Epiphyseolysis of the radius

Childhood is a period of increased traumatism, which is associated with the desire for new discoveries, with active games, with banal curiosity. Injuries can be different, and on the degree of damage, and on its localization, and on other characteristics. One of such injuries is epiphyseolysis of the radius, conjugated with trauma to the cartilage tissue in the zone of connection of the epiphysis and metaphysis of the tubular bone. This area is susceptible to traumatic effects up to the completion of upper limb length growth.

The second possible name for the pathology is Salter-Harris fracture. [1]

Epidemiology

The first mention of epiphysiolysis dates back to 1572: the pathology was identified and studied by the French surgeon Ambroise Paré. The disease can be called low prevalence, as it is found in only four or five people out of hundreds of thousands of the population. The overall incidence rate is 0.5-5% among all children with any orthopedic disorders.

Boys get the disease more often than girls (in the ratio of 3 to 2). The start of epipheolysis is observed more often in adolescence (11-12 years in girls, 13-14 years - in boys). Less often the disease is formed at a younger age (respectively at 5 and 7 years of age).

In 80% of cases, the radius is affected unilaterally. In bilateral pathologic process, one joint is affected first, and only a few months later (up to a year) - the second joint.

The following types of fractures associated with epiphyseolysis occur:

1. Transverse disruption of the integrity of the radius, which extends across the entire growth zone and completely separates the epiphysis from the bone body. The epiphyseal plate is destroyed at the same time. Occurs in 6% of patients with epiphyseolysis.
2. The line of bone disruption passes through the growth zone and partially extends to the metaphyseal region, but not to the epiphysis. Occurs in 75% of cases.
3. The line of disruption partially affects the growth zone and does not extend to the metaphysis. At the same time, part of the epiphysis is torn off. This type of epiphyseolysis occurs in about 10% of patients.
4. The line of compromised integrity extends to the growth zone, epiphyseal and metaphyseal parts. Occurs in 10% of patients.
5. Compression disorder due to compression of the bone. It is accompanied by a characteristic X-ray picture: reduced height of the growth zone associated with crushing damage to the epiphyseal plate. Occurs infrequently, in less than 1% of cases.

In addition, epiphyseolysis may occur with peripheral growth zone damage, limited growth zone damage, altered endochondral bone growth and cartilage replacement with bone tissue, periosteum damage with endesmal ossification.

Causes of the epiphyseolysis of the radius

To date, the causes of epiphyseolysis have not been definitively determined. Among the reliable proven causes the following are known:

• Hereditary predisposition (autosomal dominant type of inheritance).
• Disturbance of hormonal balance (ratio of growth hormones and sex hormones). On the background of sex hormone deficiency, growth hormone is stimulated, and at the same time the strength of the proximal bone segment suffers. Weakened bone structure contributes to the displacement of the proximal epiphyseal part downward and to the rear. Retarded puberty and hormonal imbalance are favorable conditions for the development of epiphyseolysis.
• Mechanical traumas accompanied by violation of bone integrity (fracture). Epiphyseolysis develops as a result of direct force impact on the epiphysis area in the zone of attachment of the articular bursa to the epiphyseal cartilage. Epiphyseseolysis of the radius is associated with destruction of the radial bone sprouting area: with further growth of the ulna, problems related to arm curvature may occur.

The possibility of idiopathic epiphyseolysis is not excluded. Occasionally, "gratuitous" pathology is found in thin and tall adolescents.

Epiphyseolysis of the radius can appear in children and adolescents:

• as a result of a course of X-ray therapy;
• against the background of chronic renal failure (most patients have bilateral displacement with epiphysis shift of more than 50°).

The problem with the radius bone can be caused by metabolic disorders, connective tissue pathologies, endocrine disorders, as well as other diseases in which the strength of the connection between the diaphysis and epiphysis decreases, the growth plate expands, and the ligament-capsular mechanism weakens.

Risk factors

The main factor leading to the development of epiphyseolysis of the radius is traumatism - domestic, street. The development of the disorder occurs by the type of adult dislocations or ligamentous tears. Thus, epiphyseolysis can occur with a sharp eversion of the arm, excessive extension of the hand, a fall on the upper limb, a sharp pull on it, twisting on the axis. More rarely, the problem is caused by intense muscle contraction.

Among the basic predisposing factors, experts cite the following:

• Male gender. Epiphyseolysis occurs more often in boys, which can be explained by a higher degree of motor activity and relatively late closure of the growth zones.
• Age-related periods of intense growth (particularly puberty). Uneven bone and tissue growth, incomplete adaptation to changes in body proportions and associated motor discoordination and increased injury risk play a role.
• Asthenic build. Children with an asthenic physique have some lack of muscle mass, so undergo a greater bone and joint load than normostenics.
• Participation in injury-prone sports. Children who participate in sports such as gymnastics, athletics, soccer, etc. Are more prone to radius injuries.

Metabolic disorders, nutritional deficiencies, and weakened immune defense are of some importance. Epiphyseolysis of the radius peaks at 5-7 years of age and 11-18 years of age.

Some experts believe that in children of early and preschool age pathology often remains undetected, which can be explained by blurred symptomatology and missing radiographic signs.

Pathogenesis

The radius of the upper limb is a long tubular fixed paired bone that is part of the forearm. The body of the radius is characterized by a triangular configuration and has three surfaces: anterior, posterior and lateral. There is a relationship and dependence of the radius with the ulna. In the lower part, they connect with the bony structures of the wrist: the wrist articulation is formed.

The radius is responsible for the mobility of the forearm at the elbow, and it breaks much more often than the ulna.

The epiphyseal plate is an area of hyaline cartilage located closer to the bony end fragment, between the metaphyseal and epiphyseal parts. Cartilage growth is replaced by bony replacement, which provides lengthening of the limb. If the support mechanism is damaged, the elasticity and strength of the cartilaginous segment suffers, the epiphyseal plate breaks, and epiphyseolysis develops with a preferential transition to the bony structure.

Epiphyseolysis occurs only at the site of attachment of the articular bursa to the epiphyseal or rostral region.

The pathogenetic basis of adolescent epiphyseolysis is the increasing displacement of the proximal epiphyseal part of the radius. The function of the wrist joint gradually suffers. More detailed mechanisms of pathology development have not yet been established. There are theories according to which, under the influence of certain factors, the end section of the bone weakens, which, against the background of muscle contractions, experiences increased load. With sudden movements, there is a gradual deformation, and then - violation of the integrity of the weakened area with displacement of the epiphysis.

Symptoms of the epiphyseolysis of the radius

The clinical picture in epiphysiolysis of the radius is nonspecific and is often "masked" by other pathologic disorders. Post-traumatic epiphysiolysis may manifest with the following signs:

• pain that tends to intensify at times of axial loading;
• Formation of an intrathecal hematoma in the area of injury;
• swelling that occurs shortly after an injury;
• Limitation of motor capabilities of the wrist and elbow joints.

In epiphyseolysis due to any pathologic processes (not trauma), the following signs are found:

• pain in the area of the lesion, bothering for several months, with intensification on probing, with irradiation along the radius and in the joint area;
• inability to make active movements of the hand, deformities;
• Inability to carry heavy objects using the affected limb, or to practice any other load on the radius.

Among the common symptoms, may occur:

• disorders of sexual development, decreased function of the sex glands;
• changes in blood pressure, the appearance of skin stretch marks, which is due to hormonal imbalance;
• atrophy of unused muscles of the affected upper extremity.

In general, epiphyseolysis of the radius in a child usually heals well. However, damage to the epiphyseal plate in the future can provoke improper bone growth. As a consequence of the pathological process, cartilage is destroyed, there is an asymmetry of the upper limbs, other deformities. Sometimes the growth of the limb stops completely.

Posttraumatic epiphyseolysis is not characterized by specific manifestations. As a rule, immediately after the injury, the child talks about the appearance of pain. During examination, swelling (swelling), a reddened area closer to the joint or along the radius, limited motor activity of the limb draws attention.

In epiphysiolysis, there is no crepitation characteristic of a normal fracture, and there is no pathologic mobility. The limb curvature is formed by bony displacement: it is usually not severe.

Motor activity is limited, but not as severely as in a normal fracture. Swelling is also small. It is because of these "erased" moments that the problem is often confused with a severe contusion and refuses to urgently visit a traumatologist.

Many children have a fever that rises to subfebrile digits.

If the pathology is not diagnosed in time, then in the future there may be improper bone growth, curvature of the periarticular segment, shortening of the limb.

Stages

Depending on the complexity of the pathological process, such its stages are divided:

1. Pre-epiphyseolysis, which presents with only minor discomfort, more often after physical activity.
2. The acute stage, in which symptomatology develops rapidly and the growth plate slips over 21 days.
3. Chronic stage, which is characterized by a slow course and is accompanied by symptomatology of varying degrees of intensity.

Complications and consequences

The most common complication of epiphyseolysis of the radius is premature arrest of bone growth. The damaged limb grows with a lag, which can be seen in comparative characterization. As a result, one arm may be shorter than the other.

If the growth plate is partially damaged, unilateral bony development may occur, resulting in curvature of the affected upper extremity.

Often trauma resulting in epiphyseolysis is accompanied by damage to nerve fibers and blood vessels, which can lead to trophic and other problems.

Today, world medicine is working on the possibilities of additional stimulation of tissue repair with the use of genetic engineering products. Such research will help to prevent growth arrest and limb curvature after epiphyseolysis in the foreseeable future.

Fracture and epiphyseolysis of the radius

For diagnostic purposes, it is important to perform radiographs and a competent objective examination, as radiographs may only show indirect signs of radius integrity, such as effusion into the joint cavity. Stability is checked by applying lateral and medial force to the ulnar joint and then checking for instability or excessively high range of motion. If the joint does not move after applying force, the fracture is stable and the ligaments associated with the joint are probably intact.

Methods of early detection of distal epiphyseolysis of the radius consist in performing scans with further comparison of the picture of the distal metaepiphysis of the radius of the affected limb with the same area of the healthy limb. The ratios of the shape and size of bone segments are assessed. In addition, ultrasonography of the distal zones of the left and right forearms (longitudinal scanning) with further comparative characterization of sonographic pictures is prescribed.

Distal epiphyseolysis of the radius is most common - almost 60% of cases. The most common violations of integrity are through the growth zone, with partial involvement of the bony body. Such fractures are often not amenable to complete repositioning: epiphyseolysis of the radius with displacement of up to 30% disappears relatively quickly, but 50% displacement can be remodeled only within a year, with preservation of limb functionality.

In general, injuries to the growth plate are not particularly common. The distal plate is fairly well protected, although it is vulnerable to transverse fracture. Growth arrest often results in minor shortening of the radius.

Closed epiphyseolysis of the radius is often caused by a fall on an outstretched arm with intense dorsal flexion of the hand and the epiphyseal plate. It is characterized by an epiphyseal fracture through the growth zone, with partial involvement of the bony body, or a transverse fracture through the growth zone. If the epiphysis is displaced, urgent repositioning is required.

Epiphyseseolysis of the radius without displacement is usually stable and heals quickly with good immobilization of the forearm. If the fracture is unstable, percutaneous fixation or open repositioning with internal fixation may be required.

Epiphyseolysis of the radial head is diagnosed by anteroposterior, lateral and oblique X-ray projection. The articular head is painful, with increased pain on supination. In most cases of such a fracture, a plaster cast is applied without surgical intervention.

Diagnostics of the epiphyseolysis of the radius

Epiphyseolysis is diagnosed after all the necessary tests and procedures have been performed, the main ones being:

• History taking (interviewing both the child and his/her parents or other family members).
• Orthopedic examination.
• General examination, palpation of the affected limb.
• Instrumental diagnostics (regtgenography, computer and magnetic resonance tomography).

Blood tests (OAC, biochemical AK) are prescribed for possible detection of inflammatory processes in the body, as well as for a general understanding of the state of health of the child.

On the radiological image performed in two projections, indistinct outlines of the epiphysis, enlarged cartilaginous growth tissue are visualized. The metaphyseal bone segment has no reticular pattern in the growth zone.

In the late stages of the pathological process, shortening of the damaged radius, displaced epiphysis, and a drop in the angle between the neck and head are detected. The neck is often shortened and its shape changes.

Tomographic methods are not the main methods of investigation, but are often used to clarify certain pathological points - for example, in case of contradictory X-ray information, or in preparation for surgery. Computed tomography and magnetic resonance imaging help to clearly identify the presence and location of a violation of bone integrity.

Differential diagnosis

Epiphyseolysis of the radius should be differentiated:

• with bruises;
• with other upper extremity injuries (common fractures of the radius, fracture-dislocations, traumatic dislocations, intra-articular fractures, etc.);
• with congenital diseases of the musculoskeletal mechanism of the upper extremities;
• with deforming osteoarthritis.

As a rule, differential diagnosis is not accompanied by any difficulties: epiphyseolysis of the radius is visualized with the help of instrumental diagnostic methods.

Treatment of the epiphyseolysis of the radius

The treatment of epiphysiolysis of the radius is carried out by a pediatric traumatologist or, more rarely, by an orthopedist. Treatment is started as early as possible, using mainly conservative methods. Tactics include the following points:

• Immobilization of the injured limb with a plaster cast or splint, which helps to limit any childhood activity that could harm the injured area.
• Manual or surgical repositioning of the dislocation, with fixation of the bone parts for adequate bone consolidation. Once the repositioning is complete, a cast is applied to the patient, covering the growth areas and joints. The term of wearing the plaster cast is up to several months, more precisely - until adequate bone consolidation. If there is a high risk of damage to the vascular and nerve network, with severe displacement of elements, surgical intervention may be prescribed.
• Physical therapy and physiotherapy are only applied after bone regeneration has been completed. In order to monitor regeneration, the child undergoes repeat radiography 3-6 months after the start of treatment and for two years after the injury. In some cases, radiologic follow-up is necessary until the end of the skeletal growth period.

Medications

Analgesic drugs
Ibuprofen	It is prescribed for children from 6 to 12 years of age 1 tablet (200 mg) not more than 4 times a day. Ibuprofen in tablets is used only if the body weight of the child is more than 20 kg, and if it is possible to swallow the tablet without chewing and crushing it. The interval between taking the drug should be at least six hours (daily dosage - no more than 30 mg / kilogram of weight). Among the likely side effects: difficulty breathing and bronchospasm, impaired hearing or vision, allergic swelling of the conjunctiva.
Orthofen (Diclofenac)	It is prescribed for children starting from the age of 8 years. The drug provides good pain relief, while having lower toxicity compared to sodium metamizole. The dosage is determined by a doctor individually. Possible side effects: digestive disorders, abdominal pain, erosive and ulcerative lesions of the stomach. To minimize side symptoms, tablets are taken after meals.
Calcium-containing preparations
Calcium D3 Nicomed	Children over 5 years of age take one tablet 1-2 times a day, depending on the doctor's recommendation. Other variations of the drug, such as "Forte" and "Osteoforte", are not prescribed in children. Possible side effects: constipation, nausea, abdominal pain, increased fatigue, thirst.
Calcemin	Children from 5 to 12 years of age take 1 tablet daily with food. In adolescence, the dose is increased to two tablets daily (morning and evening). Side effects are not frequent: constipation, nausea, rash, itching, hypersensitivity reactions are possible.
Calcium gluconate	Tablets are taken orally immediately before meals. Children 5-6 years - 1-1.5 g up to three times a day, 7-9 years - 1.5-2 g 2-3 times a day, 10-14 years - 2-3 g three times a day. Duration of treatment is determined by a doctor individually. Contraindications: increased blood clotting, tendency to thrombosis, hypercoagulability. Side effects: allergic reactions, digestive disorders.
External topical agents
Indovazine	The gel can be used in adolescence. The drug is applied topically three times a day with light massage movements. The duration of treatment is one week. Do not apply the gel to open wound surfaces and mucous membranes.
Voltaren	For children over 12 years of age, Voltaren Emulgel is applied to the skin three times a day, gently rubbing. Duration of use - up to 10 days.

Surgical treatment

In the presence of displacement of a bone segment, it is mandatory to perform surgery, which consists of matching and fixing the parts of the radius bone. This intervention is called osteosynthesis. The procedure helps to restore the functionality of the limb and subsequently achieve adequate treatment results.

Complete fusion of the radius in a child occurs in about one and a half to two months. After the rehabilitation period, the patient will be able to gradually but fully function the previously affected limb. Depending on the specific situation, several possible fixation options are used: a plate fixed with screws, as well as screws and spokes, or an external fixation apparatus.

In case of severe displacement, osteosynthesis of the radius is practiced with a special plate made of metal, which is fixed with screws. After staging, stitches and a plaster cast are applied for about two weeks. After the intervention of the surgeon additionally prescribe drug therapy, including analgesics, calcium-containing drugs, sometimes - local anti-inflammatory and anti-edema agents. The installed plate is not removed even after complete healing, there is no need for this.

In some situations - for example, in case of severe swelling of the arm - instead of a plate, an external fixation device is used, which helps to fix the displaced part of the radius using spokes through the skin. The device is placed above the skin like a special block with a height of about 3 cm. Installation does not require large incisions, but the device and the skin should be systematically monitored and dressings should be made. The device is removed after about a month and a half, after an X-ray examination.

Small displacements are corrected by inserting screws or spokes through small skin punctures. A plaster cast is additionally applied: it is removed after one and a half to two months and the spokes are removed. Sometimes self-absorbing implants are used.

Conductive anesthesia is most often used during the above operations. The anesthetic agent is injected into the area of the shoulder joint, where the nerve trunks innervating the entire arm run. Such anesthesia is safe, and its effect lasts on average up to five hours. In some cases, general anesthesia may be used (by indication).

Prevention

The prevention of radial epiphyseolysis mainly lies in the prevention of pediatric traumatism. The causes of injuries in children are typical in most cases. They are associated with the lack of landscaping of yards and adjacent areas, with banal negligence, inattention, carelessness, with improper behavior of the child in the domestic space, on the street, inside the game process, as well as in sports. Of course, the influence of psychological peculiarities of childhood cannot be excluded: curiosity, increased activity, emotionality, insufficient life experience, poor sense of danger.

The task of adults is to prevent possible risks and protect the child from them. Here it is important to find an approach and adhere to the "golden mean" in order not to cause the development of a constant sense of fear in the child. It is necessary to explain that it is possible not to bring to the appearance of danger, or to avoid it, if you behave correctly in this or that situation.

If a child has a hereditary predisposition to epiphyseolysis, it is important for parents to visit the doctor regularly and perform preventive diagnostic measures.

Forecast

In many cases of epiphyseolysis of the radius, complete healing is observed and no dangerous consequences develop.

Improper bone formation is only possible in the following situations:

• In complex traumatic injuries, when blood circulation in the epiphysis region is impaired, bone growth is impaired. This can also result in displacement, compression or destruction of the growth plate. In open injuries, there is an increased risk of infection with further development of the infection process and destruction of the growth plate.
• The younger the age of the child, the more pronounced the abnormalities in bone development become. At the same time, the regenerative capacity is higher in early childhood.

The prognosis is largely based on the quality and timeliness of treatment. With timely medical care and a competent approach, the bony elements are adequately fused, and there is no dysfunction of the limb. If epiphyseolysis of the radius is not treated, or treated incorrectly, or in complex bone injuries with displacements, the risk of curvature and obvious shortening of the affected arm increases significantly.