Injuries to the midtarsal joint and lesser tarsal bones.

Injuries to the midtarsal joint and lesser tarsal bones occur relatively infrequently and often present with a benign appearance on imaging studies. These facts may lead to failure of diagnosis and/or inadequate and improper treatment, with subsequent disability for the patient. The clinician with a general knowledge of the various injury patterns to the midfoot is able to approach these injuries rationally and with an appreciation of their potential severity. This article reviews the mechanism, clinical and radiologic presentation, and treatment of midtarsal joint injuries and midfoot fractures.

Lateral supporting ligament of the distal phalanx.

A 49-year-old woman complained of 3 months of constant aching pain deep to the ingrown medial nail margin of her right hallux that was unaffected by shoe wear. Physical examination disclosed no purulence, discoloration, or obvious acute inflammation; an incurved medial nail plate was seen. There was mild chronic thickening of the medial nail fold. Tenderness was maximal 2 to 3 mm plantar to the medial edge of the nail. By roentgenogram, bony projections were seen arcing from the distal phalangeal tuft and the proximal metaphyseal flare toward each other. This was considered to be a "normal" radiological variant. A partial medial onychectomy and matricectomy (Winograd procedure) was performed. Further dissection 1 to 2 mm deeper along the medial phalangeal border revealed a 1-mm wide longitudinal ligament extending from the phalangeal distal tuft to the proximal metaphyseal flare. Bony projections and ligament were excised. The wound healed satisfactorily, and symptoms ceased.

Nonoperative treatment of proximal femoral fractures in the demented, nonambulatory patient.

Two internists have recently championed the nonoperative, nonacute-care hospital management of demented nonambulatory elderly patients with proximal femoral fractures. They believe that superior care is thereby provided at lower cost and chances for survival improve. This article describes the problems encountered in applying nonoperative management to such patients in a different geographical setting, including the lack of accurate information about prefracture function, drastic alterations in patient health and function during transfers between institutions, difficulty even in recognizing fractures, the indefinite persistence of some pain, and lack of unanimity among treating professionals. Nonoperative management still remains a desirable option for truly nonambulatory, demented, aged patients with proximal femoral fracture. Triage should be done in the chronic care institution, but only by professionals who know the individual.

The management of orthopedic patients with arterial insufficiency.

The identification and management of the orthopedic patient who has chronic arterial insufficiency is presented in four cases in which failure to appreciate marginal arterial supply led to major and costly complications. Every orthopedic surgeon treating elderly patients should be aware of these possibilities. After a through history and physical examination, patients with signs or symptoms of significant arterial compromise should be evaluated by means of Doppler segmental limb pressures. This evaluation should be performed prior to the institution of the indicated orthopedic treatment whenever possible. If the segmental ankle pressure is less than 50 mm Hg, or the ankle brachial pressure index is less than 0.3, the patient should undergo complete vascular evaluation and consideration for revascularization in order to preserve marginal arterial flow and tissue perfusion during and after the orthopedic procedure. Constrictive straps, bandages, or dressings should be scrupulously avoided, as well as decreasing tissue perfusion by unnecessarily elevating the already vascular compromised extremity. The development of pain or ulceration after lower extremity surgery mandates immediate consideration of arterial ischemia and the institution of appropriate diagnostic and therapeutic measures to improve circulation to the extremity.

Scapulectomy for the treatment of malignant tumors of the scapula.

Two cases of Tikhor-Linberg resection for rhabdomyosarcoma and malignant chondromyxoid fibroma and two cases of scapulectomy for metastatic disease of the shoulder girdle are reviewed. After resection of the scapula, active motion of the shoulder will be severely restricted, but normal function of elbow, wrist, and hand permit use of the extremity in many activities of daily living. Surgical treatment for metastatic bone disease in the upper extremity and the role of radiation therapy for metastatic bone disease are discussed.

Coccidioidal spondylitis.

A review of twelve cases in which disseminated coccidioidomycosis caused localized infection of the spine showed that eight of the twelve patients were alive and well with no evidence of active infection an average of eleven years after onset (range, two to thirty-five years). One patient who was followed for more than twenty-three years had a slowly developing neurological impairment in the lower extremities as a result of lumbosarcral destruction instability. One patient died early in the course of the disease from fulminating cervical spondylitis and quadriplegia. A second patient had a paraplegia from thoracic spondylitis. On patient had no evidence of active spondylitis five years after the onset of the disease, but then died of coccidioidal meningitis. All patients were treated with intravenous amphotericin at some time in the course of their illness, although its effect was not always dramatic. The three patients with neurological impairment did not undergo spine fusion, but most of the others had that operation. Surgical evacuation of abscesses and debridement of infected bone was also performed in many cases.

Tibial adamantinoma: its histogenesis from ultrastructural studies.

Only three previous reports on the ultrastructural appearance of tibial adamantinoma have been found among some 120 cases of this tumor reported in the literature. The tumor in our case is less differentiated than the cases previously reported. We believe it is of epithelial character and the possibilities of its histogenesis have been narrowed down to either mesothelial, synovial or squamous origins among the many theories proposed. Ameloblastic origin, however, cannot be ruled out.

Results of posterior iliopsoas transfer for hip instability caused by cerebral palsy.

The incidence of subluxation or dislocation of the hip in 185 cerebral palsied patients was 25.4%. Posterior iliopsoas transfer will decrease hip deformities but complications such as weakness of hip flexion or abduction contracture are to be expected in some cases. Posterior iliopsoas transfer did not give uniformly satisfactory results; 9 out of 17 patients were fair to poor even combined with innominate osteotomy and/or versus derotation osteotomy of the femur. Early prophylactic surgery of lesser extent such as adductor release is desirable since treatment of established subluxation or dislocation is often unsatisfactory.

Fatigue characteristics of posterior elements of vertebrae.

The fatigue strength of vertebral posterior elements was determined by applying repetitive forces to the inferior joints between the articular processes of human rhesus-monkey vertebrae. The results indicate that in vivo stresses resulting from unusual activities for sustained periods can induce fatigue fracture of the lumbar vertebrae. Comparison of these data with those of other investigators suggests the use of ultimate strength as a normalizing factor to correlate fatigue-strength data obtained under different test conditions.

Pyogenic arthritis of the sacro-iliac joint. Long-term follow-up.

Nine cases of sacro-iliac pyarthrosis are presented. The difficulty in localizing the infection is attributable mostly to failure to appreciate the posteriorly situated physical findings. This, and the difficulty with early roentgenographic demonstration of the lesion, may lead to unnecessary abdominal exploration (as in two of our patients) or to prolonged delay in diagnosis and hence spread of the infection. Awareness of the usual physical findings and prompt use of radioisotope scanning to localize the infection led to earlier diagnosis and avoidance of surgery in three patients seen recently. Antibiotic therapy, with or without surgery, led to cure in all patients, with minimum sequelae.

Fat embolism revisited.

Despite continuing interest in fat embolism, the precise pathogenesis and the best treatment of the syndrome are still in doubt. To assess the effect of a high index of suspicion about the outcome of the syndrome, we have compared 37 patients seen from 1962 to 1968 with 16 patients seen from 1968 to 1974. The study of the original group of patients generated considerable interest in the diagnosis and management of the syndrome at our institution. The two groups are well matched for age, sex, and source of injury. The more recent group (1968-1974) seemed to have had more severe injuries as judged by number of fractures and need for blood transfusions. Despite this increase in severity of injury, the mortality rate for the period 1968-1974 was only 12.5% as opposed to 21% for the period 1962-1968. This improvement in mortality was achieved without resort to many of the popular pharmacologic regimens, including steroids and heparin. A high index of suspicion leading to an early diagnosis of respiratory dysfunction and aggressive supportive therapy has been responsible for the improved results.