Epiphyseal Separation Research Articles

Complete distal humeral epiphyseal separation indicating a battered child syndrome: a case report

Complete distal humeral epiphysiolysis is a rare and uncommon injury and may result from severe trauma, e.g. birth injury or battered child syndrome. This is a case report of a 5-month-old female child with distal humeral epiphysiolysis. In the course of clinical and radiological examinations, a battered child syndrome could be diagnosed. Open reduction and temporary transfixation of the distal humeral physis were performed. In the middle term follow-up, 1.5-years after the injury, the function of the elbow was nearly normal but the ulnar condyle showed growth disturbance with cubitus varus of 10 degrees. Correct diagnosis of complete distal humeral epiphysiolysis may be difficult and misinterpretation of the injury as elbow dislocation should be avoided. This particular lesion is a strong indicator of child abuse. Treatment options and the necessity of operative procedures are discussed.

Epiphyseal separations in spastic cerebral palsy

Metaphyseal and diaphyseal fractures have been reported in children with severe spastic cerebral palsy, but there is no reference to epiphyseal separations in these patients. We report nine epiphyseal separations involving the distal femur and proximal humerus in four severely affected children with spastic quadriplegic cerebral palsy. The clinico-radiological features confirmed the cause to be scurvy. These epiphyseal separations have a good prognosis unlike the physeal injuries reported in children with myelodysplasia. Treatment with vitamin C and splintage resulted in rapid healing with excellent remodeling. Scurvy should be considered a potential cause for an epiphyseal slip in a child with severe spastic cerebral palsy. Routine dietary supplementation of vitamin C is recommended for these malnourished and nonambulant children.

High-Grade Slippage of the Lumbar Spine in a Rat Model of Spondylolisthesis

Radiographic and histologic evaluation of spondylolisthesis in a rat model. To investigate the effects of etodolac, a cox-2 inhibitor, on the severity of spondylolisthesis in a 4-week-old rat model. Spondylolisthesis occurs associated with spondylolysis in some pediatric patients. In such patients, the percent of forward slippage varies individually ranging between 0% and 100%. The factors determining the severity of forward slippage have not been clarified as yet. In earlier studies, we found that growth plate stress fracture was the basic lesion and that slippage was a consequence of the stress fracture. Hence, we hypothesized that the capacity of bone healing might be an important determinant of the degree of forward slippage. A lumbar spine slippage model was prepared in 4-week-old rats with vertebral physis fracture. To disrupt the fracture healing, the cyclooxygenase-2 (cox-2) inhibitor etodolac was used, and its effects on slippage and deformity were evaluated radiologically and histologically. In the etodolac group, forward slip significantly increased (P < 0.05) to the Meyerding Grade III while in the control rats it was Grade I or II. Bone remodeling of the vertebral body was suppressed by etodolac. Histologically, epiphyseal separation with slippage was observed in all the control and etodolac-treated rats. However, in the etodolac-treated group, the epiphyseal plate was greatly separated and did not present periosteal thickening at the physis fracture site. Vertebral forward slippage occurred in young rats after epiphyseal separation. In the etodolac group, slippage increased as deterioration of the bone healing capacity increased. Poor bony healing is suggested as one of the determinants of high-grade spondylolisthesis in children and adolescents.

Chondrocyte injection in distraction epiphysiolysis (rabbit model)

The purpose of this study was to determine if cultured chondrocytes could prevent premature closure of the physis after physeal distraction in a rabbit model. Epiphyseal distraction at the proximal tibial epiphysis was performed in 24 immature rabbits. Chondrocytes were harvested from the iliac apophysis. The animals were divided into three groups: A, epiphyseal distraction alone; B, injection of phosphate buffered saline (PBS) after epiphyseal distraction; and C, injection of cultured chondrocytes after epiphyseal distraction. After epiphyseal separation was noted radiographically, each animal was evaluated at routine intervals. At 2 to 4 weeks, significant tibial lengthening as compared to the contralateral tibia was noted in all three groups. At 10 weeks, lengthening was apparent only in group C; in groups A and B, the operated tibia was shorter than the unoperated one. Histologic examination at 4 weeks revealed partial bony bridge formation with cell clustering in the fibrocartilaginous matrix in groups A and B. In group C, the matrix showed a typical hyaline aspect with cells organized in columns at the injection site. The zone of hypertrophic chondrocytes was enlarged. It appears that the injected cells differentiated into hypertrophic chondrocytes and delayed premature physeal closure. At 10 weeks after distraction of the physis, the width of the physis was restored to 75% of normal, but disordered chondrocyte growth with cell clustering was present in the cell-injected group.

Epiphyseolysis capitis femoris und Übergewicht

The slipped capital femoral epiphysis (SCFE) is defined as a nontraumatic epiphyseal separation and slipping of the proximal femoral epiphysis, which usually occurs during the adolescent growth spurt. Slipping of the upper femoral epiphysis may be classified as acute, chronic, and acute on chronic. The etiology of the disease is still not fully understood but seems to be multifactorial. The typical SCFE during puberty has to be differentiated from the atypical form, which may be associated with an endocrinological disorder or with its therapy. The typical SCFE may be found in male patients, with increased height and weight. It is likely that the growth rate is slightly accelerated before slippage. Obesity is often associated with a decreased femoral anteversion accounting for abnormal mechanical shear forces at the growth plate. SCFE is treated surgically. Surgical methods are administered according to the degree of disease. Because of possible alterations of blood supply to the femoral head, acute SCFE is an emergency. Following SCFE, complications such as chondrolysis and avascular necrosis are feared.

PAEDIATRIC GALEAZZI-EQUIVALENT FRACTURE: TWO CASE REPORTS

The authors present two rare cases of a paediatric Galeazzi-equivalent fracture. In contrast to Galeazzi's fracture-dislocation in adults, an epiphyseal separation of the distal ulna occurred instead of dislocation of the distal radioulnar joint (DRUJ) or both. A precise radiographic analysis of the epiphyseal separation of the distal ulna and its anatomical reduction were keys to obtaining a good result in the treatment of paediatric Galeazzi-equivalent fracture.

Can the practice of yoga be dangerous? Considerations over a case of epiphyseal separation of the distal tibia in a teenager

We describe a fractureseparation of the epiphyseal plate of the distal tibia (Salter-Harris type III, or juvenile fracture of Tillaux) in a 15-year-old girl. The case is of interest, above all, in that the trauma occurred during the execution of a yoga posture. The literature does not speak of complications or traumatic consequences of this type of activity. Analyzing the biomechanics of the traumatic event, it appears that even a physical exercise characterized by slow and gradual movements can cause severe damage, such as the injury described.

Analysis of 51 Tibial Triplane Fractures Using CT with Multiplanar Reconstruction

We determined the most common patterns of triplane fractures and assessed the risk of epiphyseal separation in each pattern. Fifty-one children with tibial triplane fractures underwent CT, and the resultant scans underwent multiplanar reconstruction. We categorized epiphyseal and physeal involvement, the number of fragments, the appearance of the Salter-Harris fracture in each plane, and the degree of separation of the epiphyseal fragments. The classic two-fragment type of fracture with medial epiphyseal extension occurred most frequently (33/51). All three-fragment types (8/51) of fractures resulted in a separate anterolateral fragment. Extension to the medial malleolus was common (12/51). None of the four reported fractures types involving anteromedial physeal separation was seen. Children with epiphyseal separation requiring surgery were older (odds ratio [OR] = 1.7) and had plafond involvement (OR = 5), CT and multiplanar reconstruction of triplane fractures improve the understanding of patterns of injury and their relative prevalence.

Distal humeral epiphyseal separation associated with radial nerve palsy in a neonate as a result of birth trauma

In thirdworld countries, where unsupervised home deliv-eries are common, these injuries may present late.An associated nerve injury, if present, further com-plicates the difficult situation. We present a case oftraumatic separation of distal humeral epiphysisassociated with radial nerve palsy as a result ofbirth trauma, a combination which has never beenreported before.

Vertebral forward slippage in immature lumbar spine occurs following epiphyseal separation and its occurrence is unrelated to disc degeneration: is the pediatric spondylolisthesis a physis stress fracture of vertebral body?

Radiographic and histologic evaluation of a rat model of lumbar spine slippage. To clarify the pathomechanism of slippage in the immature spine. There are controversial hypotheses regarding the pathogenesis of slippage of the pediatric spine with pars defects. Some studies supported that disc degeneration was its cause, while others indicated the growth plate injury was the cause. An immature lumbar spine slippage model in 4-week-old rats was used. Following posterior destabilizing surgery, the lumbar spine was radiographically and histologically examined at 1, 3, 5, and 7 days after surgery. Radiographically, slippage occurred about 7% in the % slip on day 7, and no slippage was observed before day 5. Histologically, epiphyseal separation also appeared on day 7; before day 5, the growth plate showed no abnormalities. Within 7 days after the operation, the anulus fibrosus did not show any sign indicating degeneration. The nucleus pulposus was also normal up to day 7. The findings of this study support the hypothesis that vertebral forward slippage of the immature spine occurs following epiphyseal separation and its occurrence is unrelated to disc degeneration.

Long-term results following pediatric distal forearm fractures.

The purpose of this retrospective study was to investigate the frequency and extent of clinical and radiological late sequelae and to identify predicting factors. A total of 220 patients of growing age with 232 closed, conservatively treated fractures were re-examined clinically and radiologically at a median follow-up time of 10 years (range 5-16 years). Clinical and radiological findings were summarised as an overall result. Of the total of patients, 19% reported pain in the injured wrist, and wrist mobility was limited in 5% of patients. Forearm rotation was decreased in 16%, primarily in epiphyseal separation of the ulna ( p=0.0033). Radial inclination was different in 6% of patients, palmar tilt in 2%, and ulnar variance in 37%, compared with the contralateral side. Ulnocarpal impaction syndrome was present in 75% of the patients with positive ulnar variance. Overall outcome was excellent in 72%, good in 19%, moderate in 6%, and poor in 3% of patients. The younger the children were at the time of injury, the more favourable the results were ( p=0.009). Children who were older than 10 years when they suffered a severe fracture dislocation had the poorest results ( p=0.008). Further factors having a negative influence on outcome were repeated reduction maneuvers and an additional fracture of the ulna. Our follow-up examinations showed that the majority of patients achieved good results, especially in children under 10 years old. Large dislocations at the time of fracture healing do not influence long-term results in this age group and thus can be tolerated. Patients over 10 years old, whose fractures healed with an angular deformity of more than 20 degrees and/or fragment dislocation over half the breadth of the shaft showed the poorest results. Thus, such dislocations should not be tolerated, and reduction should be attempted in this age group by only one reduction maneuver.

Medial clavicular epiphysiolysis in children: the so-called sterno-clavicular dislocation.

We retrospectively reviewed six pediatric cases of medial clavicular injury, i.e., epiphyseal separation (Salter/Harris type I or II injury), diagnosed between 1993 and 1997. The clavicular metaphysis was displaced posteriorly in three cases and anteriorly in three. On conventional radiographic views the diagnosis was initially missed in two of three retrosternal dislocations. A special X-ray projection (described by Heinig) or computed tomography (CT) permitted correct diagnosis. Anterior dislocations were immediately and correctly diagnosed. Closed reduction successfully treated retrosternal displacement in two of the three patients. The third patient needed open reduction and internal fixation. Open reduction and internal fixation had to be performed in all three patients with anterior displacement. Follow-up assessment showed perfect functional results in all cases. Direct visualization during open reduction, which was necessary in four of six cases, yielded clear evidence that the so-called sternoclavicular dislocation in children and young adults is, in fact, a fracture of the medial growth plate with posterior or anterior displacement of the metaphysis.

Clinical Outcomes of Epiphyseal Separation in the Proximal Humerus caused by Sports Activity

Clinical Outcomes of Epiphyseal Separation in the Proximal Humerus caused by Sports Activity

小児とう骨遠位端骨折に対するＩｎｔｒａｆｏｃａｌ ｐｉｎｎｉｎｇ（ＩＦＰ）法の検討

Twenty-three children with fracture or epiphyseal separation of the distal radius were treated with intrafocal pinning (IFP). Fifteen were boys and eight were girls. The age at surgery ranged from 8 to 15 years (mean age: 11.3 years). There were 14 extra-articular fractures and 9 epiphyseal separations (Salter-Harris type II in 8 and type III in 1). Follow-up ranged from 2 months to 42 months. The results were evaluated according to the radiographical measurements of the palmar tilt, radial inclination and ulnar variance, and were evaluated by Saito's demerit point system. The palmar tilt was reduced within the normal range in 22 of the 23 patients. The radial tilt was reduced within normal range in 21 of the 23 patients. Zero variance was achieved in 21 patients. These reductions were maintained through the end of the follow-up. All of the 11 patients who visited us for evaluation were classified as excellent. The IFP method is not only minimally invasive but also stable enough to enable early ROM exercise. We can conclude that IFP is useful for distal radius fracture and epiphyseal separation in children.

Epiphyseal Separations After Neonatal Osteomyelitis and Septic Arthritis

Complete separation of an epiphysis is a rare complication of neonatal osteomyelitis and septic arthritis. We report two cases of pathologic epiphyseal separation after neonatal osteomyelitis, involving the distal and proximal femoral epiphyses with a follow-up of 2 and 7.5 years, respectively. Birth trauma, scurvy, and nonaccidental injury should be considered in the differential diagnosis of pathologic epiphyseal slip. The pitfalls in diagnosis are many, and plain radiograms of unossified epiphyses are often misleading. A high index of suspicion and the use of imaging modalities are useful in making an early diagnosis of epiphyseal slip. The optimal treatment is controversial, and the long-term prognosis is uncertain. The potential for recovery appears to be excellent, provided an early diagnosis is made and prompt treatment by anatomic reduction of the displaced epiphysis is instituted.

Classification and Documentation of Children's Fractures

It is absolutely necessary to classify children's fractures for quality controls and clinical research. It is not possible that a classification of children's fractures will follow hierarchies, such as the prognosis of growth, the kind of treatment, the severity of the lesion, the patient's age, as well as medical expenditures and different techniques of therapy. The prognosis of growth is dependent on the patient's age and the localisation of the fracture in the bone and in the skeleton. The kind of treatment is dependent on the extent of displacement as well as on the localisation in the bone. Thus, a classification of children's fractures can only be characterized by the localisation of the fracture and the morphology. In addition, a parameter of “tolerable displacement” should be involved in the classification – as a sign for the possibility of spontaneous correction of displacements by further growth. From the morphological/functional point of view, the epiphyseal plate injuries should be differentiated into a metaphyseal part without proliferation but with mineralisation potential, and an epiphyseal part with proliferation but without mineralisation potential. From this aspect of functional morphology the epiphyseal separation – as a lesion in the metaphyseal part of the physis – belongs to the metaphyseal fractures (so to speak, it is the most peripheral shaft fracture), and the epiphyseal fracture – as a lesion in the epiphyseal part of the physis – belongs to the joint fractures. The localisation is differentiated into 4 main segments: upper arm, forearm, femur, and lower leg. In the segment itself, a subdivision is made into proximal, middle, and distal, with proximal and distal being further differentiated in metaphysis and epiphysis. In addition, it is possible to differentiate between radial and ulnar and tibial and fibular. The morphology is differentiated into typical fractures of the epiphysis, the metaphysis and the shaft fractures as well as avulsion fractures of ligaments, avulsion fractures of muscles and flake fractures. Exceptions in the consequent classification of morphology are only made at the distal end of the humerus and at the neck of the femur. the parameter of “tolerable displacement” showes up already known “ spontaneous corrections” of displacements in the joints, the metaphysis and the epiphysis. The proposed classification should be used in prospective clinical studies to evaluate the prognosis of growth and the results of different therapeutic approaches.

伸筋けんが整復障害因子となったとう骨遠位骨端離開の一例

We reported a case with epiphyseal separation of the distal radius which could not be reduced by nonsurgical manipulation due to interposition of the extensor digitorum communis tendon. The case was a 12-year-old boy who was injured by falling down from a running bicycle. X-ray findings showed markedly separated distal epiphysis of the right radius with fracture of the distal ulna. In spite of manipulation under anesthesia, the epiphyseal separation was irreducible. Operative findings showed that the extensor digitorum communis tendon was interposed between the separated radial fragments. Radius was fixed by Kirschner wires following surgical reduction.

Distal tibial and fibular epiphyseal fractures in children: prognostic criteria and long-term results in 158 patients.

From 1974 to 1993, 158 injuries of the ankle joint were treated at the Department of Orthopedics and Traumatology of Santobono Children's Hospital. One hundred thirty-two patients were treated conservatively; 26 patients underwent surgical treatment. Fibular fractures of the malleolus without epiphyseal separation or dislocation (68 patients) were excluded from this review. Of the 158 patients, 113 (70%) were available for follow-up. The mean age of patients was 11 years. The mean follow-up was 6 years (range 3-15 years). In this review, the authors compare, based on the degree of epiphyseal separation or dislocation, the Carothers-Crenshaw classification, which is based on the mechanism of trauma, with the Salter-Harris classification, which is based on anatomical-radiographic criteria. The aim is to review the authors' patients based on these classifications, to verify the prognostic ability of these criteria and thus to establish a better and more viable treatment for these injuries. Therefore, two fundamental factors should be considered for the prognosis: the mechanism of trauma and damage to the epiphyseal plate. Compressive trauma and adduction-supination trauma are the most dangerous types of injury, and any damage or gap in the physis should be perfectly reduced, by open means if necessary, to prevent a bone bridge from forming.

Right sternoclavicular dislocation after traumatic delivery: A case report

Sternoclavicular (SC) dislocation is an injury that is very rare in the newborn. Thus far there have been no reports describing this in neonates after a traumatic birth injury. This condition can be difficult to differentiate from epiphyseal separation, which occurs more often in older children. For successful treatment, early diagnosis is essential. Timely surgical reposition and fixation with following immobilization is recommended in instances of complete (SC) dislocation. We report a trauma-induced case of SC dislocation in a neonate successfully managed by polydioxanon cord fixation.

Fractures of the Base of the Middle Phalanx of the Finger

We classified fractures of the base of the middle phalanx into five types: 1) single palmar fragment; 2) single dorsal fragment; 3) two main fragments; 4) not involving the articular surface, including epiphyseal separation in children; and 5) all others. Types 1 and 2 were subclassified into avulsion, split and split-depression. Surgery is recommended for unstable type-1 avulsion fractures, type-2 avulsions which may develop buttonhole deformities, and all fractures which displace articular cartilage surfaces. Long-term follow-up showed that surgical treatment which produced good stability and congruity gave good results. These should be the primary aims of treatment.