Slide 040 — Physeal bar

Clean FRCS notes with inline figures

•Physeal bar

AP Xray of knee of skeletally immature patient

•V shaped physis of distal femoral physis, suspected connection between metaphyseal and epiphyseal area in middle (cross trabeculation)

•Suspected physeal arrest

•Would like to have long film involving contralateral limb to see LLD, angular deformity

Also lateral Xray to see angular deformity

Sequelae:

•LLD, angular deformity, epiphyseal deformity

•Hx: age, causes

Examination

•Local: deformity, length, joint involvement, features suggesting cause

•Systemic: maturity

Investigations

•CT to look for bony bar, MRI to look for fibrous tissue, also to look for underlying cause

Classification:

•Extent (partial / complete)

•Site (peripheral, central, linear)

Prognosis affected by

•Cause

•Extent

•Site

•Growth potential

•Management principle: achieve equal leg length with no angular deformities, minimize complications and hospital stay

Treatment depends on

•Growth potential and projected LLD

•Deformity present: angular, LLD

•Area / location involved

•More than 2 years growth remaining

•<50% physis involved

•Langenskiold procedure: Physeal bar excision (direct/ metaphyseal window/ through osteotomy) with interposition (bone reformation retardant eg fat, cement to avoid hematoma) + marker implantation

•Physis distraction

•>50% physis involved – hemi/epiphysiodesis + future lengthening

•Less than 2 years growth remaining

•Hemiepiphysiodesis

•No growth

•Osteotomy

•FU till maturity

Prognosis:

•Traumatic: responsive to physeal bar excision as only hypertrophic zone affected

•Tumor/ infection: decrease response as all zones affected

•JPO 2009

•Factors to determine risk of physeal bar in fractures

•Initial displacement

•Mechanism of injury (high)

•Pattern SH

•Number of reduction (not more than 2)

•Residual displacement after CR

What causes growth arrest?

•Injury to germinal matrix (resting zone)

Affecting blood supply

•Bone bar formation

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Physeal bar
2	0	None	None	0	AP Xray of knee of skeletally immature patient
3	0	None	None	0	V shaped physis of distal femoral physis, suspected connection between metaphyseal and epiphyseal area in middle (cross trabeculation)
4	0	None	None	0	Suspected physeal arrest
5	0	None	None	0	Would like to have long film involving contralateral limb to see LLD, angular deformity
6	0	None	None	0	Also lateral Xray to see angular deformity
7	0	None	None	0	Sequelae:
8	0	None	None	0	LLD, angular deformity, epiphyseal deformity
9	0	None	None	0	Hx: age, causes
10	0	None	None	0	PE:
11	1	None	None	1	Local: deformity, length, joint involvement, features suggesting cause
12	1	None	None	1	Systemic: maturity
13	0	None	None	0	Ix:
14	0	None	None	0	CT to look for bony bar, MRI to look for fibrous tissue, also to look for underlying cause
15	0	None	None	0	Classification:
16	0	171450	-171450	1	Extent (partial / complete)
17	0	171450	-171450	1	Site (peripheral, central, linear)
18	0	None	None	0	Prognosis affected by
19	0	228600	-228600	1	Cause
20	0	228600	-228600	1	Extent
21	0	228600	-228600	1	Site
22	0	228600	-228600	1	Growth potential
23	0	0	0	0	Management principle: achieve equal leg length with no angular deformities, minimize complications and hospital stay
24	0	0	0	0	Treatment depends on
25	0	171450	-171450	1	Growth potential and projected LLD
26	0	171450	-171450	1	Deformity present: angular, LLD
27	0	171450	-171450	1	Area / location involved
28	0	0	0	0	More than 2 years growth remaining
29	0	0	0	0	<50% physis involved
30	0	228600	-228600	1	Langenskiold procedure: Physeal bar excision (direct/ metaphyseal window/ through osteotomy) with interposition (bone reformation retardant eg fat, cement to avoid hematoma) + marker implantation
31	0	228600	-228600	1	Physis distraction
32	0	0	0	0	>50% physis involved – hemi/epiphysiodesis + future lengthening
33	0	None	None	0	Less than 2 years growth remaining
34	0	171450	-171450	1	Hemiepiphysiodesis
35	0	0	0	0	No growth
36	0	171450	-171450	1	Osteotomy
37	0	None	None	0	FU till maturity
38	0	None	None	0	Prognosis:
39	0	None	None	0	Traumatic: responsive to physeal bar excision as only hypertrophic zone affected
40	0	None	None	0	Tumor/ infection: decrease response as all zones affected
41	0	None	None	0	———
42	0	None	None	0	JPO 2009
43	0	None	None	0	Factors to determine risk of physeal bar in fractures
44	1	685800	-228600	2	Initial displacement
45	1	685800	-228600	2	Mechanism of injury (high)
46	1	685800	-228600	2	Pattern SH
47	1	685800	-228600	2	Number of reduction (not more than 2)
48	1	685800	-228600	2	Residual displacement after CR
49	0	None	None	0	What causes growth arrest?
50	0	171450	-171450	1	Injury to germinal matrix (resting zone)
51	0	171450	-171450	1	Affecting blood supply
52	0	171450	-171450	1	Bone bar formation

#	semantic level	section?	rewritten line
1	0		Physeal bar
2	0	yes	AP Xray of knee of skeletally immature patient
3	1		V shaped physis of distal femoral physis, suspected connection between metaphyseal and epiphyseal area in middle (cross trabeculation)
4	1		Suspected physeal arrest
5	1		Would like to have long film involving contralateral limb to see LLD, angular deformity
6	0	yes	Also lateral Xray to see angular deformity
7	0	yes	Sequelae:
8	1		LLD, angular deformity, epiphyseal deformity
9	1		Hx: age, causes
10	0	yes	Examination
11	1		Local: deformity, length, joint involvement, features suggesting cause
12	1		Systemic: maturity
13	0	yes	Investigations
14	1		CT to look for bony bar, MRI to look for fibrous tissue, also to look for underlying cause
15	0	yes	Classification:
16	1		Extent (partial / complete)
17	1		Site (peripheral, central, linear)
18	0	yes	Prognosis affected by
19	1		Cause
20	1		Extent
21	1		Site
22	1		Growth potential
23	1		Management principle: achieve equal leg length with no angular deformities, minimize complications and hospital stay
24	0	yes	Treatment depends on
25	1		Growth potential and projected LLD
26	1		Deformity present: angular, LLD
27	1		Area / location involved
28	1		More than 2 years growth remaining
29	1		<50% physis involved
30	1		Langenskiold procedure: Physeal bar excision (direct/ metaphyseal window/ through osteotomy) with interposition (bone reformation retardant eg fat, cement to avoid hematoma) + marker implantation
31	1		Physis distraction
32	1		>50% physis involved – hemi/epiphysiodesis + future lengthening
33	1		Less than 2 years growth remaining
34	1		Hemiepiphysiodesis
35	1		No growth
36	1		Osteotomy
37	1		FU till maturity
38	0	yes	Prognosis:
39	1		Traumatic: responsive to physeal bar excision as only hypertrophic zone affected
40	1		Tumor/ infection: decrease response as all zones affected
41	0		——
42	1		JPO 2009
43	1		Factors to determine risk of physeal bar in fractures
44	2		Initial displacement
45	2		Mechanism of injury (high)
46	2		Pattern SH
47	2		Number of reduction (not more than 2)
48	2		Residual displacement after CR
49	0	yes	What causes growth arrest?
50	1		Injury to germinal matrix (resting zone)
51	0	yes	Affecting blood supply
52	1		Bone bar formation

040. Physeal bar

Clean FRCS notes with inline figures

AP Xray of knee of skeletally immature patient

Also lateral Xray to see angular deformity

Sequelae:

Examination

Investigations

Classification:

Prognosis affected by

Treatment depends on

Prognosis:

What causes growth arrest?

Affecting blood supply

Direct Q&A

Local: deformity, length, joint involvement, features suggesting cause

Extent (partial / complete)

Growth potential and projected LLD

Injury to germinal matrix (resting zone)

Bone bar formation

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes