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Updated: Apr 8 2024

Physeal Considerations

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  • 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
        • 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
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