Evaluation of Intra-Articular Injection of Bevacizumab on the Prevention of Physeal Bar Formation in Type 4 Salter Harris Model in Rats: A Pilot Study

Background: This study was designed to achieve a new method as a preventive treatment for complications of growth plate fractures. In this study, we investigate the effect of intra-articular injection of anti-vascular endothelial growth factor (anti-VEGF) antibody bevacizumab on the repair process of articular cartilage in a type 4 Salter Harris injury model. Methods: A Salter Harris injury was created on the proximal tibial growth plate of 14 rats by a 1.8 mm drill. The rats were randomly classified into two groups: group LD, administration of high-dose intra-articular injection of bevacizumab (250 μg), and group HD, administration of low-dose intra-articular injection of bevacizumab (50 μg) after injury. The rats were killed 2 months postoperatively and their tibia underwent micro-computed tomography (CT) analysis, histological assessment, and measurement of tibial bone length. Results: Bony bar formation was observed in 71% of the samples in the high-dose group and in 100% of the low-dose group. Relative increase in physeal cartilage thickness (P = 0.007) and decrease in bony bar formation (P = 0.029) were observed significantly in the high dose group. There was no significant difference in tibia length between the two groups (P = 0.150). Conclusion: Intra-articular administration of bevacizumab demonstrated positive restorative effects. We suggest this method of treatment due to its potential of improving cartilage repair and capability to be used as a main or adjacent treatment in osteochondral defects.

TREATMENT OF TRIPLANE FRACTURE ANKLE FRACTURES ASSOCIATED WITH IPSILATERAL TIBIAL FRACTURES USING A NOVEL APPROACH

ABSTRACT Objective: The aim of this study is to purpose a novel approach to the concomitant triplanar and tibial shaft fracture. Methods: Retrospective study between 2001 and 2019. We collected the patients’ general information, clinical and radiographic data, and complications after the following three-step treatment: (1) fixation of the Salter-Harris II fracture of the triplane fracture, (2) fixation of the Salter-Harris II/IV fracture with cannulated screws, and (3) fixation of the tibial fracture with flexible titanium nails. Results: The study included seven patients (six males) with a mean age of 14 years and a mean follow-up of 6.4 years (minimum two years). Five triplane fractures had two fragments and two had three fragments. Five fractures were classified as Salter-Harris II and two as Salter-Harris IV. Three tibial fractures were long oblique, three were spiral, and one had a third fragment. Six fractures affected the middle third and one affected the distal third of the tibia. All triplane and tibial fractures consolidated without significant displacement. No physeal damage was identified. Conclusions: This study described the association of tibial fractures with triplane ankle fractures managed by our proposed treatment, which proved to be effective for this fracture association. Level of Evidence IV, Case Series.

Evaluation of a Diagnostic-Therapeutic Algorithm for Finger Epiphyseal Growth Plate Stress Injuries in Adolescent Climbers

Background: Finger epiphyseal growth plate stress injuries are the most frequent sport-specific injuries in adolescent climbers. Definitive diagnostic and therapeutic guidelines are pending. Purpose: To evaluate a diagnostic-therapeutic algorithm for finger epiphyseal growth plate stress injuries in adolescent climbers. Study Design: Case series; Level of evidence, 4. Methods: On the basis of previous work on diagnostics and treatment of finger epiphyseal growth plate stress injuries (EGPIs) in adolescent climbers, we developed a new algorithm for management of these injuries, which was implemented into our clinical work. During a 4-year period, we performed a prospective multicentered analysis of our patients treated according to the algorithm. Climbing-specific background was evaluated (training years, climbing level, training methods, etc); injuries were analyzed (Salter-Harris classification and UIAA MedCom score [Union Internationale des Associations d’Alpinisme]); and treatments and outcomes were recorded: union, time to return to climbing, VAS (visual analog scale), QuickDASH (shortened version of the Disabilities of the Arm, Shoulder, and Hand), and a climbing-specific outcome score. Results: Within the observation period, 27 patients with 37 independent EGPIs of the fingers were recorded (mean ± SD age, 14.7 ± 1.5 years; 19 male, 8 female; 66.7% competitive athletes). Regarding maturity at time of injury, the mean age at injury did not differ by sex. Average UIAA climbing level was 9.5 ± 0.8, with 6 ± 4.6 years of climbing or bouldering and 14 ± 9.1 hours of weekly climbing-specific training volume. Among the 37 injuries there were 7 epiphyseal strains, 2 Salter-Harris I fractures, and 28 Salter-Harris III fractures (UIAA 1, n = 7; UIAA 2, n = 30). Thirty-six injuries developed through repetitive stress, while 1 had an acute onset. Twenty-eight injuries were treated nonoperatively and 9 surgically. Osseous union was achieved in all cases, and there were no recurrences. The time between the start of treatment and the return to sport was 40.1 ± 65.2 days. The climbing-specific outcome score was excellent in 34 patients and good in 3. VAS decreased from 2.3 ± 0.6 to 0.1 ± 0.4 after treatment and QuickDASH from 48.1 ± 7.9 to 28.5 ± 3.3. Conclusion: The proposed management algorithm led to osseous union in all cases. Effective treatment of EGPIs of the fingers may include nonsurgical or surgical intervention, depending on the time course and severity of the injury. Further awareness of EGPI is important to help prevent these injuries in the future.

Periosteal Incarceration in the Growth Plate: A Rare Association in Epiphyseal Detachment Fractures

Growth cartilage is a pivotal area between the epiphysis and the metaphysis, with relative fragility. She was incarcerated for soft tissue during a Salter-Harris type I epiphysic detachment in a 13-year-old girl. Such a lesion can be easily obscured with irreversible after-effects.

Characteristics of supination-external rotation Salter-Harris II ankle fractures in computed tomography

Background: Recent literature has shown that Salter-Harris (S-H)Ⅱfractures are the most common ankle fractures and carry a higher rate of growth disturbance. Recent literature has shown that Salter-Harris (S-H) Ⅱ fractures are the most common ankle fractures. CT characteristics of S-H Ⅱ ankle fractures are not well depicted. The purpose of this study was to evaluate supination-external rotation (SER) S-HⅡankle fractures by CT and to analyze the features of the associated fibular fracture to further determine the injury mechanism.Methods: The radiographs and CT with S-H Ⅱankle fractures were reviewed. Patients suffered from SER injury were included. The medial tibial cortex (MTC) of the distal tibia broken or intact, the metaphyseal fracture angle (MFA) 5-10mm proximal to the physis was documented in axial CT. The length of the metaphyseal fragment was measured in saggital CT. The correlation of the upper limits between fibular fracture and metaphyseal fragment was analyzed. In presence of the fibular fracture, the fracture pattern was classified based on the location and morphology of the fracture line.Results: Seventy-nine SER S-HⅡankle fractures were identified. Stage 1 was present in 35 and stage 2 in 44. In axial CT, the mean MFA was 11.2 degrees. MTC was fully broken in one case and 20, in stage 1 and stage 2, respectively (P=0.001). In saggital CT, the mean length of metaphyseal fragment was 35.3mm. The length of this fragment was 35.0mm, 35.5mm, in stage 1 and stage 2, respectively (P=0.868). The upper part of the fibular fracture line was located at the same level or higher than that of metaphyseal fragment. In 44 cases with associated fibular fracture, forty were in distal metaphysis with oblique fracture line for which 4 types were demonstrated with plantar flexion. Other 4 were in distal diaphysis with spiral fracture line.Conclusions: For SER S-H Ⅱ ankle fractures, MTC and orientation of the fracture plane can be shown in CT to help to make an appropriate preoperative plan. In addition to SER, majority of the concurrent fibular fracture was in the distal metaphysis with oblique fracture line and plantar flexion.

Monteggia Variant with Salter-Harris Fracture of the Radial Head: Case Report and Litergature Review

Introduction:The Monteggia fracture is a fracture to the proximal third of ulna associated with a radial head dislocation. Although this is well described and classified in adults, it is uncommon in children. Identifying growth plate trauma and subsequent surgical management are of critical importance. This report identifies a unique variant of Monteggia fracture with a Salter-Harris Type I injury of the radial head instead of a dislocation, and how it was successfully stabilised with a closed reduction. Case Rport: We present a case of a nine 9 year-old female admitted to our unit with a deformed upper extremity following a fall from height. This was a closed and isolated injury without neurovascular compromise. Radiographs revealed a displaced fracture to the proximal ulna shaft. Unlike a true Monteggia, the radial fracture went through the proximal physis with anterior divergence of the distal fragment. The radiocapitellar joint remained congruent. The ulna fracture was stabilized with open reduction and plate osteosynthesis whilst the radial injury underwent closed reduction and intramedullary pinning with excellent outcomes and maintenance of full range of motion. Conclusion: This case highlights a new variant and successful outcome following a closed reduction intramedullary fixation technique in this emergent pattern of injury. We highlight the need for a classification of these fractures in children. Keywords: Case report, Monteggia, growth plate, pediatric, fracture, trauma, variant.

Fratura epifisária proximal de úmero em cão: Relato de caso

As fraturas de ossos longos têm papel de destaque na rotina clínico-cirúrgica da medicina veterinária visto a frequência em que ocorrem, sendo nítida a necessidade de intervenções ortopédicas reparadoras. As placas de crescimento são consideradas menos resistentes do que as estruturas que a circundam, como ossos e ligamentos, tornando a região mais suscetível a lesões. Em caso de fratura, a lesão deve ser bem avaliada, buscando o melhor método de reparo, com o menor prejuízo iatrogênico causado pelo cirurgião, mas com estabilização óssea satisfatória. Relata-se o caso de um canino jovem, sem raça definida, atendido no Hospital Veterinário Universitário da Universidade Federal de Santa Maria, apresentando fratura Salter-Harris tipo I na porção proximal de úmero direito, tratada com pinos intramedulares e banda de tensão. O método, ainda que simples, apresenta boa estabilidade do foco de fratura e retorno do apoio do membro sem comprometimento de tecidos moles.