The successful management of femoral neck fractures is obviously based upon many factors. The forces acting upon the proximal end of the femur are believed to be mainly compressive in nature, and the low-angle nail by stabilising the fully reduced fracture in the line of these forces is held to allow weight bearing to take place. Low-angle nailing is believed to offer many advantages over conventional methods of treatment but only in the presence of stability. Stable reduction is the essential preliminary to any form of treatment, and low-angle fixation with early weight bearing in the absence of stability is regarded as futile.

It is suggested that those subcapital separations which follow trivial injury may originate as stress fractures accompanying the process of bone remodelling in the aged, and that many of these fractures may remain unrecognised and heal spontaneously. With rare exceptions, subcapital fractures are regarded as being of the same essential pattern, and their varying radiological appearance is considered to be due to the different degrees of displacement to which they have been subjected. A new classification based on this premise has been suggested.

In a series of eighty subcapital fractures the incidence of avascular necrosis was not adversely affected by early weight bearing, but reduction in the extreme valgus position was invariably followed by this disaster. This is probably also true of any malposition in extreme rotation which must stretch and obliterate the vessels in the ligamentum teres.

A rough alignment index of reduction was found to provide an almost infallible guide to the prognosis both in regard to union and to avascular change. It may therefore be possible to base prognosis on the quality of reduction before the fixation appliance has been inserted. The unsatisfactory results in those cases apparently destined to non-union or avascular necrosis may then be avoided by alternative means of treatment at an early stage. Whether this will prove to be true must depend upon a much longer experience of low-angle fixation, and, in common with almost every communication on this subject, premature publication must largely offset the value of the present findings.

Cases are reported of two men who sustained bilateral hip injuries while undergoing convulsive therapy and of one woman who sustained bilateral hip injuries during a uraemic convulsion. A further twenty-three previously unreported cases are analysed, sixteen of which were of simultaneous bilateral femoral neck fractures and five of which were simultaneous bilateral central dislocations of the hip. One other patient sustained his injuries in an epileptic fit. A review of the literature has revealed another thirty-five cases of bilateral hip injuries, most of them caused by convulsive therapy, but a few by accident, disease of the femoral neck, or epilepsy.

One case is included of a rare double injury, a femoral neck fracture on one side and a central dislocation on the other. I have found no previous reference to this combined injury.

Double hip injuries are very rare in relation to the large numbers of patients receiving convulsion therapy, but the change from pharmacological to electrical methods has not prevented their occurrence and at least fifteen are known to have occurred during the last six years.

A wide age range is represented, and many fractures of convulsive origin have occurred in fit, well nourished, adult men. Only a few have been found in more elderly and possibly osteoporotic patients.

All the "convulsive " injuries were sustained during unmodified treatment, and mention is made of the differences of opinion among psychiatrists about the use of anaesthesia and of relaxant drugs in convulsion therapy.

These are the most severe injuries complicating convulsion therapy, and the most difficult for the orthopaedic surgeon to treat.

1. A method is described for measuring blood flow to the head of the femur after fracture of the femoral neck, by estimation of the rate of uptake of radioactive phosphorus.

2. Of one hundred cases investigated the readings in fifteen were incomplete, and in seventeen were unreliable. Reasons are given for discarding the latter seventeen cases. After two years seven patients had died, leaving sixty-one available for analysis.

3. The results in sixty-one surviving patients with a follow-up of not less than two years are analysed. In twenty of these radioactivity was measured by bone sampling and in forty-one by direct readings with a needle counter.

4. The twenty-one intertrochanteric fractures studied were used as controls. In these the P³² ratio varied from 0·4 to 3·0. Union occurred in all patients and none developed avascular necrosis.

5. Of the forty patients with displaced fractures of the femoral neck twenty-eight showed a low P³² ratio. In twenty-three of these (82 per cent) the fracture united.

6. Twelve patients with fractures of the femoral neck showed a borderline or abnormal P³² ratio. In ten of these there was subsequent avascular necrosis or non-union.

7. The possible reasons for the discrepancy between expected and actual results are discussed.

8. Almost 40 per cent of the cases investigated had to be abandoned because of technical faults and in one-fifth of the remaining cases the expected results failed to agree with the clinical results. The method of investigation is therefore not of much practical value at the present time. Improvements in apparatus and technique might make the method more reliable and more useful.

1. The properties and behaviour of ethoxyline resins, which are already well known in industry, are discussed.

2. Experiments in the use of these compounds for the bonding of fractures of the long bones of sheep are described.

3. There has been no evidence of toxic reaction to the presence of the resin in the tissues.

4. Application of the method to fractures in man has been studied, and two such fractures have been bonded with promising early results.

1. Fifty-one cases of fracture of the odontoid have been analysed. Forty were reported by other surgeons; eleven were new cases first reported by us.

2. Fracture of the odontoid in young children is an epiphysial separation. It occurs up to the age of seven years. As in epiphysial separations elsewhere, it unites readily, and remodelling occurs when reduction has been incomplete, so that normal anatomy is restored.

3. In adults forward displacement is twice as common as backward displacement.

4. Immediate paralysis is commoner if backward displacement occurs, but late neurological disorders are seen only after fractures with forward displacement.

5. Failure of bony healing is not dangerous if treatment has resulted in firm fibrous union, for there is neither excessive abnormal mobility nor progressive subluxation, either of which could injure the spinal cord or medulla. Neurological disorders developing after the fracture are the result of mobility from inadequate early treatment. It is the results of inadequate early treatment which have given this fracture a sinister reputation.

6. The fracture should be reduced by skeletal traction through a skull caliper. The reduction should be maintained for six weeks by continuous traction, and this should be followed by a period of six weeks in a plaster.

7. The increasing definition of the fracture-line seen in the radiographs of some patients indicates non-union.

1. Five patients with seven fatigue fractures of the lower third of the tibia are described; two had bilateral fractures. There is a striking similarity in the site and appearance of these fractures.

2. All occurred in middle-aged or elderly people without a history of unusual activity or illness.

3. The fractures are so nearly identical as to constitute an entity which, as far as we are aware, has not been described before.

1. Reduction of supracondylar fractures in children by lateral rotation of the arm combined with mechanical traction and manipulations is described. Fixation in a plaster shoulder spica is recommended.

2. The results are presented and seem to be satisfactory.

1. Ninety-eight cases of fracture of the upper end of the tibia treated by operative reduction have been reviewed.

2. The true split fractures and the mildly comminuted compression fractures showed the best results. The "mosaic" cases showed the least satisfactory results.

3. Age has scarcely any effect on the end-results and is consequently no contra-indication to operation.

4. Nearly half the patients regained normal or almost normal mobility in the knee joint.

5. In no case did a meniscus left in place cause symptoms indicating internal derangement.

1. Full recovery after fracture of the head of the radius in children may be expected in cases with tilting of the radial head from 30 to 60 degrees, whether treated by early manipulative or by operative reduction.

2. Manipulative reduction is facilitated by knowledge of the direction of displacement and tilting of the radial head, which can be determined by the study of appropriate radiographs.

3. When the upper radial epiphysis is completely displaced from the shaft, some permanent loss of movement is to be anticipated even when accurate reduction has been secured by operation. Early fusion and some deformity of the radial head are also to be expected. This is not surprising in view of the risk to the blood supply of the displaced head, particularly in those cases treated by operative reduction.

1. Trochanteric fractures are classified, with special emphasis on the stability or instability of the fracture. The importance of the cortical buttress of bone on the inner side of the femoral neck and shaft is stressed.

2. Three series of cases are presented: a) one hundred and one cases treated conservatively in hospital; b) twenty-five cases sent home by reason of lack of hospital beds; c) twenty-two cases treated by fixation with a Capener-Neufeld nail-plate.

3. From consideration of these three series, and from study of similar series of cases reported in the literature, it is suggested that routine operative treatment of trochanteric fractures has the advantages of greater comfort and mobility of the patient, lowered mortality, and economy of hospital beds.

4. Certain features of the operation of internal fixation by the Capener-Neufeld nail-plate are discussed. A director, for more efficient insertion of the nail-plate, is described.

5. The importance of early mobility after operation is emphasized. Only a small proportion of Patients can be allowed early weight-bearing but almost all can be got up in a chair, and most can be taught to get about with crutches, without weight-bearing on the fractured limb, within a few days of operation.

1. Various types of fracture of the femoral neck represent different stages of one and the same displacing movement.

2. The displacement first produces an "abduction fracture" and terminates in an "adduction fracture," passing through the stage of an " intermediary fracture" which is less well recognised.

3. These three types of fracture occur in response to the same injury and they differ only in the degree of displacement.

4. It is a mistake to believe that in " adduction fractures" the femoral head lies medially to the collum : it lies posteriorly.

5. "Impaction" is no more than the first stage of displacement of fractures in which there is limited displacement, with contact still maintained between the fragments.

6. An "impacted fracture" is not necessarily stable—if there is additional strain it may progress to the next stage of a displaced and unstable fracture.

7. These principles apply not only to fractures of the femoral neck but to all other fractures at the ends of long bones.

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty.

It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.