We reviewed the surgical treatment and oncological results of 40 patients with pathological fractures from localised osteosarcoma of the long bones to determine the outcome of limb salvage in their management. All had had adjuvant chemotherapy. There were 26 males and 14 females with a median age at diagnosis of 18 years (2 to 46) and a median follow-up of 55 months (8 to 175).

We performed limb salvage in 27 patients and amputation in 13. The margins of resection were radical in five patients, wide in 26, marginal in six, wide but contaminated in two and intralesional in one. Local recurrence developed in 19% of those treated by limb salvage and in none of those who had an amputation. The cumulative five-year survival of all the patients was 57% and in those treated by limb salvage or amputation it was 64% and 47%, respectively (p > 0.05).

Limb-sparing surgery with adequate margins of excision can be achieved in many patients with pathological fractures from primary osteosarcoma without compromising survival, but the risk of local recurrence is significant.

We performed a prospective, randomised study on 50 patients with Tscherne C1 tibial diaphyseal fractures comparing treatment with reamed and unreamed intramedullary nails. Our results show that reamed nailing is associated with a significantly lower time to union and a reduced requirement for a further operation. Unreamed nailing should not be used in the treatment of the common Tscherne C1 tibial fracture.

In a prospective, randomised trial of 81 patients with fractures of the ankle of AO types A, B and C we compared two regimes of postoperative management after internal fixation. The patients were mobilised either non-weight-bearing with crutches or weight-bearing in a below-knee walking plaster.

We found a temporary benefit in subjective evaluation only (65 v 50 points, Mann-Whitney test, cft, p = 0.02) for those with a below-knee walking plaster. There were no significant differences between the groups in the loaded dorsal range of movement (25° v 23°, Mann-Whitney test, cft, p = 0.16) or in the overall clinical result. Both treatments were considered to be satisfactory and their choice depends on the ability to mobilise non-weight-bearing, wound healing, the type of work and personal preference.

We performed a prospective, randomised controlled trial of the operative versus non-operative treatment of 42 displaced fractures of the distal femur in elderly patients.

Excellent or good results were achieved in 53% of the operated group and in 31% of the non-operated group. There were more complications in the latter, and the time to discharge was considerably longer.

We reviewed 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. Thirteen had undergone continuous monitoring of the compartment pressure and the other 12 had not.

The average delay from injury to fasciotomy in the monitored group was 16 hours and in the non-monitored group 32 hours (p < 0.05). Of the 12 surviving patients in the monitored group, none had any sequelae of acute compartment syndrome at final review at an average of 10.5 months. Of the 11 surviving patients in the non-monitored group, ten had definite sequelae with muscle weakness and contractures (p < 0.01). There was also a significant delay in tibial union in the non-monitored group (p < 0.05).

We recommend that, when equipment is available, all patients with tibial fractures should have continuous compartment monitoring to minimise the incidence of acute compartment syndrome.

The effect of the position of splintage on displacement of fractures of the waist of the scaphoid was studied during operations and in cadavers. We found that these fractures were best splinted in neutral or slight palmar flexion with no ulnar deviation. Providing the wrist was not ulnar deviated, the position of the thumb had no effect on displacement.

Forty-five patients with fractures of the tibial spine were reviewed 3 to 10 years after injury in order to determine the degree of residual laxity of the cruciate or collateral ligaments. After fractures which had been partially or completely displaced, some anterior cruciate laxity was evident, even if patients were asymptomatic. It was also found that an anatomical reduction did not prevent either laxity or some loss of full extension of the knee.

From an anatomical study and clinical review of fractures of the lateral humeral condyle in children, the following conclusions are drawn. The mechanism of injury is a violent varus force with the elbow in extension, the condyle being avulsed. by the lateral ligament and the extensor muscles. If the fracture is incomplete, with an intact hinge of pre-osseous cartilage medially, the fragment will not be displaced. If the fracture is complete the fragment may be displaced, and open reduction with internal fixation is mandatory.

The results of open reduction more than three weeks after the fracture are no better than those of no treatment at all, and may kill the lateral condylar fragment by damaging its blood supply. The major problem of a neglected fracture is tardy ulnar nerve palsy; to avoid this, immediate anterior transposition of the nerve is recommended, operation for the fracture itself being of no benefit.

1. Senile subcapital fractures in osteoporotic patients are due to fatigue, not to the impact of a fall, since they are preceded by the local accumulation of isolated trabecular fatigue fractures.

2. One pathological significance of the isolated trabecular fractures described by Todd, Freeman and Pirie (1972) has been demonstrated.

1. An initial series of 100 consecutive cases of trochanteric fracture treated by the Küntscher technique of condylo-cephalic nailing with the aid of an image intensifier has been reviewed.

2. The advantages of this simple method over internal fixation by open reduction and insertion of some kind of nail and plate are discussed.

1. In sixty mature rabbits osteochondral fractures of various types were made in the medial femoral condyle.

2. The fractures or fragments which remained stable united but those in which movement occurred progressed to non-union.

3. An ununited osteochondral fragment resembled osteochondritis dissecans in the human both radiologically and histologically.

4. Experiments in the cadaveric knee show that the patella articulates with the classical site on the intercondylar aspect of the medial femoral condyle in full flexion of the joint and here an osteochondral fracture could be sustained.

5. It is concluded that the fragment in osteochondritis dissecans follows an osteochondral fracture which remains ununited.

1. The long-term results in a consecutive series of 323 healed subcapital fractures of the femur show that, with few exceptions, the capital fragment maintains its integrity when the fragments are aligned within the narrow limits of good reduction, but undergoes superior segmental collapse when reduction is poor.

2. The effect of malreduction on the congruity of the hip joint is examined, and a remodelling response to malalignment of the aspherical femoral head in the imperfectly round acetabulum is proposed as an alternative interpretation of the radiological changes now considered to be the result of capital ischaemia.

1. Sixty-three fractures of the femur occurring in forty-eight patients with Paget's disease are presented.

2. In patients with Paget's disease the femur is the bone most often fractured, although the risk of fracture is probably not much greater than that of the normal population.

3. Many femoral fractures in Paget's disease are spontaneous and are preceded by pain. Extension of a stress fracture is the most likely cause.

4. All eleven femoral neck fractures in this series failed to unite; it is suggested that neither operation nor prolonged conservative treatment is indicated.

5. Subtrochanteric fractures, if severely displaced, are best treated by intramedullary nailing.

6. Most shaft fractures may be satisfactorily treated by conservative means. Deformity of the shaft can be corrected in fractures treated by external splintage.

7. The time required for union has been neither unduly short nor unduly prolonged.

8. The long-term results in this series have been acceptable. Sarcomatous change as a complication of fracture was not observed.

1. Experimental fracture callus in rats contains mast cells as a normal morphological element.

2. The mast cell count undergoes peculiar variations in the normal course of events in experimentally delayed or accelerated bone repair.

3. A hypothesis is presented in which the tissue mast cell granules are regarded as calcium transporters in the mineral phase of callus formation, a process probably corresponding to Selye's concept of "mastocalciphylaxis" and "mastocalcergy."

The results of 110 operations for the treatment of fractures through metastases in the femoral neck and intertrochanteric region have been studied. Of these, forty-four fractures were treated by internal fixation, forty-six by resection of the femoral head and neck, and twenty by prosthetic replacement. The following conclusions were reached.

1. Prosthetic replacement of the femoral head is a reliable procedure.

2. The long stem type of prosthesis has the advantages of greater stability and simultaneous fixation of the shaft.

3. Patients with diffuse metastatic disease of the ilium are not suitable for prosthetic replacement. These patients should be treated by resection of the femoral head and neck.

4. Resection is a less traumatic procedure and therefore useful in the palliative treatment of patients in poor general condition.

5. Internal fixation leads more often to complications and unfavourable results than do the other methods.

1. The combination of femoral shaft fracture with dislocation of the hip in the same limb has been recorded in eighty-one patients since 1823.

2. A further fourteen cases are reported.

3. In over half the cases the hip dislocation was diagnosed late or not at all, and this error has occurred more often in modern times. The reasons for this are outlined.

4. The diagnostic physical signs of hip dislocation in the presence of a femoral shaft fracture are described.

5. The mechanism, sequels and treatment of this combined injury are discussed.

1. Six cases of malunited anterior Monteggia fracture have been treated, five of them successfully, by open reduction and reconstruction of the orbicular ligament by turning down a slip from the triceps tendon.

2. One relapse occurred after a slight injury; this was because of an unsuitable triceps tendon.

3. A slip from the triceps tendon has retained reduction of the head of the radius in a patient with congenital dislocation of the radial head.