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