This document discusses physeal injuries in children. It begins by describing the anatomy of the physis, or growth plate. It then reviews several classification systems for physeal fractures, including the Salter-Harris classification which divides injuries into 5 types based on the location of the fracture line. The most common types and their typical prognosis are described. Treatment principles focus on anatomical reduction and immobilization to allow healing while preserving growth. Complications like premature growth arrest and angular deformities are risks, requiring long term monitoring.

1. PHYSEAL INJURIES
Dr . LOKESH SHAROFF
Orthopaedic surgeon, mumbai, india

2. ANATOMY OF PHYSIS
 GERMINAL LAYER
 ZONE OF PROLIFERATING
CARTILAGE
 ZONE OF HYPERTROPHIC CELLS
 ZONE OF PROVISIONAL
CALCIFICATION
 ZONE OF ENCHONDRAL
OSSIFICATION

3. CLASSIFICATIONS
 AITKENS (1936)
 SALTER&HARRIS(1963)
 OGDEN(1981)
 PETERSON(1994)

4. SH TYPE 1
 Complete seperation of
epiphysis without true #
through bone with or
without displacement
 From
shearng/torsion/avulsion
 No findings on x-ray
 Good prognosis

6. SH TYPE 2
 # seperation line traverses
along physis to a variable
distance & then out through a
portion of triangular shaped
metaphyseal
fragment(Thurstan-Holland
sign)
 Intact periosteum on the side of
metaphyseal fragment
 Prognosis-good

8. SH TYPE 3
 Vertical split from joint
surface to physis & then
along physis to
periphery(intra-articular)
 Uncommon
 Lower tibial epiphysis
 Prognosis-good

10. SH TYPE 4
Intra-articular # extending
from joint surface through
epiphysis,entire physis & a
portion of metaphysis
-Lateral condyle of humerus
Prognosis-bad

12. S H TYPE5
 Severe crushing force applied
through epiphysis damaging the
germinal layer of physis
 No osseous injury
-diagnosed in retrospect

14. S H TYPE 6
 Perichondrial injury as described by
Mercer Rang(1969)
 Rare injury
 Blow to periosteum/perichondrial ring
scarring tethering and bony bar
formation can occur

16. OGDEN 7
 INTRA-ARTICULAR
OSTEOCHONDRAL FRACTURE

17. OGDEN 8 AND 9
 METAPHYSEAL AND DIAPHYSEAL
#S RESPECTIVELY BUT SEEN TO
STIMULATE THE LONGITUDINAL
GROWTH OF THAT BONE.

18. PETERSON
He described 2 new types of fractures ..
1st
and 5th
in his classification

19. PETERSON TYPE1
 Transverse # of metaphysis
with # line extending to
physis
 Comminution-common
 MOI:longitudinal
compression
 Sites:distal radius,finger
phalanges,MC
 Prognosis:good

22. PETERSON TYPE 2
 Seperation of physis with a
portion of metaphysis
attached to epiphysis
(THURSTAN-HOLLAND sign)
 Most common type
 Site:finger phalanges

25. PETERSON TYPE 3
 Seperation of metaphyis
from epiphysis through
the physis disrupting the
physis
 Site:distal fibula

27. PETERSON TYPE 4
 # of epiphysis extending to &
along the physis
 May be comminuted/double
 Common in older children
 Premature growth arrest
common
 Sites:finger phalanges,distal
tibia(medial malleolus0

29. PETERSON TYPE 5
 # that traverses the
metaphysis,physis,epiphysis &
atricular cartilage
 Tri-plane #
 Comminution & open# common
 Premature growth arrest occurs
 sites: lateral condyle humerus,
distal tibia

31. PETERSON TYPE 6
 # in which part of
metaphysis,physis &
epiphysis is removed/
missing
 Found in open #
 Premature closure of
epiphysis occurs

33. PROGNOSIS
 Severity of injury
 Age of the child
 Site of injury
 Amount of physis injured

34. TREATMENT
 To obtain & maintain
reduction by closed/open
means
 To maintain function &
normal growth

35. PRINCIPLES OF
TREATMENT
 Physeal # should be reduced
immediately
 All reductions open/closed should
be gentle
 Forceful repeated manipulations
should be avoided
 During open reduction pressure on
physis should be avoided

36. PETERSON TYPE 1
 CMR & casting
 Immobilisation for 3-4 weeks
 Follow up to ensure normal
growth

37. P TYPE 2/S H TYPE 2
 CMR & casting under GA/block
 Metaphyseal fragment & intact
periosteum provide stability
 Surgical intervention
1.periosteal impingement
2.unstable fragment
? Bio-degradable pins

38. P TYPE 3/S H TYPE 1
 CMR & casting

39. P TYPE 4/S H TYPE 3
 Anatomical reduction of physeal &
articular cartilage by ORIF

40. P TYPE 5/S H TYPE 4
 OR & IF

41. P TYPE 6
 Initial debridement followed
by reconstructive surgery
later on

42. COMPLICATIONS
 Premature growth arrest
1.length discrepancy
2.angular deformity
 Compartment syndrome/arterial
occlusion
 Neurological complications
 sepsis & osteomyelitis
 Overgrowth & hypoplasia
 Malunion/delayed union/non union

43. HARRIS GROWTH ARREST
LINES
 Symmetrical, thin white lines
 Perpendicular to long axis of bone
 Metaphyseal at first
 Most marked in rapidly growing ends of
bones, e.g. distal femur and proximal tibia
 They migrate towards the diaphysis with
further growth and may disappear

45. HARRIS GROWTH ARREST
LINES
 Denote activity of physeal plate
 If asymmetric , denotes partial arrest
 If lines are absent , denotes growth
arrest