Revista de Medicina Desportiva (English) July 2018 - Page 24

Rev. Medicina Desportiva informa, 2018; 9 (4):22-26. XXVII Course of Rehabilitation and Traumatology of Sport Coimbra, 27 january 2018 Organizers: Prof. Doctor J. Páscoa Pinheiro, Dr. Pedro Lemos Pereira Dr. A. Pereira de Castro. Orthopedics. Lisbon Fractures with the impact of the growth cartilage. Treatment and complications Fractures are very common in children, being more frequent in males. They can result from blunt or indirect trauma. The children’s long bones have epiphyses and growth cartilages that appear to be the weak- est link in the child’s skeleton. A fracture can be defined as a solution of continuity in a bone, which is true in the adult, but it will no longer be in a child or adolescent, as it can correspond to the growth cartilage or physis. When the fracture hits the growth carti- lage, it’s called epiphysiolysis. The Growth cartilage (physis or physe) is an interposed biological structure between the epiphysis and diaphysis of the long bones. It is a mechani- cally more fragile structure consist- ing of four cellular layers: basal layer, proliferative layer or colum- nar, hypertrophic layer and tempo- rary ossification zone. The epiphyses and the physes are structures in which the normal anatomy should be preserved. Hence the dilemma: the physes, the weakest part of the bones and the site of many frac- tures in the child, are also the struc- tures that should be maintained in more normal conditions in order to prevent the stop of growth and angular deformations. The diagnosis is based on the clinical examination, but always requires a radiological examination, more than any other complementary examination (TAC or RM). A fracture is accompanied by a history of trauma, pain and functional impotence, edema and 22 july 2018 www.revdesportiva.pt deformation and, in the most seri- ous cases, mobility of the fracture focus may be noted. Of note, the presence of a painless active move- ment of the limb, does not exclude the possibility of a fracture. The suspicion of a fracture implies the immediate immobilization of the member and the referral to an emergency service. If it is an open fracture, the wound should be clean and cover with a clean compress or cloth. As for the location, it could be at the diaphysis, at the physis or at the metaphysis. As for the orienta- tion, the fracture trace can be trans- verse, oblique, helical and scallops. Classification. for epiphysis lesions there are several classifications: Weber, Poland, Ogden, but the most widely used and consensual is that of Salter-Harris. We should always try to classify the epiphysiolysis, because the type of injury is the basis of the treatment and the prog- nosis of evolution. In the classifica- tion of Salter-Harris the epiphysioly- sis are classified in five types: Type I – The rupture is transversely through the transitional area of the hypertrophic layer and provisional ossification, following the plan of these layers, not reaching the basal and proliferative layers; Type II – the rupture is transverse in a similar way to type I, but from a certain point the fracture inflects to the metaphysis, creating a triangular fragment (Holland’s triangle). Also, in this case there is no lesion of the basal or proliferative layers; Type III – a rupture is also initiated between the hypertrophic and provisional ossification layer and inflects up to the physis, crossing the prolifera- tive and basal layer, the physis, and then reaches the articular surface. In this type of injury all layers of the growth cartilage are affected; Type IV – similar to the previous one, but the fracture extends towards the metaphysis, resulting in a triangular fragment. As in type III, all layers of physis and the physis are affected; Type V – this is caused by compres- sion forces that crush the various cellular layers of the growth carti- lage. There is not exactly a trace of fracture, but rather the crushing of the cellular layers. Prognosis. This classification of epiphysiolysis can make a prognosis of the severity of the lesion: in types I and II the prog- nosis is good but in types III, IV and V there is the possibility of compli- cations. In the fracture that involves growth cartilage, parents should be alerted to any risk of growth disorders. Treatment. Similarly, this classification of epiphysiolysis helps to plan treatment: in types I and II the conservative treatment is advised, and in types III and IV there is the hypothesis of surgical treatment to achieve a good reduc- tion of the fracture. The treatment of most of the child’s fractures are mainly orthopedic, based on manual reduction, traction and/or plastered immobilization. The closed reduc- tion maneuvers of these fractures should be careful and gentle to prevent injury or crushing of the physis. If the reduction is easy to perform, it is necessary to make regular radiological control to exclude a later displacement. The bone is lined with a thick mem- brane, the periosteum which, if it is integrated, works like as a guide for the reduction and stabilization of the fracture. The angular deviations of 20° are acceptable because of the process of remodeling of bone cal- lus, as well as shortenings are also accepted by increased stimulation of growth of the fractured bone. The surgical treatment is rare and has very precise indications. It must be carried out very early on because of the type and location. The osteo- synthesis of fractures in children has their own demands that must be absolutely respected. Some of these fractures, called need fractures, the surgical treatment is in most cases necessary: external condyle of the humerus, femoral neck and distal tibial gland. Complications. The complication of a epiphysi- olysis is the eventual injury of the growth cartilage. Bone bridges, axial deviations and complete stop of