GOOD AFTERNOON

The key difference between a child's bone and

that of an adult is the presence of a physis.

Physeal injuries are very common in children

The growth plate, or physis, is the translucent,
cartilaginous disc separating the epiphysis from
the metaphysis and is responsible for the
longitudinal growth of long bones.
 Gross Anatomy
 Five regions characterize long
bones: the bulbous, articular
cartilage-covered ends
(epiphyses) tapering to the
funnel-shaped metaphyses, with
the central diaphysisinterposed
between the metaphyses.
 During growth, the epiphyseal
and metaphyseal regions are
separated by the organized
cartilaginous physis, which is the
major contributor to longitudinal
growth of the bone.
 Epiphysis incorporates
the growth plate or physis and
the secondary ossification center
 The larger long bones (clavicle, humerus, radius, ulna,
femur, tibia, and fibula) havephyses at both ends,
whereas the smaller tubular bones (metacarpals,
metatarsals, and phalanges) usually have a physis at
one end only.
 At birth, with the exception of the distal femur and
occasionally the proximal tibia, all of the above-
mentioned epiphyses are purely cartilaginous.
 At various stages of postnatal growth and
development, a secondary ossification center forms
within the epiphysis.
 This development helps define the radiolucent zone of
the physis, which persists until the physis closes at
skeletal maturation.
1. Invading metaphyseal
vessels from the nutrient
artery.
2. Peripheral periosteal
vessels supply the
perichondrial
ring area.
3. Epiphyseal vessels
nourish the central
portion of the
physis.
 The physis is divided into four zones from the
center of the epiphysis to the metaphysis:
germinal, proliferative, hypertrophic, and
provisional calcification (or enchondral
ossification).
Reserve Or Resting Zone
 Located in a thin layer
at the epiphyseal pole
of the growth plate
 Quiescent
chondrocytes.
 Cells store
lipids,glycogen.
 Has low 02 tension

 Affected in
Gaucher's,diastrophic
dysplasia,kneist
dysplasia and
psuedoachondroplasia
Proliferative Or Columnar
Zone
 Chondrocytes rapidly
divide, synthesize new
matrix,
 Longitudinal growth and
stacking of chondrocytes.
 Increased o2 tension.
 No calcification.
 The zone is the true
germinal layer of the
growth plate, with cells
actively dividing
 Type II collagen synthesis
and mRNA expression
increase in this zone.
 Affected in
Achondroplasia,Gigantism,
Multiple hereditary
exostosis.
Hypertrophic Zone
 Cell size abruptly
increases and the
columnar arrangement
is less regular.
 Increasing vacuolation
of the cells.
 Chondrocytes become
swollen and vacuolated
in process of maturation
leading to cell death.
 The main matrix
components synthesised
are types II and X
collagen and Aggrecan.
 Affected in
SCFE,enchondroma,MP
S
Provisional
Calcification zone
 chondroid matrix
becomes
impregnated with
calcium salt from
mitochondria from
destroyed cartilage
cells.
 Widened in: Rickets

 Physeal fractures
occur through the
zone of provisional
calcification.
Primary spongiosa(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
Physis Periphery
Groove of Ranvier-
 –seen as a triangular
microscopic structure
at the periphery of the
physis,
-containing
fibroblasts,
chondroblasts, and
osteoblasts.
 -responsible for
peripheral growth
of physis.
Perichondrial fibrous
ring of La Croix-

-a fibrous tissue
overlying the Zone of
Ranvier
-connects
metaphyseal
periosteum to
cartilaginous
epiphysis
- mechanical
function→ stabilizes
the epiphysis to the
metaphysis.
PHYSEAL INJURIES
• Physis only injured
• Fracture through zone of hypertrophy
 Subtle, non- • Severe, displaced
displaced SH1 SH1
 tenderness, swelling – obvious deformity and
at physis pain
 Normal radiographs – Displacement seen on
 Casting/immobilizati radiographs
on – Closed reduction and
casting favored
• Reduces risk of iatrogenic
physeal injury
• Physis +metaphysis
• Thurston-Holland metaphyseal
fragment
• Zones of endochondral ossification
and hypertrophy fractured
• Treatment options include:
• Closed reduction and casting
• Closed reduction and
percutaneous screw or wire
fixation
• Screw for larger metaphyseal
fragment
• Wires crossing physis for
smaller metaphyseal fragment
• Physis+Epiphysis Injured
• Hypertrophic, proliferative, and germinal
zones fractured
• Advanced imaging may be needed to evaluate
articular displacement
• Treatment options include:
• Closed reduction and casting
• Closed vs open reduction, screw
fixation
• Screw along width of epiphysis
avoiding physis
• Screws in epiphysis may
increase pressure on adjacent
articular cartilage and are often
removed quickly after fracture
healing
• Epiphysis, physis, metaphysis injured
• All four zones of physis involved
• Anatomic reduction of physis required to
minimize risk of physeal bar
 CT gives 3D
visualization of
fracture patterns
 Essential for surgical
planning

Courtesy of Dr Klatt
 Fixation best
accomplished from
epiphysis to epiphysis
and/or metaphysis to
metaphysis
 As with SH3, epiphyseal
hardware should be
removed to decrease
pressure on adjacent
articular cartilage

Courtesy of Dr Klatt
• Crush injury to entire physis
• Very difficult initial diagnosis as
there is only minimal
displacement
• Initial nonoperative treatment
• Late diagnosis after complication
of physeal arrest and deformity
has occured
 1. peripheral damage at the zone of Ranvier
resulting in bridge formation.
 2. Intraepiphyseal injury.
 3. Metaphyseal injury.
 4. Avulsion of periosteum which involves the
periosteal growth mechanism
 Fracture healing with maintenance of growth
potential
 Acceptable reduction and alignment
 Limit iatrogenic injury to physis
 Repeated, forceful reduction attempts
 Hardware across physis
 Maintenance of reduction/alignment
Etiology:
Physeal bridging occurs when there is contact
between the epiphysis and the metaphysis,
resulting in osseous consolidation in that region.
Contact may occur when part of the physis is
completely destroyed or when a fracture becomes
displaced. Contact also can occur when the physis
is disrupted, resulting in a liquid mixture of blood
and crushed tissue lying in continuity between
the epiphysis and the metaphysis
PERIPHERAL ELONGATED CENTRAL
 most commonly due to
the bony bar that
crosses the physes,and
very rarely gets
corrected
spontaneously.
 Central bar- shortening.

Peripheral bar- angular

deformity.
 Most commonly occur
as mixed type.
 Growth arrest can
result in shortening or
angular deformity of
both the lowerlimb
depending on the size
and location of the
growth arrest
 Limb shortening in
SH5 is due to large
central bars.
 Size and lcation of
bony bar can be seen
in 3D-CT and
volumetric MRI.
 Many type 1 and 2 can be managed
conservatively.
 Type 3 and 4 usually require ORIF
 Implants should not cross the physis or else use
the smallest diameter possible.
 Remove as soon as the fracture is stable.
 Parents need to be educated for the possibility
of growth disturbance and long term follow up
regardless of the injury type.
Complications in sh3-5 >sh 1-2
except!
Completely displaced SH1 fracture of distal femur
has more potential for growth arrest than
nondisplaced SH4 fracture of distal femur.
 Bony bar resection in Young patients with
peripheral bars (30% of physis involved), have
good success rate than old patients with large
central bars.

 Bar resection combined with osteotomy is done

to correct angular deformity.
 Epiphysiodesis of remaining physis with
staged angular correction and/or lengthening
procedures is the best option.
 Amount of growth remaining.

 Amount of physis involved.

 Moseley straight line graph

Used to Predict the amount of deformity at skeletal

maturity.
 Upto 2cm –shoe lift is given.

 2-5 cm – contralateral epiphysiodesis.

 >5cm – limb lengthening is tried.

 Reduction of displaced physeal fractures can
result in interposition of soft tissue.
 Physeal widening of >3mm or incomplete
reduction on post reduction xray is suspicious
for entrapment and MRI should be taken.
 Periosteal entrapment is a risk factor for
premature physeal closure and/or physeal bar
formation due to the bone forming reaction of
periosteum in response to injury.