Physeal Growth Disorders
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Physeal Growth Disorders Thesis Submitted for Fulfillment of Master Degree in Orthopaedic Surgery Presented by Beshoy Nazmy Bahai Nakhla (M.B., B. Ch) Supervised by Prof. Dr. Naguib Basha Professor of Orthopaedic Surgery Faculty of Medicine -Cairo University Prof. Dr. Mohamad Mahmoud Hegazy Assistant Professor of Orthopaedic Surgery Faculty of Medicine -Cairo University Dr. Amr Said Arafa Lecturer of Orthopaedic Surgery Faculty of Medicine -Cairo University Faculty of Medicine Cairo University 2012 Abstract One of the unique aspects of pediatric orthopedics is the presence of the physis (or growth plate). The physis, located near each end of the long bones, is responsible for bone lengthening during growth. There are four zones forming the physis from the center of the epiphysis to the metaphysis. Chondrocyte proliferation and differentiation are regulated by various factors. Circulation in pediatric bone differs from adult circulation due to requirements of growth & presence of epiphyseal plate. If a segment of the epiphyseal vasculature is compromised, whether temporarily or permanently, the zones of cellular growth associated with these particular vessels cannot undergo appropriate cell division. Key Words: Anatomy and Physiology of the Physis, Etiology of Physeal Growth Disorders, Physeal Growth Disorders of the Upper Limb, Physeal Growth Disorders of the Lower Limb. First of all thanks and praise to God, who gave me everything, enabled me to complete this work. Words do fail to express my deepest gratitude and appreciation to Prof. Dr. Naguib Basha, Professor of Orthopaedic Surgery, Faculty of Medicine, Cairo University, for his constructive and valuable suggestions. Without his generous help, this work not would have been accomplished in its present picture. My deepest thanks and appreciation go to Prof. Dr. Mohamed Mahmoud Hegazy, Assistant Professor of Orthopaedic Surgery, Faculty of Medicine, Cairo University, for his moral and scientific support and for giving me the honor of working under his supervision and valuable guidance. I am also so grateful to Dr. Amr Said Arafa, Lecturer of Orthopaedic Surgery, Faculty of Medicine, Cairo University, for his patience and support. Beshoy Nazmy Bahai Nakhla Dedication In particular I would like to thank my dear wife who has suffered a lot during the preparation of this work, and I thank my parents who live their entire lives waiting for a moment like this. Beshoy List of Contents Title Page ♦ List of Figures................................................................. i ♦ List of Abbreviations ...................................................... v ♦ Introduction .................................................................. 1 ♦ Review of the Literature: ♦ Chapter 1: Anatomy and Physiology of the Physis............ 3 Zones of the physis.................................................. 5 Regulation of physeal growth ................................... 9 Vascular supply of the physis .................................. 10 Epiphyseal ischemia ................................................ 12 Metaphyseal ischemia.............................................. 14 ♦ Chapter 2: Etiology of Physeal Growth Disorders ............. 15 Trauma ................................................................... 15 Other causes ........................................................... 15 Stress injury............................................................ 16 Physical loss of the physis ....................................... 18 Infection .................................................................. 20 Chronic illness......................................................... 21 Effect of glucocorticoids ........................................... 22 Renal diseases......................................................... 23 Effect of hypoxia ...................................................... 23 List of Contents (Cont.) Title Page Catch-up growth phenomenon................................. 24 Arthritis and effect of MMP ...................................... 24 Rare Causes ............................................................ 26 ♦ Chapter 3: Physeal Growth Disorders of the Upper Limb .... 27 Osteochondritis dissecans of elbow.......................... 27 Cubitus varus.......................................................... 42 Cubitus valgus ........................................................ 48 Proximal humerus varus ......................................... 50 Wrist deformities after fracture ................................ 50 Madelung's deformity............................................... 51 Ollier’s disease......................................................... 53 ♦ Chapter 4: Physeal Growth Disorders of the Lower Limb..... 57 Slipped upper femoral epiphysis .............................. 57 Coxa vara ................................................................ 77 Blount’s disease ...................................................... 81 Genu valgum ........................................................... 86 Osgood–Schlatter's disease ...................................... 89 Calcaneal apophysitis (Sever’s disease ..................... 95 ♦ Summary......................................................................... 98 ♦ References ..................................................................... 100 ♦ Arabic Summary ............................................................. -- List of Figures Fig. No Title Page Chapter (1) Figure (1) Typical age (and range) of development of the secondary ossification centers of the epiphysis............. 4 Figure (2) Typical age (and range) of closure of physes ................. 5 Figure (3) Schematic diagram of the organization of the physis ........................................................................... 6 Figure (4) Epiphyseal circulation .................................................. 12 Figure (5) Patterns of response to ischemia of the epiphyseal versus metaphyseal circulatory systems......................................................................... 13 Figure (6) Histologic section showing an area of central ischemic growth arrest.................................................. 13 Chapter (2) Figure (1) Stress injury of the distal radius and ulna in both wrists of a competitive gymnast............................ 17 Figure (2) Stress injury of the proximal tibia in an elite soccer player ................................................................. 17 Figure (3) Valgus deformity of the distal femur ............................. 19 Figure (4) X-ray of a 12-year-old boy with multifocal physeal disturbance from purpura fulminans associated with meningococcemia ................................ 20 Figure (5) Proximal tibial physeal growth disturbance with angular deformity after irradiation for Ewing sarcoma ........................................................................ 26 Figure (6) Premature closure of the distal phalangeal physes after a frostbite injury to the digits.................... 26 Chapter (13) Figure (1) Panner disease and osteochondritis dissecans lesion............................................................................. 28 Figure (2) Magnetic resonance image of osteochondritis dissecans lesion of the capitellum................................. 29 Figure (3) Blood supply of the capitellum...................................... 30 -i- List of Figures (Cont.) Fig. No Title Page Figure (4) Radiographs of osteochondritis dissecans of the elbow.................................................................... 36 Figure (5) Preoperative 3-dimensional computed tomography scan in patient with osteochondral dissecans of capitellum....................... 37 Figure (6) Coronal and sagittal MR images of osteochondritis dissecans of the elbow ...................... 38 Figure (7) MRI of osteochondritis dissecans of the elbow ........... 39 Figure (8) Predisposition to lateral condyle fracture................... 44 Figure (9) A normal Baumanns angle ........................................ 44 Figure (10) Typical crescent sign.................................................. 45 Figure (11) Lateral closing-wedge osteotomy of cubitus varus.......................................................................... 47 Figure (12) Milch type I fracture pattern ...................................... 50 Figure (13) Postero-anterior radiograph of the wrist revealing subtle Madelung's deformity....................... 51 Figure (14) Radiograph of left hand with enchondromata............ 55 Figure (15) Radiograph showing enchondromatosis of the fourth and little fingers of the left hand ..................... 56 Chapter (4) Figure (1) Severe slipped capital femoral epiphysis of the left hip........................................................................ 57 Figure (2) Plain radiograph of a unilateral left SUFE.................. 60 Figure (3) Ring of Lacroix ........................................................... 60 Figure (4) MRI axial projection of slipped capital femoral epiphysis.................................................................... 61 Figure (5) Plain AP radiograph showing bilateral SUFE in a Down's syndrome patient........................................ 63 Figure (6) Same patient as in Fig. 4-5 after three years ............. 63 Figure (7) Southwick's method for the classification of SUFE ......................................................................... 66 -ii- List of Figures (Cont.)