Elbow Ossification Centers

Interpretation of elbow radiographs can be complicated. There are a lot of ossification centers in the elbow that can be confusing. Elbow trauma and injuries are common and ossification centers can look like bony fragments, and bony fragments can look like ossification centers. Knowing the time of development of the normal ossification centers can be important. Although this timing may be variable, you can guess the approximate time of the appearance of the ossification centers by using the mnemonic CRITOE. CRITOE, 1 3 5 7 9 11, are the ages when the ossification centers appear around the elbow. The time of appearance of these ossification centers is reliable, although they can be variable, especially in girls where they can occur earlier than in boys, sometimes by two years earlier. A rough timing estimate that is easy or simple will be helpful. This is more helpful in looking for the medial epicondyle for example, after an elbow dislocation that is avulsed and may be trapped in the joint, and you could not find it in its normal location because you could not remember if the ossifications center was even developed. If you find the trochlea ossification center and you do not find the medial epicondyle ossification center in its normal location, then look inside the joint, especially if you know the age of the patient and you know that the internal or the medial epicondyle should be developed by then. The internal epicondyle (medial) should be seen because it develops before the trochlear ossification center. One of the most important things is to know the age of the patient. Look for the normal position of the ossification center. Finding what appears to be a fracture or an ossification center in the area of the olecranon or the lateral epicondyle in a young child (5 years) should not be interpreted as an ossification center which should be developed later.

Iliac Bone Fracture

Iliac bone fractures have unique characteristics. You can have stable fractures such as avulsion of the iliac spine, anterior superior spine, due to pull of the Sartorius muscle. There may also be avulsion of the anterior inferior iliac spine (AIIS) due to the pull of the direct head of the rectus femoris muscle. The iliac bone can be part of acetabular fractures, and when it breaks as part of the acetabular fracture, it can be an associated both column fracture, and the iliac fracture will be seen in the CT scan in a coronal view. You can also see the “spur sign” which is part of the posterior ilium in its undisplaced position, and this can be seen in the obturator view. The fractured ilium can also be a part of pelvic fractures. This can be partially stable, such as posterior iliac bone fracture in the crescent type. The fractured pelvis can also be unstable, and you will have unilateral iliac fracture and complete disruption of the posterior arch complex. If it is not treated adequately, it can lead to malunion, deformity of the iliac wing and leg length discrepancy. Isolated iliac fracture occurs due to a direct blow to the pelvis. It is usually rotationally and vertically stable and is usually treated conservatively. It is not a benign injury; it can be a serious injury, especially if the fracture ilium is comminuted. Comminuted iliac fractures are uncommon and difficult to treat. There can be significant associated injuries such as soft tissue injury. Iliac and flank soft tissue injuries such as iliac and flank degloving injuries that is called Morel-Lavallee lesion. In the internal degloving injury, the fat is sheared off of the fascia. An open fracture and entrapment of the bowel within the fracture site. There may be a variety of abdominal, vascular and neurological injuries. If the fracture extends into the greater sciatic notch, then the patient may have an arterial injury or a lumbosacral plexus injury. In general, treatment is nonoperative if the fractured ilium is isolated and nondisplaced. Surgery is done by open reduction and internal fixation for displaced fractures. In case of open fracture, the patient may need a colostomy.

Crescent Fracture of the Pelvis

Crescent fractures of the pelvis is a sacroiliac joint fracture dislocation. The fracture of the iliac wing enters the sacroiliac joint. The fracture of the iliac wing enters the sacroiliac joint. There is a varying degree of injury to the sacroiliac joint ligament (combination of iliac fracture and sacroiliac joint disruption). The posterior ilium remains attached to the sacrum by the posterior sacroiliac ligaments. The anterior ilium has an internal rotational deformity. The posterior superior iliac spine remains attached to the sacrum. This injury is known to be rotationally unstable; however, some people believe it is more than that. Crescent fracture occurs by a laterally directed force applied to the anterior part of the involved iliac wing. There are three types of fractures based on the Young-Burgess Classification. Type I is a small impacted fracture of the anterior sacrum. Type II is a crescent fracture of the pelvis which is partially stable. Type III is an unstable fracture type with ipsilateral lateral compression and contralateral anteroposterior compression (windswept pelvis). CT scan defines the posterior pelvic fracture adequately, and it also can define the crescent fracture type. You can fix it by two screws from posterior to anterior, and you can add a reconstruction plate on top of it. The whole idea is to achieve anatomic reduction of the iliac wing, and the sacroiliac joint dislocation and stable fixation. The fixation can be done by extra-articular internal fixation using intertable lag screws and outer table neutralization plates. It can be done through a posterior approach, and this will be fixing the iliac component. The fixation can also be done percutaneously, and it also can be done with screws through the sacroiliac joint.

Skin Graft

A skin graft is usually needed to cover wounds which can occur due to trauma, infection, or surgery. High energy fractures may cause compartment syndrome which will require fasciotomy. Fasciotomy wounds can be treated by different ways, and one of these ways is a skin graft. In open fractures, when the wound is extensive, it may require a skin graft.  Wounds can be divided into two types: simple and big. Simple, uncomplicated wounds can usually be closed with sutures or staples. If the wound is big, the surgeon cannot close the wound. The surgeon cannot approximate the edges of the wound together. A different method for coverage of the muscles, and the sound becomes necessary. A skin graft is one technique used in this situation. The wound is initially treated with wet to dry dressings or with a VAC (Vaccum Assisted Closure). A VAC is very helpful because it promotes healing and reduces swelling of the open wound. Before you obtain a skin graft to cover the wound, the wound will be debrided, cleaned, and measured. A bulb syringe is usually used for irrigation of the wound. A skin graft involves cutting a thin slice of skin from a donor area. The skin sample is commonly taken from the area of the thigh. The skin sample is prepare before applying it to the recipient site. The donor skin is then meshed, which will cut tiny slits in the graft, allowing the graft to be stretched for covering large areas of the wound (this allows for using less skin). The meshed skin is now ready to be placed over the wound, and staples are used to adequately secure the skin graft to the wound. Be careful not to put the staples into any neurovascular structures. Skin grafts are very fragile, and great care must be taken when looking after them, even after the wound has healed. Therefore, sterile dressing is applied to the wound and should remain in place for approximately 5 days. During the first dressing change, the clinician will slowly remove the bandages and normal saline may be used to moisten the dressing in order to avoid damaging the skin graft. The wound is inspected for signs of infection. Covering the wound early may help in preventing infection.

Compartment Syndrome of the Thigh- Thigh Fasciotomy

The condition of increased pressure within the muscle compartment is called compartment syndrome. Acute compartment syndrome of the thigh is rare. In this case, fracture of the femur causes increased pressure of the thigh that requires fasciotomy. High suspicion for thigh compartment syndrome is recommended even in cases of minor trauma when anticoagulation therapy or hemophilia is involved. The anterior compartment of the thigh is the most commonly involved compartment. Fasciotomy is often necessary when the pressure within the muscle compartment is increased. Increase pressure is defined as an increase of absolute pressure to 30 mmHg or the pressure of the compartment is within 30 mmHg of the diastolic pressure. If the surgeon suspects compartment syndrome during surgery, the preoperative diastolic pressure and not the intraoperative diastolic pressure, is used as a guide. Once the compartmental pressure becomes elevated as mentioned before, fasciotomy becomes necessary. Fasciotomy should be done urgently within a reasonable period of time in order to avoid ischemia of the muscles.

Distal Third Clavicle Fracture

Fracture of the distal third of the clavicle is a problem fracture. Its management and its outcome can be complicated. There are some ligaments called the coracoclavicular ligament that goes between the coracoid and the clavicle. These ligaments are called the conoid and trapezoid ligaments. The conoid is medial (inserts about 4.5cm from end of clavicle). The trapezoid is lateral (inserts about 3 cm from the lateral end of clavicle). The integrity of the conoid and trapezoid ligaments (coracoclavicular ligaments) is important. The coracoclavicular ligaments provide the primary resistance to superior displacement of the lateral clavicle. The ligaments are holding the clavicle down. If fracture of the lateral third of the clavicle occurs and the medial part is not attached to the ligaments, then the medial part of the clavicle will become displaced superiorly by the pull of the sternocleidomastoid muscle. When you assess the fracture of the lateral or distal third of the clavicle, you assess the stability of this fracture. The stability of this fracture is based on the location of the fracture in relationship to the coracoclavicular ligaments, the AC joint, and the fracture pattern. Is the fracture pattern simple or comminuted which could be unstable. There are several types, and they can be summed up as two types: stable fractures and displaced fractures with coracoclavicular ligament not attached to the proximal fragment. In displaced fractures, the proximal fragment will displace superiorly. This type will have delayed union up to 50% and nonunion approximately 20%. Because the proximal fragment is not attached to any ligaments, it is just displaced superiorly. The distal segment continues to be attached to the coracoid by the coracoclavicular ligament. Some physicians believe that the displacement of the fracture, and the fracture stability is usually decided in surgery, but you do not want to do that, you want to decide the stability and the displacement of the fracture before surgery so that you can make the proper decision for treatment and also to select the proper implant for dealing with this problem. The Zanca view x-ray may be needed. 15 degrees cephalic tilt to show the superior inferior displacement. A fracture that is lateral to the ligament makes the fracture stable, you will treat the patient conservatively with a sling. A fracture that is medial to the ligament and makes the fracture unstable is treated by open reduction internal fixation. You can use the guideline of the ligament insertion, which is 4.5cm from the AC joint, can use the Zanca view to help you in visualizing the displacement superiorly or inferiorly, and when the fracture is medial to the ligament that is unstable, this means that you need to do ORIF because if you treat it conservatively, there will be a high incidence of nonunion. You can use multiple techniques for reduction and fixation of the distal clavicle fracture. One of these techniques is plates and screws called a “cluster plate” that has multiple holes which allows you to put small screws and lock the screws to the plate. Another technique is the hook plate which is used when there is insufficient bone in the distal segment for fixation with plates and screws. Not every hospital has the hook plate. You may not be able to fix the distal clavicle fracture with plate and screws in surgery. Make sure you have the hook plate in house in case it is needed (hook plate is a backup plan). Most hook plates will require removal after healing of the fracture (secondary surgery). If the fracture is a nonunion and the patient has symptoms, you need to fix this fracture with a plate and bone graft if the fracture is atrophic. This problem is very difficult to treat, and it does not matter what type of fixation that you use, there will be a high incidence of failure in the treatment of nonunion of the distal clavicle. The patient may require two types of stabilization for this nonunion. The patient may require two types of stabilization for this nonunion. The first type is a plate and bone graft fixation. The second type is additional help to the plat and bone graft by stabilizing the coracoclavicular area. You can use a tendon allograft, or you can use anchors in the coracoid or a tight rope fixation. Fracture distal to the line drawn vertically to the coracoid process is probably a stable fracture. You will give the patient a sling for comfort and give a structured PT program when the pain is less, starting with pendulum exercises and progress to active assisted when the pain is manageable. In a child, a distal clavicle fracture could be a periosteal sleeve fracture which will remain attached to the intact coracoclavicular ligament.

Seymour Fracture

Seymour fracture is a complex pediatric fracture of the fingers or the toes. It is an extra articular transverse Salter Type I or Type II fracture at the base of the distal phalanx of the fingers or the toes. There is a flexion injury that leads to physeal separation between the extensor tendon dorsally and the flexor digitorum profundus volarly. This flexion injury which causes flexion of bone also causes avulsion of the proximal edge of the nail from the nail fold. In addition to disruption of the nail plate, there is a disruption of the germinal matrix. The patient will have pain, swelling, and deformity. The finger will appear flexed, and it will look like a mallet finger with the nail appearing too long compared to the nail on the other side. There is blood coming from the root of the nail. This injury is an open fracture, it is not a mallet finger fracture, and it should not be treated with a splint alone. When you see bleeding around the nail bed in a child, be suspicious of a Seymour fracture. If the fracture is missed, there may be complications such as infection and finger deformity. Because this is an open fracture, you must give the patient antibiotics. The patient will need to go to the operating room for nail removal and debridement of the wound. Reduce the fracture, fix it with a K-wire and repair the nail bed. Splint the fracture or use a cast for protection.