The details in technique which are most essential to ensure a perfect Syme's stump are the provision of a broad area of support for the heel flap by transecting the tibia and fibula as low as possible; the maintaining intact of the specialised weight-bearing qualities of the heel flap; and the proper placement of the heel flap under the cut ends of the tibia and fibula. If these aims are achieved a good and useful stump is assured; if they are neglected the stump will be imperfect and may be unsatisfactory and no further operation can restore the qualities of the heel flap which are lacking.

It must be recorded, however, that Syme's stumps which are not technically perfect often function so well that there has been no need to consider re-amputation. A loose heel pad can be held beneath the end of the bone by firm lacing of the corset of the prosthesis.If its area of bony support is reasonably large it may serve well, though not perfectly, as an end-bearing stump. Syme's stumps so completely unsatisfactory as to necessitate re-amputation have been those in which the plane of transection of the tibia is so high that the area supporting the heel flap is too small; or the weight-bearing qualities of the heel flap have been damaged; or there is instability of the heel flap which cannot be controlled; or there is impairment of nutrition of the heel flap.

A carefully planned operation may be expected to check increasing deformity without doing harm, and to make subsequent bony stabilisation easier. In favourable cases it may be possible to restore muscle balance and stability, making further surgery unnecessary. A longer follow-up is necessary to determine to what extent this ideal can be achieved.

The etiological factors concerned in paralytic scoliosis are complex. Four main types of paralytic scoliosis can be recognised.

1. The general C-curve due to the body's anatomical attempt to shift its centre of gravity towards the weaker side. Vertebral rotation is not usually marked. This type usually occurs when patients with relatively slight paralysis have been allowed up too early ; it does not usually progress to severe deformity but may occasionally do so, gradually changing into Type 2. This type usually responds well to a period of rest and muscle redevelopment in recumbency. It also responds favourably to correction and fusion because correction is easy and there is little tendency to deterioration. Many of the "successes" of correction and fusion are in this class—almost equal success would often have been gained without "correction." The spine is slightly, but not very, unstable and a relatively localised fusion will give the little extra support that is needed.

2. The "general collapse" type of curve due to extensive spinal weakness. This is the type in which simple head suspension produces marked correction. Rotation is moderate. Provided the patient's general condition is satisfactory extensive spinal fusion is usually the best treatment and produces gratifying improvement.

3. The primary lumbar curve due to a combination of pelvic obliquity, extraspinal imbalance and imbalance of the deep rotator muscles. Rotation is usually marked. Treatment must include the correction of all these factors. In mild cases correction of the pelvic obliquity is enough, but in marked cases the spine must also be corrected. The disability from a lumbar paralytic scoliosis is much greater than that from a lumbar idiopathic scoliosis of the same degree; so correction is necessary in this type. Correction in a Risser-type jacket is often inadequate and recourse to operative correction is usually required.

4. The primary thoracic curve—often associated with weakness of the scapular muscles. The indications for and methods of treatment are practically the same as in primary idiopathic thoracic curves. These curves tend to be progressive and uncompensated. Although the most popular treatment is correction and fusion, wedge osteotomy of the spine gives better correction in intractable cases.

The main need is for further investigation into the etiology of paralytic scoliosis so that adequate preventive measures may be undertaken at an early stage. It is essential that every child who contracts poliomyelitis should have his back muscles examined before he gets up. If there is any suggestion of scoliosis further investigations including radiography and electromyography are essential.

1. The prognosis of paralytic scoliosis has been studied by defining curve patterns and establishing the natural development as seen in fully grown patients who have not had surgical correction.

2. The prognosis, unlike that in idiopathic scoliosis, is related to the age of onset of the curvature and the degree of muscle imbalance rather than the site of the primary curve.

3. Paralysis of limb muscles is shown to be unrelated to the development of scoliosis. The intercostal muscles and the lateral abdominal flexors produce scoliosis when weaker on the convex side of the curve. Gravity and the other trunk muscles certainly play a part in the development of lumbar curves but their importance is difficult to assess.

1. Ten patients are described in whom pain due to arterial obstruction simulated pain caused by bone or joint disease or by disorder of the intervertebral disc.

2. The importance is stressed of arterial obstruction at the aortic bifurcation or in the iliac vessels as a possible cause of pain in patients attending orthopaedic clinics.

A boy aged eleven with a solitary chondroma of the right tibia, and angiomata of the skeletal muscle, subcutaneous tissues, and periarticular tissues of the same limb, is considered to be a case of Maffucci's syndrome (dyschondroplasia with angiomata), although there was not the severe deformity encountered in the previously reported cases. There was a secondary atrophy and adiposity of skeletal muscle, and this was attributed to anoxic effects produced by the angiomata.

1. The term "bumper fracture" is colourful but usually inaccurate. The injury is a valgus split or crush.

2. A series of sixty bumper fractures is reported: forty-eight were treated without operation or plaster.

3. Twenty-seven of the forty-eight patients treated without splintage have been followed up for more than five years, and seventeen of these for more than ten years.

4. The results are satisfactory and there is no evidence that there is any late deterioration of the joint.

5. It is suggested that bumper fractures should be treated without operation and without fixation in plaster.

1. A case is described in which a malignant tumour developed in the soft tissues at the site of a bone-plating operation performed thirty years before.

2. The plate and screws were found to be composed of dissimilar metals and a difference of potential existed between them.

3. A careful consideration of the history and clinical course indicates that the tumour arose because of the presence of the metals.

1. Ten cases are recorded of the entity known as non-osteogenic fibroma of bone.

2. We believe the evidence is in favour of the condition's being a localised disturbance of bone growth (metaphysial fibrous defect) rather than a true neoplasm.

3. The disorder usually pursues a symptomless course and in many instances the lesion disappears spontaneously.

1. A case, believed to be the fifth on record, of supracondylar fracture with rupture of the brachial artery is described.

2. The relative immunity of the median nerve in these injuries is discussed, with brief reference to a recent case of complete rupture. Only a single previous report of this complication could be found.

3. It is suggested that these injuries are less uncommon than the number reported would indicate.

4. The anatomy of severe displacement is discussed, with special reference to the role of the brachialis.

5. The danger of closed reduction when the relationship of the upper fragment to the neurovascular bundle is in doubt is stressed.

6. The indications for open reduction are given.

1. The factors producing electrolytic corrosion of stainless steels are reviewed, and it is shown how several factors operating together can accentuate corrosion in certain positions in the plated fracture.

2. These factors can be minimised by good metallurgy and good engineering on the part of the manufacturers.

3. When and if materials become metallurgically satisfactory, or a truly inert substitute for metal is discovered, it will be possible to assess the true contribution of infection, faulty operative technique and mechanical factors to the failures of internal fixation. Such a critical assessment of these probably more important factors is at present bedevilled by uncertainty as to the purely physical condition of the materials as supplied to the surgeon.

1. Measurements have been made of the relative calcification of different types of bone in tibia of the rabbit at the ages of six weeks, three and a half months and seven months by comparing their absorption of x-rays.

2. Calcified cartilage is between 8 and 10 per cet more highly calcified than periosteal and endosteal bone and about 20 per cent more highly calcified than bone formed immediately adjacent to cartilage.

3. Young and adult bones have a framework of approximately the same strength; that is, calcified cartilage, bone adjacent to cartilage and the interstitial areas of periosteal and endosteal bone have each approximately the same degree of calcification at all ages.

4. Adult rabbit bone approaches uniform calcification throughout, equal to the calcification of the interstitial areas of periosteal and endosteal bone. Evidence for this is the replacement of the lowly calcified epiphysial bone by osteones of higher calcification.