1. Some of the problems of treatment of a patient with a head injury and a fractured femur are mentioned.

2. The methods of treatment and results obtained in fifty-nine such patients from the Oxford Accident Service are described.

1. The strength of the pelvic arch depends on the integrity of the anterior interpubic ligament, whose strength has been demonstrated by dissections. Once that ligament is divided the sacro-iliac ligaments offer little resistance to opening out of the pelvis.

2. The structure of the pelvis and hips is compared to an arcade formed by a central and two lateral arches. The weight of the trunk is transmitted to the lower limbs through this arcade.

3. Fractures of the pelvis are classified according to the mechanism of production. The case for anatomical reposition and internal fixation is stated, and case histories are given to illustrate the disabilities due to persistent deformity.

4. Reduction can be achieved as late as two or three weeks after injury. However, if early operation for visceral injury is necessary, there is a strong case for combining this with open reduction and fixation. In some cases the patient's general condition may preclude such procedures, but more usually the additional manipulations cause little additional operative shock and are fully justified by the subsequent increased comfort of the patient and the greater ease of nursing.

1. Absence of a thumb, whether congenital or due to injury, is a severe disability. Reconstructive surgery has much to offer.

2. Pollicisation is the most satisfactory method, being the only means of providing a thumb with normal tactile sensibility. The importance of this has often been overlooked and has been emphasised by Moberg (1958). Pollicisation offers also the best functional and aesthetic results. When applicable, the neurovascular pedicle technique of Littler is the one of choice. It is indicated in group 2 cases associated with a partly amputated finger, when this is swung on to the thumb stump, and for patients in groups 3 and 4 when the normal index finger is used. If this method is not feasible a staged pollicisation may be used instead.

3. The Gillies method of thumb lengthening has a more limited application, but it is valuable in selected cases.

4. Reconstruction by tubed pedicle and bone graft is seldom indicated and is best reserved for reconstruction in the mutilated hand when local elements are deficient.

5. Replacing a thumb by a toe should be reserved for exceptional cases.

6. Autografting the amputated thumb is feasible, and should be considered when the amputated digit has been preserved.

The results of Charnley stabilisation of the hip in forty-three patients observed for one to four and a half years are reported. The operation readily produced a bony fusion in young patients and also in some of the older ones. Fibrous ankylosis, with or without some movement in the joint, gave an excellent result. Even when a pseudarthrosis or a stress fracture occurred, the clinical result often showed a definite improvement. Only three patients did not benefit from the operation, though none of these showed any significant increase in their disability.

1. Ninety-one patients with Charnley stabilisation have been reviewed.

2. The patients' ages ranged from fifteen to seventy-eight, with an average of fifty-seven years.

3. Patients have been followed up for at least one year, the average period being almost three years.

4. Early complications included low grade pyrexia (33 per cent), femoral thrombosis (10 per cent) and pulmonary embolus (5 per cent).

5. Fifty-four per cent of patients had no backache, 36 per cent had slight and 10 per cent had troublesome backache.

6. Sound bony fusion occurred in 72 per cent, unsound union in 19 per cent and stress fracture in 9 per cent.

7. Stress fracture and unsound union occurred most frequently in those over sixty years of age.

8. In eighteen patients under fifty there was one unsound fusion and no stress fracture.

1. Nine out of ten patients who undergo McMurray osteotomy may expect lasting relief of pain. Seventy-five per cent should have a satisfactory functional result. It is rare for a patient to be made worse.

2. Osteoarthritis of the hip and ununited fracture of the femoral neck are good reasons for operation; avascular necrosis after fracture is not.

3. Internal fixation shortens the time in plaster and in hospital, and reduces the incidence of stiffness of the knee.

4. The common observation that the joint space may be increased after osteotomy is due often to the altered position of the femoral head. Occasionally there occurs a true increase in joint space, presumably indicating regeneration of articular cartilage, and an accompanying regression in the changes of osteoarthritis.

1. The results are reported of a series of operations designed to stimulate growth of the bones of the lower limb by the insertion of pegs of bone or ivory close to the epiphysial cartilage.

2. The evidence is that growth was stimulated in twelve of twenty-eight patients.

3. Growth is more likely to be stimulated if the operation is done on children between the chronological ages of six and twelve.

1. The results of excision of the trapezium for degenerative changes in the first carpometacarpal joint are given.

2. The grip is usually permanently reduced by an appreciable amount, but functional power is improved by the absence of pain.

3. The patients most commonly affected, middle-aged women, usually derive appreciable benefit.

4. Recovery after operation often takes several months.

5. Interference with the radial nerve should be preventable by modification of the incision.

Six patients with longitudinal stress fractures of the tibia and femur are described. The difficulties of diagnosis and its confirmation are emphasised.

1. Two cases are reported of the uncommon condition of simple anterior dislocation of the head of the ulna at the inferior radio-ulnar joint.

2. The literature concerning the condition and its treatment is reviewed.

3. The mechanism of the inferior radio-ulnar joint is discussed with particular reference to the function of the triangular fibrocartilage.

4. The mechanism of injury is discussed and a new idea of this mechanism is put forward.

1 . A specific mechanism of injury can produce a tear of the articular disc of the wrist without any associated bony lesion.

2. Torn discs have been found associated with Colles's fractures and with dislocation of the inferior radio-ulnar joint.

3. The injury gives rise to clear-cut symptoms and definite physical signs.

4. Operation in fourteen cases has shown five types of tear of the disc.

5. Arthrographs of the wrist are helpful in establishing the diagnosis.

6. In isolated tears removal ofthe disc relieves the symptoms and does not prejudice function.

7. If there is other joint injury, removal of the disc cannot be expected to give as satisfactory a result.

A case of calcification of articular cartilage in association with a parathyroid tumour is described. Previously reported cases of articular calcification are briefly discussed, and it is recommended that patients with articular calcification of undetermined cause should be investigated for hyperparathyroidism.

1. Forty-five cases of acute osteomyelitis have been reviewed with the object of determining the causes of relapse. The importance of an early diagnosis and prompt treatment is stressed, and the question of when to stop antibiotic drugs is discussed.

2. The provisional diagnosis was anterior poliomyelitis in seventeen out of forty-five patients; acute osteomyelitis was diagnosed in twelve only. The criteria for making an early diagnosis are discussed, including the value and limitation of blood culture.

3. The place of operation is discussed and certain conclusions are set out.

1. A case of chondromyxoid fibroma of the tibia is reported.

2. Initial removal by curettage was followed by regrowth of residual foci; these were removed by a second curettage three years later. Re-examination after a further three years shows no evidence of regrowth, and suggests that cure has been achieved.

3. Some histological features of the neoplasm are briefly described.

Three cases of ulnar dimelia, one in an adult, are described and reference is made to earlier reported cases. The etiology of the condition is discussed.

1. A case of chordoma of the thoracic spine is described.

2. Certain features of this case–notably the absence of vertebral destruction–are contrasted with those of cases previously described.

A case of chordoma affecting the first lumbar vertebra is reported, with comments on its situation, diagnosis and treatment.

In this work the role of the blood vessels surrounding the epiphysial growth plate has been studied. The nutritional dependence of the proliferative cells on the epiphysial vessels has been established whereas the metaphysial vessels were seen to take part in calcification and ossification at the metaphysis.

As it does not seem likely that the blood circulating in the two systems of vessels had a different constitution, particularly in hormones and vitamins, it seems permissible to assume that it is the characteristics, particularly in shape and number, of such vessels that make growth the orderly process it is, with the repeated birth of a cell at the top of a column and burial at the bottom end. But, despite this undeniable role of the vessels, growth depends on the ability of the cartilage cell to form a matrix which, in due course, will be avid for apatite crystals.

1. The arrangement of collagen fibres in the secondary osteones in human femora and tibiae has been examined. The fibres were observed in paraffin sections stained by Weidenreich's method.

2. Three fibre patterns have been observed. They differ from one another in the relative numbers of longitudinal and circumferential fibres which they contain, and in the degree of lamellation which they exhibit.

3. The incidence of the three fibre patterns has been correlated with the relative ages of the regions of bone in which they occur.

4. The possibility of a correlation between variations in fibre pattern and certain recent microradiographic observations is discussed.

When large daily doses of vitamin D were administered to rats endochondral growth was inhibited and bone resorption occurred; later in the process uncalcified matrix (osteoid) like that seen in rickets formed on trabecular margins. When vitamin D was given only for a short period and then discontinued, little resorption of bone was seen during the withdrawal period and wide seams of osteoid material appeared which eventually calcified in an irregular manner. When normal endochondral growth was resumed a wide transverse band of dense bone with enclosed cartilaginous cores was left in the marrow cavity. If, after a few days, a second large dose of the vitamin was given resorption again occurred and calcification of osteoid material was accelerated, the first microscopic sign being a dense, wide, granular, deeply staining line at the junction of the bone and new osteoid. After a second withdrawal period a second layer of osteoid formed; eventually another transverse band appeared in the metaphysis. If this hypervitaminosis D cycle (+4 -12) was continued rats continued to form new bone with relatively little remodelling, so that after three such cycles bones became dense and hard.

Histological study showed that little marrow cavity remained in either skull, vertebrae or epiphyses and a dense mass of bone enclosing cartilage cores filled the metaphysial part of the long bones. In addition, ankylosis ofteeth, calcification of spinal ligaments and widespread metastatic calcification were present.

When hypervitaminosis D cycles (+1 -12, +1 -21) were adjusted to produce minimal resorptive changes a wide range of bone change was observed. This varied from uniform dense metaphysial bone containing abnormal cartilage matrix arranged in longitudinal striations, dense transverse bands parallel to the epiphysial cartilage, to remnants of dense trabeculae extending into the marrow cavity.

Bone changes in osteopetrosis structurally closely resembled the induced bone changes in the rat. It is concluded that an important mechanism in the production of osteopetrosis is an accentuated rhythm of bone change like that shown experimentally to be produced in these animals. It is emphasised that these changes are but part of a range of bone disorders associated with abnormalities of cycles of resorption and deposition of bone, the type of change differing with the nature of the cycles.

1. Experimental avascular necrosis of the femoral head was produced in rabbits and the histological and radiographic changes were compared.

2. Avascular bone which was not re-ossified or altered in any way showed no change in density to x-rays.

3. Areas of avascular bone which were being repaired by the formation of appositional new bone showed an absolute increase in density in the radiographs. This is apparently due to simple increase in bulk of bone to be penetrated by the x-ray beam. On this basis, increasing density in radiographs of bone suspected of being dead is a sign of increasing re-ossification rather than of increasing necrosis.

4. Re-ossification of dead bone occurred rapidly in the absence of simultaneous resorption of necrotic trabeculae. It is thus suggested that the term "creeping substitution" is misleading and does not reflect accurately the histological findings, at least as they occur in rabbits.

1. If a vertical load is applied to the head of the femur parallel to its shaft, the upper cortex is stretched and the lower cortex is compressed. The neck breaks from the upper subcapital border to the lesser trochanter. This type of fracture is rarely found clinically.

2. If a compressive force is applied to the area between head and greater trochanter while the head is loaded vertically, a transverse fracture of clinical appearance is produced. If this axial pressure acts along the part of the neck above the central axis a subcapital comminuted fracture results. If the pressure acts below the central axis the result is a transcervical fracture.

3. Strain gauge experiments have shown that axial compression within the upper segment of the neck is produced by the abductor muscles of the hip. Adductor muscles produce a low axial compression. It is suggested that muscular action at the time of injury influences the type of fracture produced by the injury.