صدمات فیزیکی

صدمات فیزیکی

اسلاید 1: PHYSEAL INJURIESCHETAN

اسلاید 2: Bone growth is achieved by adding newly synthesized bone to existing bone by two mechanisms: Endochondral ossificationIntramembranous ossificationBone growth

اسلاید 3: bone forms via a cartilaginous intermediatephysis best reflects this processFrom 9 to 10 weeks gestational age to skeletal maturity at 15 to 17 years, they are responsible for the longitudinal growth of boneEndochondral ossification

اسلاید 4: Physeal injuries represent 15% to 30% of all fractures in children.The incidence varies with age and has been reported to peak in adolescents.Physeal injuries involving the phalanges account for over 30% of all physeal fractures (wrist jt more common)

اسلاید 5: Growth hormone increases the number of cells in the physeal columns;Thyroid hormone potentiates cytoplasmic proliferation;Oestrogens play an important role in triggering physeal closure.Hormonal effects upon skeletal growth

اسلاید 6: zones/resting zone

اسلاید 7:

اسلاید 8:

اسلاید 9: Epiphyaseal vessels—supply germinal layerMetaphyseal vessels—supply central ¾ of physisPeriosteal physis—supply peripheralTypes of epiphysisPressure epiphysisTractionAtavisticaberrantBlood supply of physis

اسلاید 10: The first two zones have an abundant extracellular matrix and, consequently, a great deal of mechanical integrity, particularly in response to shear forces. The third layer, the hypertrophic zone, contains scant extracellular matrix and is weaker. On the metaphyseal side of the hypertrophic zone there is an area of provisional calcification leading to the zone of enchondral ossification. The calcification in these areas provides additional resistance to shear. Thus, the area of the hypertrophic zone just above the area of provisional calcification is the weakest area of the physis, and it is here that most injuries to the physis occur

اسلاید 11: It is a wedge-shaped group of germinal cells that is continuous with the physis  The zone of Ranvier consists of three cell types—Osteoblasts form the bony portion of the perichondral ring at the metaphysis; chondrocytes contribute to latitudinal growth;fibroblasts circumscribe the zone and anchor it to perichondrium above and below the growth plate.Zone of Ranvier

اسلاید 12: It is a fibrous structure that is continuous with the fibroblasts of the zone of Ranvier and the periosteum of the metaphysis. It provides strong mechanical support for the bone–cartilage junction of the growth platePerichondrial Ring (LaCroix)

اسلاید 13:

اسلاید 14: Epiphyseal blood supply by Dale and Harris Type A, The epiphysis is nearly entirely covered by articular cartilage. Consequently, the blood supply traverses the metaphysis and may be damaged on separation of the metaphysis and epiphysis. Type B, The epiphysis is only partially covered by articular cartilage. Because the blood supply enters through the epiphysis, separation of the metaphysis and epiphysis will not compromise the blood supply to the germinal layerProximal femur Proximal humerusDistal femurProximal & distal tibiaDistal radius

اسلاید 15: The most frequent mechanism of injury is fractureM C, fracture injury is direct, with the fracture pattern involving the physis itself. Occasionally, physeal injury from trauma is indirect and associated with a fracture elsewhere in the limb segment, either as a result of ischemia or perhaps compressioninfection, disruption by tumour, cysts, tumour-like disorders, vascular insult, repetitive stress, irradiation, and other rare etiologiesEtiology

اسلاید 16: Long bone osteomyelitis or septic arthritis (particularly of theshoulder, hip, and knee) can cause physeal damage resulting in either physeal growth disturbance or frank growth arrest

اسلاید 17: Partial or complete growth arrests can occur from a pure vascular injury to an extremity.Salter–Harris type V injuries; the most common location for this is the tibial tubercle after femoral shaft or distal femoral physeal fracturesVascular Insult

اسلاید 18: EPIDEMIOLOGYSH2 MCPHALNGES 44%, DISTAL RADIUS 18%,DISTAL TIBIA11%MALE:FEMALE -2:1- 14YEARS:12YEARSoccurred twice as often in the upper extremities as in the lower extremities.

اسلاید 19: Salter and harrisBased on the Radiographic appearance of fracture.The first three types were adopted from Poland (types I, II, and III) and Aitken (Aitken type III became Salter-Harris type IV)The higher the classification the more likely Is physeal arrest or joint incongurity to occur

اسلاید 20: Is a separation of the epiphysis from the metaphysis occurring entirely through the physis. It usually occurs in the zone of hypertrophy (weakest)It is rare and seen most frequently in infants or in pathologic fractures, such as those secondary to rickets or scurvy. Because the germinal layer remains with the epiphysis, growth is not disturbed unless the blood supply is interrupted, as frequently occurs with traumatic separation of the proximal femoral epiphysis.PhalengesMetacarpals

اسلاید 21: Radiographs of undisplaced type I physeal fractures, are normal except for associated soft tissue swelling.type I fractures occurred most frequently in the phalanges, metacarpals, distal tibia, and distal ulna. Epiphyseal separations in infants occur most commonlyin the proximal humerus, distal humerus, and proximal femurUltrasound is particularly helpful for assessing epiphyseal separations in infants (especially in the proximal femur and elbow regions) without the need for sedation

اسلاید 22: The fracture extends along the hypertrophic zone of the physis and at some point exits through the metaphysis. The epiphyseal fragment contains the entire germinal layer as well as a metaphyseal fragment of varying size. This fragment is known as Thurston Hollands sign. The periosteum on the side of the metaphyseal fragment is intact and provides stability once the fracture is reduced. Growth disturbance is rare because the germinal layer remains intact.distal radius

اسلاید 23: By def:- they cross the germinal layer and are usually intra-articular.Often ass with high-energy or compression mechanisms of injury, which imply greater potential disruption of the physis & higher risk of subsequent growth disturbanceConsequently, if displaced, they require an anatomic reduction, which may need to be achieved openTillaux #distalhumerus

اسلاید 24: Salter–Harris type III fractures begin in the epiphysisas a fracture through the articular surface and extend vertically toward the physis. The fracture then courses peripherally through the physis.The articular surface is involved and the fracture line involves the germinal and proliferative layers of the physis.

اسلاید 25: Vertical shear # Extend from the metaphysis across the physis and into the epiphysis.Thus, the # crosses the germinal layer of the physis and usually extends into the joint. (articular)This # pattern is frequent around the medial malleolus, Lateral condylar fractures of the distal humerus (milch type 1) and intra-articular two-part triplane fractures of the distal tibiawith displacement, may result in metaphyseal–epiphyseal cross union there by causing growh disurbancetreatment principles include obtaining anatomic reduction and adequate stabilization to restore the articular surface and prevent metaphyseal–epiphyseal cross union

اسلاید 26: Is a crushing injury to the physis from a pure compression force.Those authors who have reported type V injuries have noted a poor prognosis, with almost universal growth disturbanceEg:- Of such an injury is closure of the tibial tubercle, often with the development of recurvatum deformity of the proximal tibia, after fractures of the femur or distal femoral epiphysis unrecognized on initial radiographs. Undoubtedly, more sophisticated imaging of injured extremities (such as with MRI) will identify physeal injuries in the presence of normal plain radiographs

اسلاید 27: Injury to the perichondrial ringType 6 injury RANG

اسلاید 28: Trauma to epiphysis (chondral to osteochondral)Isolated injury of the epiphyseal plateType 7 ogden

اسلاید 29: # of metaphysisIsolated injury of the metaphysis with possible impairement of enchondral ossificationType 8

اسلاید 30: Avulsion injury to periosteum which may impair intramembranous ossification Type 9

اسلاید 31:

اسلاید 32: The higher the classification, the more likely is physeal arrest or joint incongruity to occur.

اسلاید 33: Peterson

اسلاید 34: Type I is a fracture of the metaphysis extending to the physis. Types II to V are the equivalents of Salter-Harris types I, II, III, and IV, respectively. Peterson type VI is epiphyseal (and usually articular surface) loss. Lawnmower injuries are a frequent mechanism for type VI injuries

اسلاید 35:

اسلاید 36: Salter-Harris I fracture of the distal femur. (widening)

اسلاید 37: Displaced Salter-Harris II fracture of the distal femur (with the Thurstan Holland fragment)

اسلاید 38: Salter-Harris II fracture of the distal tibial epiphysis

اسلاید 39: CT scan -Salter-Harris III fracture of distal anterolateral tibial epiphysis (ie, Tillaux fracture).

اسلاید 40: Displaced Salter-Harris IV fracture of the proximal tibia The lateral portion of the epiphysis and the medial portion of the epiphysis are independently displaced

اسلاید 41: initial injury radiograph of ankle subjected to significant compressive and inversion forces. minimally displaced fractures of tibia and fibula with apparent maintenance of distal tibial physeal architecture.

اسلاید 42: Follow-up radiograph - growth arrest secondary to Salter-Harris V injury. Note the markedly asymmetric Park-Harris growth recovery line, indicating that the lateral portion of the growth plate continues to function and the medial portion does not.

اسلاید 43: Mortise radiograph -The Salter-Harris VI pattern. In this case, the radiograph indicates that it is quite likely that a small portion of the peripheral medial physis (as well as a small amount of adjacent epiphyseal and metaphyseal bone) has been avulsed

اسلاید 44: Growth plate (physeal) fractures. Radiographic evidence of a pediatric stubbed great toe.

اسلاید 45: Xray of the injured limb in atleast 2 viewsClassification of injury types usually done by radiographCt scans may clarify complex # patternsMri may show considerably more physeal damage

اسلاید 46: Treatment

اسلاید 47: Generally all type 1 and type 2 # do well with closed reductionAll type 3 &4 # should be treated by ORIF regardless of the amount of displacementIn type V fractures, the cartilage cells of the physis are crushed, and regardless of the form of treatment, growth disturbance can occur. A type V fracture usually is diagnosed only in retrospect when a growth disturbance develops

اسلاید 48: General principles of RxMost SH I and II injuries can be treated with closed reduction and casting or splinting and then reexamination in 7-10 days to evaluate maintenance of the reduction.Displaced injuries:- require reduction (within 48 hours) because growth arrest is common after late reduction.

اسلاید 49: Greater angular deformity can be tolerated in the upper extremity than in the lower extremity, More valgus deformity can be tolerated than varus, More flexion deformity can be tolerated than extension.

اسلاید 50: More proximal deformities of the lower extremity (in the hip) are better compensated for than distal deformities (the knee and, least of all, the ankle). Spontaneous correction of angular deformities is greatest when the asymmetry is in the plane of flexion or extension (ie, the plane of joint motion), Function often returns to normal unless the fracture occurs near the end of growth.

اسلاید 51: younger the patient,:- more remodeling potential, greater degrees of displacement are acceptable. But have greater potential for deformity. A growth plate that requires higher energy to cause failure tends to have a higher rate of growth arrest. For instance, the distal femoral and proximal tibial

اسلاید 52: (SH III and IV)-require ORIF. Smooth pins should parallel physis in epiphysis or metaphysis, avoid physis. Oblique application of pins across physis considered only when satisfactory internal fixation is unattainable with transverse fixation. Type V fractures - rarely diagnosed acutely, treatment often delayed until formation of a bony bar across physis. A high level of clinical suspicion is necessary

اسلاید 53: Correct placement of cannulated screws across epiphysis and metaphysis

اسلاید 54: Crossing the physis with any form of fixation should be avoided if possibleIn type III and IV fractures the pins should cross the epiphysis in the fractured areasIn type II and IV fractures they should cross the metaphysis and epiphysis rather than the physis if possible. Small cannulated screws are well suited for these fractures.

اسلاید 55: COMPLICATIONS1)Growth accelerationfirst 6-18 months after injury. increased vascular response. use of fixation devices that may stimulate longitudinal growth. Treatment in adolescents may involve an epiphysiodesis. If more than 6 cm of correction is desired- lengthening procedures for bilateral limb-length equilibration.

اسلاید 56: 2) Growth arrestPremature partial growth arrest is far more common and can appear as peripheral or central closures. Complete growth arrest is uncommon.angular deformities and limb-length discrepancies. Peripheral arrests are produced when (bone bar/bridge) forms, connecting metaphysis to epiphysis, traversing the physis. If bar is located medially, the normal physis continues to grow laterally, producing a varus deformity. Anterior bone bars - recurvatum deformity.

اسلاید 57: Central growth arrests - tented lesions of physis and epiphysis due to a central osseous tether with metaphysis, resulting in physeal coning. Some longitudinal growth continues in patients with growth retardation, though at a much slower rate; thus, a progressive shortening of the limb occurs. Partial growth arrests may be visible on radiographs as early as 3-4 months postinjury or may be delayed as long as 18-24 months. Follow-up checks may be necessary for 1-2 years postinjury to monitor physeal healing and growth response.