The pathology of acute chondro-osseous injury in the child

Skeletal tissues from children sustaining acute skeletal trauma were analyzed with detailed radiologic and histologic techniques to assess the failure patterns of the developing skeleton. In the physis- and epiphysis-specific fracture propagation varied, usually going through the portion of the hypertrophic zone adjacent to the metaphysis. However, the physeal fracture in types 1 and 2 sometimes involved the germinal zone. There may also be microscopic propagation at oblique angles from the primary fracture plane, splitting cell columns apart longitudinally. The cartilage canals supplying the germinal zone appear to be "weak" areas into which the fracture may propagate, especially in infancy. Incomplete type 1 physeal fractures, which cannot be detected by routine radiography, may occur. Types 1, 2, and 4 physeal injuries may be comminuted. In type 3 injuries, discrete segments of physis that include the germinal zone may "adhere" to the metaphysis, separating the cells from their normal vascularity. In types 2 and 3, comminution may occur at the site of fracture redirection from the physis. Direct type 5 crushing of the physeal germinal zone does not occur, even in the presence of significant pressure-related changes within other areas of the epiphysis. Type 7 separation between cartilage and bone at any chondro-osseous epiphyseal interface may occur, but is similarly impossible to diagnose radiographically. In the metaphysis torus, fractures result from plastic deformation of the cortex, coupled with a partial microfracturing that may be difficult to visualize with clinical radiography. Some of the energy absorption may also be transmitted to the physis, causing metaphyseal hemorrhage adjacent to the growth plate and variable microscopic damage within the physis. In the diaphysis, the greenstick fracture is associated with longitudinal tensile failure through the developing osteons of the "intact" cortex. The inability of these failure patterns to "narrow" after the fracture force dissipates is the probable cause of retained bowing (plastic deformation). In both torus and greenstick fractures, the fractured bone ends show micro-splitting through the osteoid seams. In the diaphysis, metaphysis, and epiphyseal ossification center there may be areas of focal hemorrhage and microfracture that correlate with the reported MRI phenomenon of "bone bruising." Again, such injury cannot be diagnosed during routine radiography.