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1、Radiology of Pediatric FracturesJean-Marc Gauguet, HMS Year IV Gillian Lieberman, MD 9/14/06Jean-Marc Gauguet, HMS IV Gillian Lieberman, MDOverview Osteology Salter-Harris Fractures Greenstick Fractures Torus FracturesJean-Marc Gauguet, HMS IV Gillian Lieberman, MDLongitudinal Bone Growth The physis
2、 is divided into metaphyseal and epiphyseal sections. Mitosis of chondrocytes in the epiphyseal section and growth in the metaphyseal section leads to longitudinal growth. The resting and proliferating zones contain high amounts of chondoitin sulfate, which imparts strength. The hypertrophing zone l
3、acks chondroitin sulfate or calcium and is the weakest layer - this is the site of physeal fractures .Pediatric Fractures and DislocationsRestingProliferatingHypertrophingProvisional CalcificationModified from: http:/www.unu.edu/Unupress/food2/UID06E/uid06e0u.htmJean-Marc Gauguet, HMS IV Gillian Lie
4、berman, MDKids bones are special Epiphyseal growth plates in children have not completely ossified. The periostium in children is thicker, more metabolically active, less easily torn, and more easily stripped from the bone.Jean-Marc Gauguet, HMS IV Gillian Lieberman, MDEndplate Closure Prior to endp
5、late closure there is a balance between chondrocyte proliferation and bone mineralization. Once proliferation slows and ceases mineralization can be completed. Endplate closure occurs when mineralization crossed into the epiphysis.Pediatric Fractures and DislocationsJean-Marc Gauguet, HMS IV Gillian
6、 Lieberman, MDSalter-Harris (SH) Overview Developed 5 level classification system in 1963. Fracture involving injury to the physis of long bones before complete closure occurs. 35% of all skeletal injuries in children. 75% of cases occur in kids between 10-15 years. Most common sites: wrist 50%, ank
7、le 30%. The growth plate is 2-5 times weaker than joint capsule or ligaments. Jean-Marc Gauguet, HMS IV Gillian Lieberman, MDType I Line of cleavage confined to the physis. Accounts for 6% of cases. Most commonly occurs in the phalanges. Growth disturbance uncommon because germinal layer and vessels
8、 not disturbed. Excellent prognosis, treat with closed reduction and immobilization. Patients often treated if no overt signs of fracture, but there is soft tissue swelling or patient is symptomatic. Jean-Marc Gauguet, HMS IV Gillian Lieberman, MDType I continued Best identified by comparing to norm
9、al joint and looking for widening of the physis.SH INormal Swischuk, L.E., et al., Frequently missed fractures in children (value of comparative views). Emergency Radiology. (2004) 11: 22-28.Jean-Marc Gauguet, HMS IV Gillian Lieberman, MDSwischuk, L.E., et al.Type II Fracture line through the physis
10、 and extends through margin of metaphysis - “corner sign” Most common type (75% of cases) Distal radius most common site Minimal shortening, good outcomes. Treat with closed reduction and Boston Childrens HospitalSH Type IIJean-Marc Gauguet, HMS IV Gillian Lieberman, MDType III Fracture runs through
11、 epiphysis then horizontally through physis. Accounts for 8% of cases. Typically seen after partial epiphyseal plate closure in tibia and distal femur. Some deformity, but most problems arise from fracture entry into joint space. Treat with closed reduction and immobilization, occasional ORIF.Boston
12、 Childrens HospitalSH Type IIIJean-Marc Gauguet, HMS IV Gillian Lieberman, MDType IV Vertically oriented fracture through epiphysis, physis, and metaphysis. 10% of injuries. Most commonly in distal femur and distial tibia. Requires surgical repair, and often causes disability and joint deformity fro
13、m damage to germinal layer and epiphyseal blood SH Type IVJean-Marc Gauguet, HMS IV Gillian Lieberman, MDType V Crush injury of physis typically from axial loading, no injury to epiphysis or metaphysis. Accounts for 2mm and fragment could not reduced closed, decision made to surgically repairBoston
14、Childrens HospitalJean-Marc Gauguet, HMS IV Gillian Lieberman, MDConfirmed SH-IV fracture through metaphysis, physis, and epiphysis.Case I: TreatmentA screw was placed through displaced fragment and the patient was casted.Boston Childrens Hospital3 months later, cast removed, good fracture healing.
15、Patient did well. Boston Childrens HospitalPlain FilmPlain FilmJean-Marc Gauguet, HMS IV Gillian Lieberman, MDComplications of SH Fractures: Case Ia12 year old boy with a triplane fracture: - SH-II of medial tibial - SH-III of lateral epiphysisPatient still has occasional pain 7 months after injury. Boston Childrens HospitalOrthopedic surgeons requested a CT to evaluate patient for epiphyseal plate damage. Plain FilmJean-Marc Gauguet, HMS IV Gillian Lieberman, MDCase Ia: Bone Bridge Formation When area of growth arrest less than 50%, then outcomes are good wi
