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    Fracturas Pediatricas

    Uploaded by

    Elbanis Márquez

    Copyright:

    © All Rights Reserved
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    2 Epiphyseal Plate Injuries Robert B. Salter Experience is the mother of science. Injuries involving the epiphyseal plate present special problems in diagnosis and management. The dread complication of serious disturbance of growth is usually predictable and, in certain circumstances, can be pre- vented. Thus, knowledge of the prognosis for a given injury to the epiphyseal plate in a particular child is of considerable importance to the surgeon, who has the <éual responsibility of treating the child and advising the parents. APPLIED ANATOMY AND HISTOLOGY Each epiphysis has its own plate through which skele- sal growth occurs: itis important that a distinction be ‘made between the epiphysis and the epiphyseal plate {also referred to as the physis). Histology A knowledge of the microscopic features of the nor- mal epiphyseal plate is pivotal in understanding the problems associated with the various types of injuries to which it may be subjected. The three main types of inju- ries are separation of the epiphysis through its epiphyseal plate, fractures that cross the epiphyseal plate, and crushing injuries ofthe plate itself. When seen in longitudinal section, four distinct layers ‘can be identified in the normal epiphyseal plate: the layer of resting cells, the ayer of proliferating cells, the layer of| hypertrophying cells, and the layer of endochrondral os- sification (Fig. 2-1). The space between the cellsis filed with cartilage matrix or intercellular substance. Itis this intercellular substance, and not the cells, that provides the strength of the epiphyseal plate, particularly its re- sistance to shear. In common with the intercellular sub- stance of other sorts of connective tissues, that of carti- lage is made up of collagen fibers embedded in an amorphous cement substance. Because the refractive in- ‘dexes of these two componentsare the same, the collagen fibers cannot be identified in ordinary preparations, but they can be seen by special techniques, for instance, phase-contrast microscopy. ‘These collagen fibers in the matrix of the epiphyseal plate are arranged longitudinally and no doubt play a role similar to that of the steel rods in reinforced con- crete. In the first two layers of the plate the matrix is abundant, and here the plate is strong. Inthe third layer the matrix is scanty, and here the plate is weak. On the ‘metaphyseal side of this layer, however, the matrix is calcified, forming the so-called zone of provisional calci- fication. The addition of calcification seems to reinforce this part of the third layer, because the plane of cleavage after separation lies in the third layer at approximately the junction of the calcified and uncalcified parts. It seems logical, then, that the constancy of the plane of cleavage is the direct result of the structural details of the normal plate. The significance of the constant location " 12 / Management of Pediatric Fractures EPIPHYSIS. LLRESTING. Z CARTILAGE 2. PROLIFERATING CARTILAGE ———2 maturine CARTILAGE 4. CALCIFYING. CARTILAGE ——— merarnysis Fig.2-1. Low-power photomicrograph of an epiphyseal plate from the proximal end of the tibia ofa child. (From Salter and Harris,* with permission.) of the plane of cleavage after complete epiphyseal sepa- ration is that the growing cells remain attached to the epiphysis. Thus, if the nutrition of these cells is not dam- aged by the separation, there is no reason why growth should not continue in a normal fashion. The crux of the problem, then, is not the nature of the mechanical dam- age to the plate, but whether the separation interferes with its blood supply. Fractures that cross the epiphyseal plate and crushing, injuries of the epiphyseal plate present additional prob- lems and are discussed below. Mechanism of Nutrition ‘There are two separate systems of blood vessels to the epiphyseal plate. The epiphyseal system arises from ves- sels in the epiphysis that penetrate the bone plate of the epiphysis and end in capillary tufts or loops in the layer of resting cells of the plate. These vessels are essential to the viability of the chondrocytes of the epiphyseal plate. ‘The metaphyseal system arises in the marrow of the shaft and ends in vascular loops in the layer of endochrondral ossification. Dale and Harris! have demonstrated that the nutrient, vessels of the epiphysis (from which the terminal vascu- lar loops to the epiphyseal side of the plate are derived) enter in one of the two ways, The first, and more com- ‘mon, occurs when the sides of the epiphysis are covered with periosteum, as is the case in the distal femoral and proximal tibial epiphyses, in which the nutrient vessels penetrate the side of the epiphysis at a point remote from the epiphyseal plate. The second, and decidedly less common, occurs when the entire epiphysis in intra-ar- ticular and hence covered with articular cartilage. In this ‘case, the nutrient vessels enter the epiphysis by travers- ing the rim of the epiphyseal plate. Itis easy to see that the vessels to this type of epiphysis are in danger in the event of epiphyseal separation and might easily be ruptured. ‘The upper femoral epiphysis is the main example of this type; the upper radial epiphysis probably belongs to this group as well. Relative Strength The cartilaginous epiphyseal plate is obviously less strong than bone, and yet fractures through bone are much more common in childhood than epiphyseal sep- arations. The probable explanation for this apparent paradox is that only shearing and avulsion forces are capable of separating an epiphysis. ‘The epiphyseal plate is also less strong than normal, tendons and ligaments in adolescents. For this reason, injuries that may result in complete tear of a major liga- ment in the adult actually produce a separation of the epiphysis in the adolescent. For example, an abduction injury of an adolescent's knee will result in epiphyseal separation rather than a rupture of the medial collateral ligament of the knee. Thus, tears or ruptures of major ligaments are very uncommon in adolescence, and every adolescent suspected of having torn a major ligament should have a radiographic examination to study the epiphyses of the arca. By the same token, the epiphyseal plate is not as strong as the fibrous joint capsule, and traumatic dislocations of major joints, such as the knee, during adolescence are thus decidedly less common than epiphyseal separations. Relative Growth at the Ends of ‘Long Bones In the lower extremity, more longitudinal growth ‘occurs in the region of the knee than in the regions of the hip orankle. In the femur, 70 percent of growth occursin the distal end and 30 percent occurs in the proximal end. In the tibia, 55 percent of growth occurs in the proximal end and 45 percent occurs in the distal end. DIAGNOSIS Clinical Diagnosis Although the accurate diagnosis of epiphyseal plate injuries depends on radiographic examination, suspect such an injury in any child or adolescent who exhibits evidence of a fracture near the end of a long bone, a dislocation, ligamentous rupture, or even a severe sprain ofa joint, Remember that an epiphysis may be displaced at the moment of injury and then return to its normal position, in which case clinical examination is likely to be of considerable importance in recognizing the nature of the injury. The history of the mechanism of injury, although often inadequate, may arouse suspicion of a ‘crushing type of epiphyseal plate injury, which is diff- ccult to detect on the radiograph, Radiographic Diagnosis Accurate interpretation of the radiographs of adoles- cent bones and joints necessitates a knowledge of the ‘normal appearance of epiphyses and epiphyseal platesat various ages. Two views at right angles to each other are essential, and often two additional oblique views are re- quired. If in doubt, obtain comparable views of the op- posite uninjured extremity. When the clinical examination suggests an epiphyseal plate injury but the radiographs do not reveal such an injury, stress radiographs taken with the patient under ‘general anesthesia frequently reveal that a separation through the epiphyseal plate has, in fact, occurred and that in the initial radiographs the epiphysis had returned to its normal position. Late radiographic diagnosis of an undisplaced epiphy- seal separation can be made by demonstrating subper- iosteal new bone formation in the metaphyseal region 10 days or more after injury. Epiphyseal Plate Injuries / 13 INJURIES INVOLVING EPIPHYSES (Ofall injuries to the long bones during childhood ap- proximately 15 percent involve the epiphyseal plate Age and Sex Incidence [Although injuries tothe epiphyseal plates may occur at any age during childhood, they are somewhat com- ‘moner in periods of rapid skeletal growth, in the first year, and during the prepuberty growth spurt. These injuries —and others —are more frequent in boys than in girls, presumably because of the more active physical life of boys. Site In general, epiphyseal plates that provide the most growth are most commonly separated by injury. This is not true, however, of two types of epiphyseal injury — fractures that cross or crush the epiphyseal plate. “The lower radial epiphyseal plate is by far the one most, frequently separated by injury; indeed, injuries to this Fig.2-2. Type l epiphyseal plate injury. Separation of epiph- ysis. (Adapted from Salter and Harrs,* with permission.) 14 / Management of Pediatric Fractures 2.3. Type I separation of the distal fibular epiphysis in a 14-year- old boy. (A) This radiograph appears normal because after the injury the fibular epiphysis had returned to its ‘normal position. (B) In this stress ra- diograph (taken while a varusstress is being applied to the ankle joint with the child under anesthetic) there is a tilt of the talus and the separation of the fibular epiphysis is apparent. (From Salter and Harris with per mission.) epiphyseal plate are nearly as frequent as all other inju- ries to the epiphyseal plates combined.‘ In order of de- ‘creasing frequency, slipping is found in the lower ulnar, lower humeral (lateral condyle), upper radial (head), lower tibial, lower femoral, upper humeral, upper femo- ral (head), upper tibial, and phalangeal epiphyseal plates. POSSIBLE EFFECTS OF EPIPHYSEAL INJURIES Fortunately, most epiphyseal-plate injuries are not as- sociated with any disturbance of growth. After separa- tion of an epiphysis through its epiphyseal plate there may be a slight and transient acceleration of growth, in which case no significant deformity ensues. ‘The clinical problem associated with premature cessa- tion of growth depends on several factors, including the bone involved, the extent of involvement of the epiphy- seal plate, and the amount of remaining growth nor- mally expected in the involved epiphyseal plate. Ifthe entire epiphyseal plate ceases to grow, the result is progressive shortening without angulation. However, ifthe involved bone is one ofa parallel pair (such as tibia and fibula or radius and ulna), progressive shortening of the one bone will produce progressive deformity in the neighboring joint. Ifgrowth in one part of the epiphyseal plate ceases but continues in the rest of the plate, pro- gressive angulatory deformity occurs. Cessation of growth does not necessarily occur imme- diately after injury to the epiphyseal plate, and, indeed, growth arrest may be delayed for 6 months or even longer. Furthermore, there may be a period of retarda- tion before growth ceases completely. Fig.2-4. Type epiphyseal plate injury. Fracture-separation of epiphysis. (Adapted from Salter and Harris,* with permis- sion.) Epiphyseal Plate Injuries / 15 2.5, Type'll fractureseparation ofthe distal radial epiphysis. Inthe anteroposterior projection the epiphy: seal plate of the radius is not apparent because the epiphysis is displaced and angulated. In the lateral project the backward displacement and angulation of te epiphysis are apparent. The arrow identifies the small triangular ‘metaphyseal fragment attached to the epiphysis and its epiphyseal plate, CLASSIFICATION ‘The following classification, developed by Salter and Harris, is based on the mechanism of injury and the relationship of the fracture line to the growing cells of the epiphyseal plate and isalso correlated with the prognosis, for growth disturbance.*-* Type I Ina type I epiphyseal plate injury (Figs. 2-2 and 2-3), there is a complete separation of the epiphysis from the ‘metaphysis without any bony fracture. The growing cells of the epiphyseal plate remain with the epiphysis. This type of injury, which is caused by a shearing or avulsion force, is more common in birth injuries and during early childhood, when the epiphyseal plate is relatively thick. Iti also seen in pathologic separations of the epiphysis associated with scurvy, rickets, osteomyelitis, and endo- crine imbalance. Wide displacement is uncommon be- ‘cause the periosteal attachment is usually intact. Reduc- tion is not difficult, and the prognosis for future growth is excellent unless the epiphysis involved is entirely cov- ered by cartilage (e.g, upper end of the femur), in which case the blood supply is frequently damaged with result- ant premature closure of the epiphyseal plate. ‘Type II Ina type II epiphyseal plate injury (Figs. 2-4 and 2-5), the most common type, the line of separation extends along the epiphyseal plate for a variable distance and then moves out through a portion of the metaphysis, providing the familiar triangular metaphyseal fragment 16 / Management of Pediatric Fractures Fig. 2-6, Type IIl epiphyseal plate injury. Fracture of part of Cpphysis. (Adapted from Salter and Harris, with permission.) Fig. 2-7. ne scroluscral corner of the epiphysis is more obvious in the lateral projection than in the anteroposterior projection, sometimes referred to as Thurston Holland’s sign. This type of injury usually occurs in children over the age of 10 yearsand isthe result of shearing injury oran avulsion force. The periosteum is torn on the convex side of the angulation but is intact on the concave side, that is, the ‘side on which the metaphyseal fragment is seen. Reduc- tion is relatively easy to obtain and to maintain; because of the intact periosteal hinge and the metaphyseal frag ‘ment, overreduction cannot occur. The growing carti- lage cells ofthe epiphyseal plate remain with the epiphy- sis, and thus the prognosis for growth is excellent, provided the circulation to the epiphysis is intact; it nearly always is. ‘Type III Intype Ill epiphyseal injury (Figs. 2-6 and 2-7), the fracture, which is intra-articular, extends from the joint surface to the weak zone of the epiphyseal plate and then along the plate to its periphery. This type of injury is ‘uncommon, but when it does occur itis usually in the upper or lower tibial epiphyses and is due to an intra-ar- Type IIT injury of the eft distal tibial epiphysis in a 14-year-old boy. Note that the displacement of Epiphyseal Plate Injuries / 17 Fig. 2-8. Type IV epiphyseal plate injury. (A) Fracture of epiphysis and epiphyseal plate. (B) Bony union will ‘cause premature closure ofthe plate. (Adapted from Salter and Harris. with permission.) ‘Seslar shearing force. Accurate reduction is essential, "getso much for the sake of the epiphyseal plate as for the “ssstoration of a smooth joint surface; open operation ‘sey De necessary to obtain such reduction. As in types T ‘injuries, the prognosis is good, provided the blood to the separated portion of the epiphysis intact. ‘Type IV Ina type IV epiphyseal injury (Figs. 2-8 to 2-10), the fracture, which is intra-articular, extends from the joint surface through the epiphysis, across the full thickness of the epiphyseal plate, and through a portion of the meta Tab dl Fig. 2-9. ‘Type IV epiphyseal plate injury. Fracture of the lateral condyle of the humerus in children (A) Relatively undisplaced. (B) Moderately angulated. (C) Completely distracted and rotated. (D) Aer open reduction and internal fixation of the fracture with Kirschner sires. 18 / Management of Pediatric Fractures 2-10. Type IV injury ofthe dis- tal tibial epiphysis. (A) Note that the fracture line begins at the joint sur- face, crosses the epiphyseal plate, and extends into the metaphysis. The en- tire medial malleolus is shifted medi- ally and. proximally. This fracture should have been treated by open re- duction and internal fixation, Notice also the type I injury ofthe distal flbu- lar epiphysis. (B) One year after i jurya growth disturbances apparet the medial part of the distal tibial epiphysis has ceased growing while the lateral part has continued to grow. ‘The varus deformity of the ankle will be progressive. (From Salter and Harris? with permission.) physis, thereby producing a complete split. Perfect re- duction of a type IV epiphyseal plate injury is essential, not only for the sake of the epiphyseal plate but also for the restoration of a smooth joint surface. Unless the fracture is undisplaced, open reduction is always neces- sary. The epiphyseal plate must be accurately realigned in order to prevent bony union across the plate with resultant local premature cessation of growth. If metal fixation is required to obtain stability, preferably place it across the metaphysis, although fine, smooth Kirschner wires that traverse the plate for a few weeks do not inter fere with subsequent growth. Type V ‘The type V epiphyseal injury (Figs. 2-11 and 2-12), a relatively uncommon type of injury, results from a se- vere crushing force applied through the epiphysis to one area of the epiphyseal plate. It occurs in joints that move Fig. 2 ‘Type V epiphyseal plate injury. (A) Crushing of epiphyseal plate. (B) Premature closure of the plate fon one side with a resultant angulatory deformity, (Adapted from Salter and Harris with permission.) Fig. 2-12. Type V injury of the distal tibial epiphysis. (A) Clinical varus deformity ofthe ankleina9-year-old boy 5 years after a fall from a considerable height. He landed on his right foot and was thought to have susiained “only a sprained ankle.” One year later he began to develop a progressive defor- mity ofhis ankle, Note aso the shortening ofthe right leg. (B) ‘A radiograph ofthe ankle reveals a growth disturbance of the

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