Epiphyseal disorders Z. Rozkydal Epiphyseal disorders • •Idiopathic avascular •necrosis of epiphysis •of long bones • •Etiology unkown • • •Epiphysis •Metaphysis •Diaphysis •Metaphysis •Epihysis •Obr. 1 •Perthes disease • •It is a complication of the necrosis •of proximal epiphysis of the femur • •4 -12 years •10 % bilateral •More often in boys • •Symptoms: limping, pain •limited ROM (rotation, abduction) •Obr. 2 AVN •Frejka classification • •1. st. latency 6 - 18 months •2. st. necrosis •3. st. decalcination •4. st. recovery •5. st. consequences • • •Obr. 3 •Perthes disease- stages AVN AVN •Obr. 4 •Obr. 5 •Perthes disease • •Ischemia of the whole epiphysis •Articular cartilage continues to grow •Bone is resorbed and replaced by •wowen bone •The bone is soft and vulnerable •Subchondral fracture •- showes the extent of damage •New bone is gradualy revascularised •New bone is plastic- •can be deformed AVN subchondr •Obr. 6 •Subchondral fracture •of femoral epiphysis •M. Perthes • •1. Ischemic stage: avascular necrosis • growth arrest of epiphysis • revascularisation from periphery • ossification • •2. Ischemic stage: trauma, subchondral fracture • resorption under the fracture • replacement by plastic woven bone • subluxation, deformity •Catterall classification AVN Caterall •I. 25 % • •II. 50 % • med.- lateral column •III. 75 % • •IV. 100 % •Obr. 7 A Caterall •Subchondral fx •less than one half •Subchondral fx •more than one half Necro- caterall 1 necro- caterall2 •Catterall I •Catterall II • • • • • • • • • • • • • •Obr. 9 •Obr. 8 Necro- caterall3 Necro- caterall 4 •Catterall III •Catterall IV • • • • • • •Obr. 10 • • • • • • •Obr. 11 •Salter classification • •A Catterall I. a II. • less then one half of the epiphysis • short subchondral fracture • lateral column intact • conservative treatment • Necro- caterall 1 necro- caterall2 •Obr. 12 •Obr. 13 •B Caterall III. a IV. • more then one half of the epiphysis • long subchondral fracture • lateral column is absent • operative treatment •Salter classification Necro- caterall3 Necro- caterall 4 •Obr. 14 •Obr. 15 •Examination • •X-ray •Artrography •CT - 3 D reconstruction •MRI •Scintigraphy •Ultrasonography •Prognosis • •I. a II. stage good prognosis •III. a IV. stage wrong prognosis • • •Risk factors: • •Older age •Loss of containment, subluxation •Large extent •Limited movements A Perthes 1 •Types of deformity in Perthes disesase Management -containment of the head in the acetabulum -good range of motion - Conservative methods - Atlanta orthesis - Operative methods Osteotomy of the pelvis (Salter, Steel, Sutherland, Dungl) Shelf plasty Osteotomy of the femur A perthes 2 •Stulberg classification of deformity •of the femoral head in Perthes disease •Conservative methods •Rest in bed •Crutches •Atlanta orthesis • Necro-Atlanta •Obr. 16 •Atlanta orthesis •Operative methods •Salter pelvic osteotomy • • • •Varus osteotomy of the femur Necro- Salter op Necro- varisace u Perthesu •Obr. 17 •Obr. 18 AVN-Salter AVN •Salter osteotomy •Obr. 19 •Obr. 20 A perthes 3 •Perthes disease on the right hip •after Salter osteotomy •Almost normal hip in 18 years of age A perthes 3 •Consequences •of Perthes disease • • •Coxa plana •Shortening of the leg •Limited movements •Early osteoarthritis • •Better prognosis •Younger age •Less extent of danage •No subluxation AVN • • • • •Obr. 21 •Tibia vara Blount •Disorder of proximal epiphysis •of the tibia • •Early arrest of growth plate on medial •side with smaller epiphysis • • •Infantile – up to 3 years •Juvenile - up to 10 years • •Th: orthesis, osteotomy Osteo- Blount1 •Obr. 22 Osteo- Blount 1 Necro- Blount 2 Osteo-Blount 3 Osteo- Blount 4-6 •Tibia vara Blount • Obr. 25 • Obr. 24 •Slipped upper femoral epiphysis • •Growth plate of proximal epiphysis •of the femur is weak and soft •Imbalance of growth hormon and •sexual hormons •Obese patients •Fröhlich syndrom •Adiposogenital syndrom •9-15 years •Bilateral in one third AVN-CVA 4 •Obr. 26 AVN- CVA3 •Slipping of epiphysis •down and backwards •to varus and to retroversion • •Metaphysis goes proximaly •and to external rotation • • •Slipped upper femoral epiphysis •Obr. 27 AVN-CVA 4 •Symptoms • •Pain in groin and in the thigh •Limping •Shortening of the leg •Limited abduction and external rotation •Positive Trendelenburg sign •Obr. 28 •Types • •1. Preslip (6%) •2. Acute slip (11%) •3. Chronic slip (after two weeks, 60 %) •4. Acute slip on chronic sliping (23%) AVN-CVA 4 •Obr. 29 •Stages •1. 2. 3. •Obr. 30 CVA 10 kopie •Stages • •1. Slight: slip up to 30% • •2. Moderate : slip 30-60 % • •3. Severe: slip above 60 % •Management • •Fixation in situ (K wires, Knowles pins) • •Closed reduction and K wires • •Open reduction • •Osteotomy of proximal femur - •Southwick, Imhäuser-Weber AVN- CVA1 •Fixation in situ Necro- CVA2 •Obr. 31 •Obr. 32 AVN •Open reduction •Obr. 33 •Southwick osteotomy AVN- CVA southwick2 AVN- CVA Southwick3 •Obr. 34 AVN- CVA 5 •Pertrochanteric •osteotomy •Obr. 35 •Complication of slipped upper femoral epiphysis • • •Avascular necrosis of the femoral head • •Chondrolysis of the femoral head • •Osteoarthritis of the hip AVN - os lunatum •Necrosis of os lunatum •m. Kienbőck • •Therapy • •Rest •Immobilisation •Removal and replacement •by tendon, by os pisiforme •or by arteficial material •Obr. 36 AVN •M. Köhler I. - necrosis of navicular bone •Therapy • •Rest •Immobilisation •Arthrodesis • • • •Obr. 37 AVN- Kohler 2 •M. Köhler II. •M. Freiberg-Köhler •Necrosis of metatarsal head •Therapy • •Rest, padding • •Surgery: •Removal of necrotic part •Osteotomy •Obr. 38 AVN - hlavice fremuru •Avascular necrosis of femoral head in adults •Etiology unknown • •Pain •Limited movements •Limping •Obr. 39 •Avascular necrosis of femoral head AVN - nekróza hlavice femuru 2 •Obr. 40 •Management • •Crutches •Forrage, bone grafting •Osteotomy-varus, valgus, derotation •Arthrodesis •Total hip replacement Olšová 15 •Necrosis after fracture •of the neck of the femur •Obr. 41 Gaža 15 •Necrosis of the femoral head •after coxitis •Obr. 42 •M. Ahlbäck – necrosis of medial condyle of the femur • •m. Osgood- Schlatter – proximal apophysis • of the tibia • •Necrosis of sesamoid bone • •M. Panner – osteonecrosis of humeral head • •Vertebra plana Calvé • •Necrosis of apophysis of calcaneus • • •Literature •Janíček, P.: Ortopedie. Lékařská fakulta MU v Brně, • 2001. •Spoluautoři: Dufek, P., Chaloupka, R., Krbec, M., • Poul, J.,Procházka, P., Rozkydal, Z. •Figures •Edmonson A.S., Crenshaw, A.H. : Campbell´s •Operative Orthopaedics. Sixth Edition, •The C.V. Mosby Company, 1980. •Obr. 19,20,27,33,34,35. • •Netter, F.: The CIBA collection of medical illustrations •Vol. 8, part. I, II., Ciba- Geigy Corporation, 1990. •Obr. 5,8,9,10,11,12,13,14,15,16,17,18,22,24,25,30,31,32. • •Bartoníček, J., Heřt, J.: Základy klinické anatomie •Pohybového aparátu. Maxdorf, Jesenius, 2004. •Obr. 2 •Figures •Turek, S.: Orthopaedics. J.B. Lippincott Company, •Third Edition, 1977 •Obr. 6,38,40. • •Frejka, B.: Základy ortopedické chirurgie. Avicenum •Praha, 1970 •Obr. 3,21,26,28,29,36,37. • •Janíček, P.: Ortopedie. Masarykova univerzita, 2001. •Obr. 4. • •