Traumatic separation of epiphyses. An experimental study in rats

Four types of physeal fracture-separations, defined by the Salter-Harris classification, were created experimentally in the proximal physis of the right tibia of immature rats. The four types are: Type I, pure epiphyseal separation; Type II, separation of the epiphysis with a metaphyseal fracture; Type III, partial epiphyseal separation with a vertical fracture of the epiphysis; and Type IV, vertical epiphyseal and metaphyseal fractures. A sham operation performed on the left tibia served as the control. The animals were killed at various intervals up to 25 days after the operation. The findings were assessed by roentgenographic, histologic, and vessel injection methods. For Types I and II morphometric analyses were also performed. The influence of various types of lesions on the growth rate and the healing process was documented. For Types I and II lesions there was a transitory growth arrest and an increased thickening of the zone of hypertrophic cells. The alterations regressed after Day 15, and by day 25, a nearly normal plate was seen. For Type III lesions an angular deformity of the tibia occurred that increased with time. For Type IV lesions, a step-off developed on the articular surface that became more severe with time. Early vascular anastomoses between the epiphysis and the metaphysis led to the formation of bone bridges in Type III and Type IV lesions.

Triplane fracture of the distal tibial epiphysis. Long-term follow-up

The cases of twenty-three patients in whom a triplane fracture had been treated at the Naval Hospital, Oakland, California, between 1974 and 1985, were reviewed. The anatomical configuration of the fracture was confirmed in fifteen patients. Eleven of the fifteen patients had a three-fragment fracture. Plain radiographs alone did not accurately demonstrate the configuration of the fracture. Twenty patients were asymptomatic when they were evaluated eighteen to thirty-six months after the injury, but only eight of fifteen patients were asymptomatic when they were evaluated thirty-eight months to thirteen years after the fracture. Residual displacement of two millimeters or more after reduction was associated with a less than optimum result unless the epiphyseal fracture was outside the primary weight-bearing area of the ankle.

Pitfalls and complications of fractures of the distal radius and ulna in childhood

Fortunately, most bone forearm fractures in children heal with minimal functional disability. My approach to management of the most common injuries is presented. By following the guidelines outlined in this article, the generalist as well as the most sophisticated upper extremity surgeon should be able to avoid pitfalls and complications when managing forearm fractures in children.

Bilateral avulsion fractures of olecranon apophyses

Avulsion fracture of the olecranon is a relatively common injury in the adult. In the child, however, it is a rare occurrence. The injury is usually due to a fall on the outstretched elbow, with a sudden contraction of the triceps muscle. The contraction of this muscle avulses the olecranon and tears the distal triceps expansion. The fracture is well described in standard textbooks on paediatric orthopaedic surgery.

Humeral trochlear hypoplasia secondary to epiphyseal injury as a cause of ulnar nerve palsy

Humeral trochlear hypoplasia (HTH) is a rare condition that occasionally results in ulnar nerve palsy. A 41-year-old man developed HTH secondary to an epiphyseal injury of the trochlea incurred 33 years earlier. This may be the first report of a case of HTH caused by injury. The ulnar nerve appeared compressed by the malposition of the HTH against the medial head of the triceps brachii when the joint was flexed. The close proximity of the olecranon to the HTH also allowed the triceps brachii muscle to compress the nerve by displacing medially and overriding the bone. The condition was resolved surgically and the patient returned to his former occupation as a coal miner.

Biodegradable implants in the fixation of physeal fractures in cats and dogs

In a preclinical and a clinical study physeal fractures of cats and dogs were fixated with biodegradable implants. The preclinical part consisted of 4 cats with experimental physeal fractures of the distal femurs and the clinical part of 6 cats and 8 dogs with different physeal fractures. All fractures were fixated with selfreinforced polyglycolic acid (PGA) implants of different sizes. No external support was applied after the fixation. All cats and dogs used their operated legs during the first postoperative week and they could walk without lameness in 6 weeks. The fracture healed without delay or malformations. The retardations of the growth of the physeal regions were considered minimal.

[Miniaturized osteosynthesis of articular fractures of the fingers. Results of a series of 60 cases]

The importance of anatomical reduction of articular fractures and early mobilisation of these severe forms of trauma which frequently damage the extensor apparatus (58% of cases, led us to propose direct miniaturised osteosynthesis as described by the Nancy-Strasbourg team. Of the 1,000 cases of osteosynthesis performed between 1978 and 1985, we selected 12 fractures of the MP joint, 38 fractures of the PIP joint and 10 fractures of the DIP joint, differentiated into 4 stages according to the condition of the skin and tendons and into 9 categories according to the anatomical type and the site of the fracture. Direct osteosynthesis (screw, bolt, pin) was used in every case. The clinical results were evaluated in terms of the Total Active Range of Movements, the local trophic state, the amount of pain and return to work, for each joint. When well conducted and with effective skin cover, this technique allows almost normal reconstruction in simple fractures and is valuable in more complex fractures by preserving sliding of the tendinous apparatus due to early mobilisation.

Irreducible Salter-Harris type II fracture of the distal radial epiphysis

A Salter-Harris Type II fracture of the distal radius in a skeletally immature adolescent was irreducible by closed means. At open reduction, an invaginated periosteal flap was found to be responsible for the incomplete reduction. Removal of the flap resulted in an anatomic reduction.

Radiographic diagnosis of fracture-separation of the entire distal humeral epiphysis

Twenty children with fracture-separation of the entire distal humeral epiphysis have been reported. The key to the radiographic diagnosis is the relationship between the radius and capitellum. A line extending from the shaft of the radius will always pass through the capitellum regardless of the position in which the radiograph is obtained. Posteromedial displacement of the humeral fracture fragment together with the ulna and the radius most commonly occurs. The injury must be distinguished from dislocation of the elbow, fracture of the lateral condyle, and supracondylar fracture of the distal humerus.

Posterior dislocation of the hip associated with separation of the capital epiphysis. A case report

A 14-year-old boy with a posterior dislocation of the femoral head suffered an epiphyseal separation with reduction of the femoral neck into the acetabulum during an attempted closed reduction. He was treated by an open reduction with care taken not to damage the retinacular blood supply to the head. He did not develop avascular necrosis and is totally asymptomatic four years following his injury.

Bilateral Salter-Harris type II upper tibial epiphyseal fractures

We present a case of bilateral Salter-Harris type II epiphyseal injury to the proximal tibial epiphysis that occurred during gentle exercise. The mechanism and the likely contribution of preexisting Osgood-Schlatter disease are discussed.

The classification and prognosis of epiphyseal injuries

Because of the difficulty of assessing prognosis, a clinical and radiological review of 103 injuries of growth plates was performed. Thirteen patients showed retardation of growth and in 4 it was clinically obvious. In addition, external deformity occurred because of failure of remodelling in 1 case. In 9 cases there appeared to be slight stimulation of growth. The correlation between the Salter-Harris classification and retardation of growth was not always clear, especially in Salter-Harris type IV injuries, wherein prognosis varied with site. At the distal end of the tibia two groups of type IV injury were identified having respectively a 0 and 62.5 per cent incidence of retardation of growth. A new classification of distal injuries of the tibia is proposed, with superior predictive value for retardation of growth than that of Salter and Harris. This is valuable as a guide to prognosis and may facilitate treatment.

Metacarpal epiphyseal fractures

Five cases of injuries to the distal metacarpal physis and epiphysis are reviewed. Axially applied loads may result in growth disturbances. The extent of the physeal injury is not always evident on the initial radiographs. Decreased longitudinal growth of the metacarpal occurs in those injuries in which the physis has been damaged.

Fractures about the interphalangeal joints in children

Fracture patterns in 87 interphalangeal joint fractures in children's hands were studied and correlated with unique anatomic features of these joints. The collateral ligaments, which extend beyond the physis into the metaphysis, were found to protect the growth plate in the frontal plane. With laterally directed forces, fractures on the proximal side of the joint occurred, rather than epiphyseal fractures. There was good remodeling of angular deformities in the sagittal plane, but minimal correction in the frontal plane. In those patients treated surgically, angular deformities did not result. Of 24 condylar fractures followed for an average of 55 months, 11 (46%) demonstrated some restriction of joint motion.

Treatment of nonunion of fractures in the epiphyseal-metaphyseal region of long bones

Twenty-four consecutive patients with fracture nonunion in the metaphyseal-epiphyseal areas of long bones were surgically treated. Average time from injury to treatment of the nonunion was 10 months, and average follow-up time after surgical treatment was 29 months. Eight patients with infected nonunions had initial debridement procedures; three of these patients then had placement of external fixators and bone grafting. The remaining five patients and 13 others were then treated by open reduction and internal fixation alone or with the addition of autogenous cancellous bone grafting. Single or double plates and screws were used. Arthrolysis, joint manipulation, and intensive postsurgical exercises were considered necessary to regain joint function. One patient underwent a hemiarthroplasty, and two others underwent arthrodesis as the initial nonunion treatment. Twenty of the 21 patients not treated by arthrodesis or arthroplasty healed their fractures in an average time of 7 months. Fifty-two percent of the patients achieved good or excellent range of motion (ROM) of the contiguous joint, with 70% of the patients reporting no pain in this joint. These fractures have excellent intrinsic healing capability because they occur in anatomical regions with a normally abundant circulation. We recommend stable fixation, with the need for bone grafting only in defect nonunions, together with intra- and postoperative joint mobilization to obtain a satisfactory functional end result.