Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: May 25 2024

Physeal Considerations

Images
https://upload.orthobullets.com/topic/4002/images/salter_2.jpg
https://upload.orthobullets.com/topic/4002/images/Histology of zones_moved.jpg
https://upload.orthobullets.com/topic/4002/images/forearm greenstick fx (medcyclopaedia.com).jpg
https://upload.orthobullets.com/topic/4002/images/wrist move (midfordathleticclub.org).jpg
https://upload.orthobullets.com/topic/4002/images/ring.jpg
https://upload.orthobullets.com/topic/4002/images/perichondral artery.jpg
https://upload.orthobullets.com/topic/4002/images/femur sh2(medcyclopaedia.com).jpg
https://upload.orthobullets.com/topic/4002/images/salterharris3 (handbook.muh.ie).jpg
https://upload.orthobullets.com/topic/4002/images/figner sh4(medcyclopaedia.com).jpg
  • Introduction
    • Always look to see if physis is open
    • Unique principals in pediatric bone
      • elasticity
        • more elastic which leads to unique fracture patterns
          • buckle fractures
          • greenstick fractures
      • remodeling potential
        • open physes (growth plates) can allow extensive bone deformity remodeling potential
          • can determine skeletal age with hand and wrist radiograph to accurately asses growth potential 
        • occurs more rapidly in plane of joint motion
          • sagittal plane in wrist, due to primarily extension/flexion
        • occurs more at the most active physes, due to most growth and potential for remodeling
          • most active physes in upper extremity
            • proximal humerus
            • distal radius
          • most active physes in lower extremity
            • distal femur
            • proximal tibia
            • distal tibia
              • lateral ligament sprains are more common than Salter-Harris 1 fractures in pediatric ankle inversion injuries
    • Same principles as adult bone
      • intra-articular fractures must be reduced
  • Physeal Anatomy
      • Physeal Growth Plate
      • Reserve zone (B) 
      • Cells store lipids, glycogen, and proteoglycan aggregates for later growth and matrix production
      • Low oxygen tension
      •  Gaucher's
      • Diastrophic dysplasia
      • Kneist
      • Pseudoachondroplasia
      • Proliferative zone (C)
      • Proliferation of chondrocytes with longitudinal growth and stacking of chondrocytes.
      • Highest rate of extracellular matrix production
      • Increased oxygen tension in surroundings inhibits calcification
      •  Achondroplasia
      •  Gigantism
      • MHE
      • Hypertrophic zone (D)
      • Zone of chondrocyte maturation, chondrocyte hypertrophy, and chondrocyte calcification.
      • Three phases occur in the hypertrophic zone
      •        Maturation zone: preparation of matrix for calcification, chondrocyte growth
      •        Degenerative zonefurther preparation of matrix for calcification, further chondrocyte growth in size (5x)
      •        Provisional calcification zone: chondrocyte death allows calcium release, allowing calcification of matrix
      • Chondrocyte maturation regulated by local growth factors (parathyroid related peptides, expression regulated by Indian hedgehog gene)
      •  Type X collagen produced by hypertrophic chondrocytes important for mineralization
      • Rickets (provisional calcification zone)
      • Mucopolysacharide disease
      • Fractures most commonly occur through zone of provisional calcification
      • Primary spongiosa (E)
      • (metaphysis)
      • Vascular invasion and resorption of transverse septa.
      • Osteoblasts align on cartilage bars produced by physeal expansion.
      • Primary spongiosa mineralized to form woven bone and then remodels to become secondary spongiosa (below)
      •  Metaphyseal "corner fracture" in child abuse
      •  Scurvy
      • Secondary spongiosa
      • (metaphysis)
      • Internal remodeling (removal of cartilage bars, replacement of fiber bone with lamellar bone)
      • External remodeling (funnelization)
      • Renal SCFE
      • Physis Periphery
      • Groove of Ranvier
      • During the first year of life, the zone spreads over the adjacent metaphysis to form a fibrous circumferential ring bridging from the epiphysis to the diaphysis.
      • This ring increases the mechanical strength of the physis and is responsible for appositional bone growths
      • Supplies chondrocytes to the periphery
      • Osteochondroma
      • Perichondrial fibrous ring of La Croix
      • Dense fibrous tissue that is the primary limiting membrane that anchors and supports the physis through peripheral stability
      • Perichondrial artery
      • Major source of nutrition to physis
  • Injury Classification
    • Salter-Harris classification
      • Type 1: physeal separation
      • Type 2: fracture traverses physis and exits metaphysis
        • most common type
        • Thurston Holland fragment
      • Type 3: fracture traverses physis and exits epiphysis
      • Type 4: fracture passes through epiphysis, physis, metaphysis
        • Thurston Holland fragment
      • Type 5: crush injury to physis
  • Treatment
    • Closed reduction vs. CRPP vs. ORIF
      • depends on injury pattern
      • intra-articular fractures must be reduced
  • Complications
    • Growth arrests
      • overview
        • complete arrest leads to shortening
          • see Leg Length Discrepancy
        • partial arrest leads to angulation
        • most commonly encountered with injury to epiphyseal plate
      • treatment
        • bar resection with interposition
          • indications
            • < 50% physeal involvement
            • > 2 years or 2cm growth remaining
        • ipsilateral completion of arrest
          • indications
            • > 50% physeal involvement
            • can combine with contralateral epiphysiodesis and/or ipsilateral lengthening
Card
1 of 3
Question
1 of 16
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options