Phillip G. Spiegel

Fractures of the tibial pilon.

Fractures of the tibial pilon are difficult to manage because of their severity. They are the product of high-energy compression forces and too frequently result in comminution and impaction of the weight-bearing surface of the distal tibia. Other fractures involving the roof of the ankle joint may be called “pilon fractures,” but have a better prognosis because the compressive force is coupled with torsional forces. Operative reduction with the application of stable fixation in a clinically proven sequence of steps may lead to a satisfactory outcome in approximately three fourths of the cases, but must be accomplished with a sound understanding of the anatomy of the ankle joint and the principles of stable internal fixation by a surgeon with good atraumatic technique.

Triplane fractures of the distal tibial epiphysis.

Triplane distal tibial fractures can occur as two-, three-, or four-part fractures with or without a fibular fracture. Diagnosis of the particular anatomy of each fracture is ascertained by plain radiographs; if the fracture is displaced 2 mm or more on any view, anteroposterior and lateral tomograms and, if possible, a limited computerized tomography (CT) scan should be done. A plaster cast in situ for nondisplaced fractures or closed reduction for displaced fractures should be attempted first by internal rotation and anterior movement of the fibular metaphyseal piece. Failure to obtain and/or maintain an adequate closed reduction (less than 2 mm displacement), determined by plain radiographs, is an indication for operative treatment. Operative treatment consists of screw fixation for the metaphyseal fragment alone in two-part fractures and both metaphyseal and epiphyseal screw fixation in three-part fractures. Associated fibular fractures may also require internal fixation. The prognosis is generally good if adequate reduction has been achieved by closed or open means.

Femoral neuropathy as a complication of heparin anticoagulation therapy.

Femoral nerve compression by retroperitoneal hematoma is an uncommon but significant complication of Heparin anticoagulation. The orthopedic surgeon today, utilizing anticoagulation more frequently than ever, must be ever mindful of the early warning signs and symptoms of this syndrome.

Autologous corticocancellous bone paste for long bone discontinuity defects: an experimental approach.

A number of materials have been used in treating long bone discontinuity defects, some with rewarding results and some without. These materials vary from autologous, allogenic, and xenogenic grafts, to bone implants. Other inorganic implants, such as plaster of Paris and gold, have been used, most inducing a strong inflammatory reaction. In this experiment, a paste of autologous corticocancellous bone particles was used to reconstitute discontinuity defects in long bones. The defects were healed to a solidified state within six months. This finding confirms our previous work; in membranous bone discontinuity defects, autologous corticocancellous bone gave best overall results either when used alone or with a template carrier for contouring purposes.

Minimal Internal and External Fixation in the Treatment of Open Tibial Fractures

The advantages of rigid internal fixation for open tibial fractures are well documented. There is also a large literature describing various forms of external fixation for open tibial shaft fractures. Because of the enthusiasm for internal and external fixation, the disadvantages and complications warrant new emphasis.

A study of autologous cancellous bone particles in long bone discontinuity defects.

Long bone discontinuity defects in dogs were restored by particulate autologous cancellous bone grafts and a Dacron-urethane mesh implant. In six months the discontinuity defects were filled by new bone formation, which was analyzed histologically, radiographically, and by densitometric methods. The postulated mechanism is a field phenomenon of bone induction. The discontinuity defects remained unrestored in the control groups without bone graft material. In the dogs killed at three months incorporation of the graft material was incomplete in the central area of the defect.

Dislocation of the Hip with Traumatic Separation of the Capital Femoral Epiphysis: Report of a Case with Successful Outcome

Experience with a successfully treated transepiphyseal fracture-dislocation of the femoral head in a 4-year-old boy, a review of 6 similar injuries from the literature, and consideration of the anatomy of the immature femoral head and neck, suggest that the treatment of choice for this injury is immediate open reduction and internal fixation with a smooth pin followed by cast protection. Contrary to recommendations in the literature, closed manipulation does not seem justified at any time, since it could eliminate residual blood supply to the femoral head by disruption of the soft tissue hinge between the head and neck. In a child, preservation of the blood supply through intra-articular soft parts is even more imperative than in adults.

Acute Carpal Tunnel Syndrome Secondary to Pseudogout: Case Report

Acute carpal tunnel syndrome secondary to chondrocalcinosis seems not to have been previously reported. In a 75-year-old woman, with arthropathy and calcification of the triangular fibrocartilage of the wrist, hyperparathyroidism was suspected, but not proven. Hydroxyapatite and calcium pyrophosphate crystals were found together in the pathological specimen. The patient obtained complete relief from sectioning of the transverse carpal ligament.

Prevention of medical complications in orthopedic trauma.

In severely traumatized patients, morbidity and mortality can be reduced by early management of the skeletal injuries. However, prevention of the complications of shock, pulmonary distress syndrome, embolic phenomena, blood disorders, and immunologic, neuroendocrine, and metabolic problems have a very high priority in overall patient management.

Childhood leukemia presenting as a diaphyseal radiolucency.

A 41-month-old black child with a symtomatic diaphyseal destructive lesion of the femur, and a corresponding area of increased uptake on a technetium99m bone scan, had an upper respiratory tract infection. An open biopsy was performed because of an initial clinical diagnosis of osteomyelitis, histiocytosis X or a round cell sarcoma. The biopsy showed numerous blast cells compatible with acute lymphocytic leukemia. Acute leukemia should be included in the differential diagnosis of symptomatic diaphyseal destructive lesions in children. A peripheral blood smear should be carefully interpreted prior to any other invasive diagnostic tests.