1. Pain at the front of the radial side of the wrist may be caused by various lesions of the tendon and sheath of the flexor carpi radialis tendon. 2. The diagnosis may be established by testing resisted movement at the wrist and by the effect of injecting local anaesthetic into the tendon sheath. 3. In women over the age of fifty the lesion is associated with osteoarthritis of the joint between the scaphoid and the trapezium. 4. Osteoarthritis of the joint between the scaphoid and the trapezium is found in about 25 per cent of women over the age of fifty. 5. If the pain is not relieved by simple conservative measures it can usually be cured by incision of the tendon sheath. 6. The histological changes in the tendon sheath are similar to those found in tenovaginitis of the abductor pollicis longus and tibialis posterior tendons

1. Eight cases of monarticular brucellar arthritis in children are described. They have been followed up from between one and six years and all are now fully active and clinically normal. 2. The history was usually short, with limp, swelling of the joint and pain as the presenting symptoms. Constitutional disturbance was slight in all cases. 3. Diagnosis was confirmed by high concurrent serum agglutinin titres which were not found in control children of the same age from the same areas. Mercaptoethanol resistant antibody (IgG) and complement fixing antibodies were also demonstrated in the sera of four cases. One child had a positive blood culture. 4. The condition responded rapidly to rest and splintage and, to date, recovery seems to have been complete

1 . Thirty-four cases of Perthes' disease followed into adult life were reviewed twenty-five to forty years (average thirty years) after diagnosis. 2. Rather more than one-third of the patients developed hips which were good, an equal number were considered fair and about one-quarter were poor. 3. Four out of five patients were fully active and free from pain but only two out of five had hips which were radiologically good. 4. Clinical and/or radiological deterioration had seldom occurred in the last twelve years. 5. A good result in childhood is likely to be maintained with no pain and good function up to the age of forty years and perhaps longer

We report the long-term outcome of 218 Charnley low-friction arthroplasties in 141 patients who were 40 years old or younger at the time of surgery. The minimum follow-up was ten years with a mean of 16 years. The probability of the femoral component surviving 20 years was 86% and of the acetabular component, 84%. The chance that both components would survive for this period was 75%. The pathological diagnosis significantly influenced implant survival. In rheumatoid patients the probability of both components surviving at 20 years was 96% compared with 51% in patients with osteoarthritis. Clinical assessment of 103 patients (166 hips) in whom the arthroplasty was still functioning showed that 94% of hips had minimal pain or none. We conclude that in young patients cemented total hip replacement is a good procedure for those with rheumatoid arthritis but that the results are much less reliable in those with osteoarthritis

Radiographs of the scaphoid after injury are difficult to interpret, and bone scintigraphy is widely used to increase the accuracy of diagnosis, though many fractures suspected on scintigraphy cannot be confirmed radiologically. We have reviewed the clinical consequences, after one year, of managing suspected scaphoid fractures according to the bone-scan results. We studied 160 patients, 35 of whom had initially positive radiographs and were treated in a cast for 12 weeks. The other 125 had bone scintigraphy and were managed according to the result. After a minimum of one year 119 patients were reviewed. Scintigraphically suspected scaphoid fracture could not be confirmed radiologically in 25%. There were no cases of nonunion. The long period of immobilisation in patients with positive radiographs or positive bone scans did not influence the frequency or severity of late symptoms compared with those with a normal bone scan

We selected 20 matched pairs of patients who had had total hip arthroplasty by the same surgeon using the same cemented technique. Matching was by age, sex, height, weight and diagnosis. One of each pair had received hypotensive epidural anaesthesia, with less than 300 ml blood loss: the other had normotensive general anaesthesia with more than 500 ml of blood loss. Early postoperative radiographs were evaluated independently by three blinded observers, using a scoring criteria which assessed the quality of the cement-bone interface. The results showed that patients who had received epidural anaesthesia had significantly better radiographic scores (p less than 0.02). Our findings suggest that hypotensive anaesthesia facilitates penetration of cement into bone

Serial serum C-reactive protein (CRP) measurements were made, for three weeks, in 42 consecutive patients with solitary tibial fractures. The CRP response was related to the treatment: lower values were observed in 27 patients treated conservatively than in 15 operated patients. Open reduction and plating resulted in a greater response than closed intramedullary nailing. The timing of the CRP response was related to the timing of the treatment: the highest values were usually recorded two days after admission or operation. The timing of the operation did not affect the degree of CRP response. Neither the site, nor the type of fracture, nor the age of the patient played any role. Awareness of these natural CRP responses after fractures may help in the diagnosis of early post-traumatic and postoperative complications, especially infections

We analysed 42 weight-bearing lateral radiographs of the ankle, 20 of which were from patients with a clinical and plain radiological diagnosis of talocalcaneal coalition (TCC) who subsequently had CT. The remainder were from 22 healthy volunteers with no clinical findings suggestive of hindfoot pathology. Four observers, blinded to the CT findings, independently evaluated the radiographs on two separate occasions. With the 95% confidence interval and using the CT findings as the comparison we calculated the sensitivity, specificity, accuracy, and positive and negative predictive values for the C-sign, and for other signs known to be associated with TCC. Similarly, we also calculated the interobserver and intraobserver reliability for these signs using the kappa statistic. Our results suggest that the C-sign is highly sensitive and specific for TCC. It is an accurate indicator and significantly more reliable than other previously recognised radiological signs of TCC. Features of the C-sign, however, cannot be relied upon to indicate whether the TCC is fibrous or bony

We report a prospective study, using multivariate analysis, of the factors which influence the range of movement after total knee arthroplasty in 74 patients with 83 arthroplasties at a mean follow-up of 23.6 months (12 to 41). All the patients had a diagnosis of osteoarthritis, a severely disabled knee with a Knee Society system score of less than 60, varus deformity, no previous surgery to the knee, identical prostheses implanted with a similar surgical technique, and no postoperative complications which may have affected the range of movement. The most important factors which influenced the range of movement after arthroplasty were the preoperative range of flexion and the body-weight of the patient. There was a significant improvement in flexion and reduction of flexion contracture at each successive review up to 12 months after operation. Patients with restricted movement before operation showed a satisfactory gain at final review

Basilar impression is a well-recognised though rare complication of osteogenesis imperfecta. Three patients, all members of the same family, with advanced basilar impression complicating osteogenesis imperfecta tarda, are described. The clinical features in these cases illustrate the natural history of this condition: from asymptomatic ventricular dilatation, through the foramen magnum compression syndrome, to death from brain-stem compression. The radiological criteria on which the diagnosis is based, are defined. Review of the literature reveals only seven previously documented cases, all in patients with mild forms of osteogenesis imperfecta. The unusually low incidence of basilar impression in osteogenesis imperfecta and its apparent restriction to patients with mild forms of the disease is discussed. The examination of close relatives of patients with basilar impression and osteogenesis imperfecta is emphasised in order to anticipate the onset of severe neurological complications

Five cases are presented of bilateral simultaneous rupture of the quadriceps tendon and the English literature of six isolated case reports is reviewed. All the patients were men, and most were over 50 years old. The injury often happens in elderly people and there is diagnostic confusion with other causes of inability to use the legs, notably with mild strokes. In three of our five cases there was a delay in diagnosis. The cardinal features are diffuse swelling around the knee, a visible or palpable suprapatellar defect and the inability to lift the straight leg despite a functioning quadriceps and normal activity in all other muscle groups in the leg. In all our patients operative repair was undertaken, followed by six weeks immobilisation in plaster and subsequent physiotherapy. Even late repair was associated with successful rehabilitation of the patient and a return to useful function

A series of 75 patients who had undergone anterior cervical fusion between 1965 and 1977 were reviewed. The patients were divided into two groups: those in Group A had had the level of fusion indicated by cine radiography, whereas in Group B the level had been determined by plain radiographs and clinical symptoms and signs. Results showed that cine radiography was the more accurate diagnostic technique. Accurate diagnosis of the level to be fused, the careful clinical selection of patients and sound bony union were found to be vital to the success of anterior cervical fusion. The incidence of pseudarthrosis was significant in single-level fusions and was even greater in double-level fusions and in patients with a history of trauma, especially whiplash injuries. It was rare to develop recurrence of symptoms in adjacent levels after fusion of a level localised by cine radiography

The role of arthroscopic meniscectomy in middle-aged patients has not previously been evaluated. This paper reports on 73 knees in 68 patients aged over 40, all of whom were shown arthroscopically to have meniscal tears and who were felt to be suitable candidates for meniscectomy. Many of these patients had typical traumatic meniscal tears, and if no degenerative joint changes were present at the time of meniscectomy, 95 per cent of them had good or excellent results an average of two and a half years later. In those instances where degenerative joint changes were present, removal of the offending segment of torn meniscus produced 80 per cent good or excellent results over the same period of time. These facts seem important now that arthroscopy permits such precise diagnosis of meniscal tears and of joint degeneration

Needle biopsy is an established technique for the histological diagnosis of bone tumours, usually guided by fluoroscopy or CT. Surface lesions and aggressive tumours which have extended through the cortex are also amenable to imaging with ultrasound (US). We have assessed the diagnostic accuracy of US-guided Trucut needle biopsy in a consecutive series of patients referred to a Bone Tumour Unit with suspected primary bone tumours. Of 144 patients (83 men, 61 women; mean age 34.7 years) referred over a period of two years, 63 were considered suitable for US-guided biopsy. This was based on the presence of a relatively large extraosseous component, seen typically in osteosarcoma and malignant round-cell tumours. The results of needle biopsy were compared with those of surgical biopsy. The diagnostic accuracy was 98.4%, with only a single failed biopsy. Thus, in a selected group of patients, US is a very reliable technique of guidance for percutaneous needle biopsy of bone tumours

Infection of the intervertebral space is a rare complication of operation on the disc (Ford and Key 1955). It occurred in five cases in a series of 650 operations for lumbar disc protrusion done by two of the authors of this paper--an incidence of 0-8%. Symptoms began between seven and twelve days after operation. After initial relief of the original sciatic pain, the patients developed severe back pain and muscle cramps in the legs. Straight-leg raising became much more limited than before operation. The erythrocyte sedimentation rate was raised in all cases. The diagnosis was confirmed by rescreening the Myodil, when an indentation was seen opposite the intervertebral space from which the disc had been excised. Early removal of infected material from the disc space resulted in complete relief of pain and cure of the infection

1. The technique of arthrography in congenital displacement of the hip is described. No complications have been encountered in a series of over 200 examinations. The interpretation of the arthrographs is discussed. 2. It is suggested that the abnormal hips may be classified in three degrees: 1) Primary instability; 2) partial displacement without interposition of soft tissue; 3) complete displacement with interposition of soft tissue between head and socket. 3. Two types of complete displacement or dislocation are recognised: 1) the "tight" dislocation; 2) the "loose" dislocation. In the latter there is marked displacement of the femoral head, and arthrography done before reduction demonstrates interposition of a fold of capsule lying in front of the inverted limbus. 4. Arthrography is of special help in making the diagnosis between partial displacement with eversion of the labrum and "tight" dislocation with an interposed limbus. It is helpful too in establishing the cause of failure of reduction

1. Twelve children are described in whom gradual limitation of knee flexion developed, without previous injury or inflammation. 2. Clinical and histological investigation showed progressive fibrous degeneration of the vastus intermedius and rectus femoris. 3. As the patella showed signs of retarded development a particular form of myodysplasia, probably congenital, may be supposed. 4. Conservative treatment always failed to stop the progress of this disease. 5. Surgical treatment (Bennett's method or an elongation of the ligamental apparatus of the intermedius muscle) was carried out in ten cases and gave good permanent results. Flexion remained possible only to the extent obtained at operation; rehabilitation gave no further improvement. 6. In the opinion of the author, these cases occur more often than is generally believed, but they are recorded under a different diagnosis and consequently are not submitted to rational treatment

1. An unusual congenital anomaly of the cervical spine is described. This lesion caused a localised cervical kyphosis and resulted in the development of a mild tetraparesis. 2. The case reported is believed to be the first on record in the English literature of multiple posterior hemivertebrae in the cervical region. 3. The neck deformity was associated with an unusual combination of developmental anomalies–namely, brachyphalangy and bilateral congenital optic atrophy. 4. The importance of differentiating between congenital and acquired causes of kyphosis is emphasised. 5. The radiographic appearances of posterior hemivertebra are described, and the differential diagnosis is considered. 6. The development of the vertebral body, and the relationship between coronal cleft vertebra and posterior hemivertebra, are discussed. The possible role of a disturbance of vascular supply in pathogenesis is mentioned. 7. This report augments the growing literature on congenital skeletal anomalies occurring in combination with isolated congenital ocular defects

1. Six cases of posterior dislocation of the shoulder are described. 2. In four cases the diagnosis was made on clinical grounds. 3. The important clinical signs are the adducted and medially rotated position of the arm, a hard mass posteriorly below the acromion representing the displaced humeral head, and limitation of movement, especially abduction and lateral rotation. 4. In two cases the dislocation was not recognised at the first examination. This confirms the statement of previous authors that posterior dislocation is easily missed. 5. The value of the vertical projection in the radiography of suspected posterior dislocation is emphasised. 6. Reduction was accomplished without difficulty in five cases and the subsequent progress of these was uneventful. In the remaining case reduction was difficult and unstable, and the final recovery incomplete. It is considered that this patient would have been better treated by early open reduction

1 . Voluntary activity of any given muscle in the hand is not an absolute indication of the state of the nerve which usually supplies it. 2. Significant variations in the standard pattern of innervation have been found in 20 per cent of 226 cases studied. 3. The pattern of innervation described in standard text-books occurred in only 33 per cent. of cases. 4. A striking variation is the supply of every thenar muscle by the ulnar nerve. In other cases the first dorsal interosseous muscle may be supplied by the median nerve. 5. In order to arrive at an accurate diagnosis when anomalous innervation is suspected, nerve blocks at appropriate levels are required. 6. Great care must be taken during operations to avoid damage to connections between the ulnar and the median nerves, especially in patients with anomalous innervation of the hand muscles