
 CELLS ACCUMULATE GLYCOGEN/LIPIDS
 INCREASED ALKALINE PHOSPHATASE ACTIVITY
 WEAKEST ZONE AND SITE OF PHYSEAL FRACTURES
• ZONE OF CALCIFICATION
 MINERALISATION OF CHONDROID MATRIX
 INFILTRATION BY METAPHYSEAL BLOOD VESSELS

7. ANATOMY OF PHYSIS

8. AETIOPATHOGENESIS OF PHYSEAL INJURIES
• AETIOLOGY –
 RTI
 FALLS
 SPORTS
 PLAYGROUND ACTIVITIES
• BIOMECHANICS
 COMPRESSION
 SHEAR
 TENSION
• FRACTURE CONFIGURATION USUALLY
TRANSVERSE

9. CLASSIFICATION
• SALTER-HARRIS (1963) – MOST WIDELY USED:
▫ TYPE 1: TRANVERSE FRACTURE IN HYPERTROPHIC ZONE
▫ TYPE 2: ABOVE FRACTURE VEERING OFF INTO
METAPHYSIS TO INCLUDE A TRIANGULAR CHIP OF BONE
▫ TYPE 3: FRACTURE SPLITS EPIPHYSIS AND RUNS
TRANVERSELY IN HYPERTROPHIC ZONE
▫ TYPE 4: FRACTURE RUNS LONGITUDINALLY SPLITTING
EPIPHYSIS, PHYSIS & METAPHYSIS
▫ TYPE 5: LONGITUDINAL COMPRESSION INJURY
• TYPE 6 ADDED IN 1969 – INJURY TO PERICHONDRAL
RING
• COMMONEST IS TYPE 2 (75% OF PHYSEAL INJURIES)
• TYPE 5 IS RARE, MAY BE ASSOCIATED WITH
DIAPHYSEAL FRACTURE
• TYPES 3 – 6 HAVE HIGH RISK OF GROWTH ARREST

10. CLASSIFICATION

11. MANAGEMENT
• HISTORY
▫ PAIN/SWELLING AROUND THE CONTIGUOUS
JOINT
▫ UPPER LIMB – FUNCTION LIMITED BY PAIN
▫ LOWER LIMB – INABILITY TO BEAR WEIGHT
ON AFFECTED LIMB
▫ PRECEEDING TRAUMATIC EVENT
• EXAMINATION
▫ SWELLING
▫ DEFORMITY +/- (MINIMAL IF PRESENT)
▫ FOCAL TENDERNESS OVER PHYSIS
▫ LIMITED ROM

12. INVESTIGATION
•X-RAYS
 WIDENING OF PHYSEAL GAP
 JOINT INCONGRUITY
 TILTING OF EPIPHYSIS
 PRESENCE OF DISPLACEMENT MAKES
DIAGNOSIS MORE OBVIOUS
 TYPES 5 & 6 INJURIES ARE USUALLY
DIAGNOSED RETROSPECTIVELY

13. X-RAY FINDINGS IN PHYSEAL INJURY – NORMAL
PHYSIS

14. SALTER HARRIS TYPE 1

15. SALTER HARRIS TYPE 2

16. SALTER HARRIS TYPE 2

17. SALTER HARRIS TYPE 3

18. SALTER HARRIS TYPE 4

19. INVESTIGATION
• CT
 TO VISUALISE FRACTURE ANATOMY IN SEVERELY
COMMINUTED FRACTURES OF EPIPHYSIS AND
METAPHYSIS
• MRI
 MOST ACCURATE FOR FRACTURE ANATOMY IF DONE IN
ACUTE PERIOD
 IDENTIFIES FORMATION OF BONY BRIDGE EARLIER
THAN X-RAYS

20. TREATMENT
• DEPENDS ON THE FOLLOWING FACTORS
 TYPE OF INJURY
 AGE OF PATIENT
 FRACTURE STABILITY
• FOR TYPES 1 & 2
 CLOSED REDUCTION AND IMMOBILIZATION IN
CAST WILL USUALLY SUFFICE
 CHECK X-RAY IN 7 – 10 DAYS
• FOR TYPES 3 & 4
 REQUIRE ANATOMICAL REALIGNMENT VIA ORIF
 ORIF CAN BE WITH LAG SCREWS OR KIRSCHNER
WIRES RUNNING PARALLEL TO PHYSIS
• FOR TYPES 5 & 6
 USUALLY DIAGNOSED RETROSPECTIVELY
HOWEVER HIGH INDEX OF SUSPICION MUST BE
MAINTAINED IN HIGH RISK INJURIES

23. COMPLICATIONS
• GROWTH ARREST
 OCCURS BY DISRUPTION OF PHYSEAL BLOOD
SUPPLY OR BONE BRIDGE FORMATION
 MAY BE PARTIAL OR COMPLETE
• GROWTH ACCELERATION
• SECONDARY OSTEOARTHRITIS

24. FOLLOW-UP/REHABILITATION
• TYPES 1 & 2 FRACTURES ARE IMMOBILIZED
FOR 3 – 6 WEEKS
• TYPES 3 & 4 FRACTURES ARE IMMOBILIZED
FOR 4 – 8 WEEKS
• PATIENT RESUMES UNRESTRICTED
PHYSICAL ACTIVITIES 4 – 6 WEEKS
FOLLOWING REMOVAL OF IMPLANTS FOR
FRACTURES THAT REQUIRED OPERATIVE
FIXATION

25. FOLLOW-UP/REHABILITATION
• FOLLOW-UP CHECK XRAYS ARE DONE AT 6
MONTHS AND 12 MONTHS POST INJURY
AND MAY BE EXTENDED UP TO 2 YEARS AS
GROWTH ARREST MAY BE DELAYED FOR
THAT LONG

26. PROGNOSIS
• AGE OF PATIENT AT TIME OF INJURY
• TYPE OF INJURY
• EXTENT OF CHONDRO-OSSEOUS
DISRUPTION

27. CURRENT TRENDS
• GROWTH PLATE INTERPOSITION
 FAT
 BONE WAX
 SILICON RUBBER
 POLYMETHYLMETHACRYLATE
 LABORATORY-DERIVED CHONDROCYTE
ALLOGRAFT
• GENE THERAPY & TISSUE ENGINEERING
 USE OF RETROVIRUSES TO INTRODUCE GENES
CODING BMP-7 INTO RABBIT PERIOSTEAL
MESENCHYMAL CELLS

28. CONCLUSION
PHYSEAL INJURIES MAY NOT BE READILY
OBVIOUS IN CHILDREN PRESENTING WITH
PERIARTICULAR TRAUMA; A HIGH INDEX
OF SUSPICION DURING EVALUATION,
TREATMENT AND FOLLOW-UP OF SUCH
PATIENTS IS OF THE ESSENCE TO
FORESTALL FUTURE COMPLICATION.

29. THANK
YOU

30. REFERENCES
• Nayagam S. Principles of Fractures. In: Solomon L,
Warwick D, Nayagam S. Apley’s System of Orthopaedics
& Fractures. 9th ed. Hodder Arnold;2010: 727 – 730.
• Mann DC, Rajmaira S. Distribution of physeal and non-physeal
fractures in 2,650 long-bone fractures in
children aged 0-16 years. J Pediatr Orthop. Nov-Dec
1990;10(6):713-6.
• Neer CS, Horowitz BS. Fractures of the proximal
humeral epiphyseal plate. Clin Orthop Rel Res.
1965;41:24-31.
• http://emedicine.medscape.com/article/1260663-overview
• http://www.wheelessonline.com/ortho/growth_plate_anatomy
• http://www.orthobullets.com/pediatrics/4002/physeal-considerations