성장판 손상의 4가지 솔터- 해리스 분류법. 그리고 치료에 대한 논문

[문형철]

골절로 야기되는 성장판의 손상에 대한 논문

- 성장판 손상은 아이들 골격손상에서 15-30%를 차지한다고 보고. 대개 10세 이후에 많음.

- 성장판 손상의 80%는 10-16세(평균 13세). 여아보다는 남아가 흔함. 

- distal radius에서 가장 흔한 성장판 손상이 발생(약 30-60%). 

역시 bone regeneration을 촉진하는 한약이 중요해지는군 ㅎㅎㅎ

Orthopedic Pitfalls in the ED - Pediatric Growth Plate Inju.pdf

Musculoskeletal injuries are frequently the reason children and adolescents seek care in the emergency department. In the skeletally immature patient, injury to the open growth plate can occur. When missed or mismanaged, these injuries can result in growth plate arrest. The emergency physician needs to remain vigilant for these injuries. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician.

- 성장판 손상이 간과되거나 제대로 치료되지 못할때, growth plate arrest를 야기할 수 있으므로 주의깊게 살펴야 함. 

eipdemiology

Physeal injuries have been reported to account for between 15% and 30% of all skeletal injuries in children,1-4

occurring most commonly after the age of 10. Approximately 80% of physeal injuries will occur between the ages

of 10 and 16 years, with a median age of 13 years. Injuries to the physis occur much more frequently in boys than girls,

reflective of the overall increased incidence of musculoskeletal injury in this population, as well as later development of

skeletal maturity in boys as opposed to girls.6,8 The distal radius is the most common anatomic site of physeal injury,

accounting for 30% to 60% of cases.6,7,9-12 Physeal injuries occur most frequently in April through September when

children are more likely to be playing outdoors.8

- 성장판 손상은 아이들 골격손상에서 15-30%를 차지한다고 보고. 대개 10세 이후에 많음.

- 성장판 손상의 80%는 10-16세(평균 13세). 여아보다는 남아가 흔함. 

- distal radius에서 가장 흔한 성장판 손상이 발생(약 30-60%). 

PATHOPHYSIOLOGY

The physis is the fundamental mechanism of endochondral ossification (Fig 1). The primary function of the physis is rapid, integrated longitudinal bone growth. As such, injuries to the physis are unique to the skeletally immature patient. The growing physis consists of 4 distinct zones, listed in order from the epiphysis to the metaphysis: the zone of resting cells, the zone of proliferating cells, the zone of hypertrophic/maturing cells, and the zone of provisional calcification. It is the third zone, the zone of hypertrophic/maturing cells that is the weakest link in the physis, and consequently the zone where a cleavage plane is most likely to pass. 

The nutrient blood supply to the physis comes predominantly from the epiphysis. Normal growth and maturation

at the physis is dependent on this intact vascular pathway.13-16 Although several classification systems exist to describe

physeal injuries, the Salter-Harris classification system is used most frequently. This classification scheme, described by the investigators in 1963, is based on the extent of involvement of the physis, epiphysis, and the joint.9 The

higher the Salter-Harris fracture classification number, the greater the chance of physeal arrest and joint incongruity.

This is predominantly attributable to the fact that higher Salter-Harris fractures (III, IV, and V) are much more likely

to injure the vascular supply to the physis.9,16 The classic patterns described by Salter and Harris, and later modified

by Ogden17 are as follows (Fig 2):

Type I

Type I fractures are seen most frequently in infants and toddlers. The injury mechanism generally involves a shearing,

torsion, or avulsion movement—essentially producing a separation through the physis (Fig 3) In these injuries, which represent 6% of all physeal fractures, the epiphysis in effect separates from the metaphysis. There is no osseous

fracture to the epiphysis or metaphysis. The line of cleavage runs through the hypertrophic zone of the physis, with the

growing cells remaining on the epiphysis, in continuity with their nutrient blood supply. Because of this fact, Salter-

Harris I fractures usually carry a good prognosis, and infrequently result in any growth disturbances.

Type II

Salter-Harris II injuries are the most common type encountered, accounting for 75% of physeal injuries.5,9,11 The

line of fracture runs through the hypertrophic cell zone of the physis and then out through a segment of metaphyseal

bone (Fig 4). The segment of metaphyseal bone is referred to as the “Thurston-Holland” sign or fragment. As with type

I fractures, growth is usually preserved, because the reproductive layers of the physis maintain their connection to the

epiphysis and their nutrient blood supply.

Type III

The hallmark of a Salter-Harris type III fracture is an intraarticular fracture of the epiphysis with extension through the hypertrophic cell layer of the physis (Fig 5). Type III fractures are relatively rare, accounting for approximately 10% of physeal injuries.5,9,11 The prognosis for normal bone growth is generally good, but more guarded than with type I or II injuries. The chance for growth disturbance is related to preservation of blood supply of the epiphyseal bone fragment. The greater the displacement and/or fragmentation, the greater the chance for blood supply disruption and subsequent growth disturbance. 

Type IV

A Salter-Harris type IV fracture line originates at the articular surface, crosses the epiphysis, extends through the

full thickness of the physis, and exits through a segment of the metaphysis (Fig 6). Type IV injuries are seen most commonly at the lower end of the humerus.9,11 Like type III injuries, type IV injuries represent approximately 10% of all

physeal fractures.5,9,11 As with type III fractures, future growth disturbance is at risk, dependent on the degree of

blood supply disruption from the epiphysis.

Type V

Salter-Harris type V injuries are fortunately the most rare fracture pattern (they account for approximately 1% or less

of physeal injuries5,9,11), as they are by the far the most likely injury to result in focal bone growth arrest.3,4,5,9,11

These injuries occur most frequently at the knee or ankle, and are the result of a severe abduction or adduction injury

that transmit profound compressive forces across the physis. 

This resultant axial compression crushes the physis, and specifically injures the cells of the reserve and proliferative

zones. With a type V fracture, usually there is minimal or no displacement of the epiphysis. Type V injuries are most 

often diagnosed in retrospect, once a bone growth abnormality has been identified on serial radiographs.19

TREATMENT

If the diagnosis of “sprain” is being entertained the emergency physician in the skeletally immature patient, the practitioner should question why this injury does not represent a Salter-Harris injury. With negative radiographs and point tenderness over a physis, it is prudent to treat these patients as if they have Salter-Harris type I injury. It is equally prudent to counsel the parents and patients regarding the potential for future growth abnormalities, even with minor injuries. Parents should be  counseled that treatment is being given for the “worst case” scenario, and it may well turn out that their child does not have a fracture, but that this can only be determined with serial radiographs. Treatment for type I injuries consists of splint immobilization, intermittent icing, and elevation. Referral to an orthopedic surgeon for re-eval‎uation and follow-up is warranted, and the prognosis with type I injuries in most cases is good. 

Type II injuries, if there is no angulation or significant displacement of the fracture fragment, can be similarly managed with splinting and outpatient follow-up. The prognosis for this type of fracture is also excellent. 

Type III fractures usually require an orthopedic consultation in the emergency department, as it is critically important to achieve anatomic alignment of the epiphyseal fracture fragment for both blood supply maintenance and joint congruity. Near perfect alignment of the articular surface is a critical factor in attempting to assure a good outcome from these injuries. Open reduction and internal fixation techniques are frequently required in these types of fractures. 

Type IV injuries have an even higher likelihood of requiring operative intervention to achieve anatomic reduction than type III injuries. These injuries, even with good reduction, carry a significant risk of growth disturbance.5,9,11 

Type V injuries carry the worst prognosis, and focal bone growth arrest can be anticipated with these fortunately rare fractures. When diagnosed, orthopedic consultation is warranted. Usually affecting the lower extremities, patients with type V injuries are usually casted and kept nonweightbearing.

SUMMARY

Orthopedic injury is a frequent occurrence in the pediatric and adolescent patient population. When orthopedic injury

is coupled with a skeletally immature patient, growth plate injury can result. The emergency physician needs to maintain

a high level of suspicion for these injuries, even in the face of negative radiographs. Although bone growth abnormalities

are relatively rare after physeal injury, early recognition and appropriate management will help to minimize this orthopedic pitfall.

REFERENCES

1. Mann DC, Rajmaira S: Distribution of physeal and nonphyseal

fractures in 2,650 long bone fractures in children aged 0-16 yrs.

J Pediatr Orthop 1990;10:713-16

2. Mizuta T, Benson W M, Foster BK, et al: Statistical analysis of

the incidence of physeal injuries. J Pediatr Orthop 1987;7:518-23

3. Ogden JA: Skeletal growth mechanism injurypatterns. J Pediatr

Orthop 1982;2:371-377

4. Greenfield R: Orthopedic injuries, in Strange G, Ahrens W, et al

(eds): Pediatric EmergencyMedicine. New York, McGraw-Hill,

1996, pp113-118

5. Della-Giustina K, Della-Giustina DA: Emergencydepartment

eval‎uation and treatment of pediatric orthopedic injuries. Emerg

Med Clin NA 1999;17:895-922

6. Rogers L:. Children’s Fractures. Philadelphia, Lippincott Co.,

1970

7. Peterson CA, Peterson HA: Analysis of the incidence of injuries

to the epiphyseal growth plate. J Trauma 1972;12:275-281

8. Musharafieh RS, Macari G: Salter-Harris I fractures of the distal

radius misdiagnosed as wrist sprain. J Emerg Med 2000;19:265-270

9. Salter RB, Harris WR: Injuries involving the epiphyseal plate.

J Bone Joint Surg Am 1963;45:587-622

10. Neer CS II, Horowitz BS: Fractures of the proximal humeral

epiphyseal plate. Clin Orthop 1965;41:24-31

11. Norlock P, StowerM: Fracture patterns in Nottingham children.

J Pediatr Orthop 1986;6:656-660.

12. Lee BS, Esterkai JL: Fracture of the distal radial epiphysis.

Clin Orthop 1984;185:90-96

13. Trueta J, Morgan JD: The vascular contribution to osteogenesis

I. Studies bythe injection method. J Bone Joint Surg Br

1960;42:97-112

14. Trueta J, Amato VP: The vascular contribution to osteogenesis

iii. Changes in the growth cartilage caused byexperimentally

induced ischaemia. J Bone Joint Surg Br 1960;42:571-578

15. England SP, Sundberg S: Management of common pediatric

fractures. Ped Clin NA 1996;43:991-1012

16. Robertson WW Jr: Newest knowledge of the growth plate.

Clin Orthop Rel Res 1990;253:270-278

17. Ogden JA: Skeletal Injuryin the Child (ed 2). WB Saunders,

Philadelphia, 1990 pp 38-68

18. Kaeding CC, Whitehead R: Musculoskeletal injuries in adolescents.

Prim Care Clin Off Prac 1998;25:211-223

19. Canale TS (ed): Physeal injuries, in Campbell’s Operative

Orthopedics. Mosby, St. Louis 1998, pp 2364-2367

20. Carson WG Jr : Little Leaguer’s shoulder: A report of 23

cases. Am J Sports Med 1998;26: 575-80

21. Rizzo PF, Gould ES, Lyden JP, et al: Diagnosis of occult

fractures about the hip: Magnetic resonance imaging compared

with bone scanning. J Bone Joint Surg Am 993;75:395-401

22. Marks PH, Godenberg JA, Vezina WC, et al: Subchondral

bone infractions in acute ligamentous knee injuries demonstrated

on bone scintiographyand magnetic resonance imaging. J Nucl

Med 1992;33:516-520

23. Gleeson AP, Stuart MJ, Wilson B, et al: Ultrasound assessment

and conservative management of inversion injuries of the

ankle in children. J Bone Joint Surg Br 1995;75:484-487

24. Berger P, Ofstein RA, Jackson DW, et al: MRI demonstration

of radiographicallyoccult features: What have we been missing?

Radiographics 1989;9:407-436

25. Naranja RJ, Gregg JR, Dormans JP, et al: Pediatric fracture

without radiographic abnormality: Description and significance. Clin

Orthop Related Res 1997;342:141-146

26. Tolo VT, Wood B: Pediatric Orthopaedics in PrimaryCare.

Williams & Wilkins, 1994