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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
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
1. The findings in this series of fractures of the shaft of the femur treated by intramedullary nailing confirm the observation of Smith (1959) that the incidence of non-union is significantly diminished when operative intervention is postponed more than one week from the time of the injury.
2. The series is too small to afford conclusive proof, and it offers no explanation of the opposite findings of Smith and Sage (1957), but it indicates that this very important aspect of the operative treatment of fractures ought to be submitted to thorough investigation by many more observers.
The use of a subcortical graft of autogenous iliac bone in patients with delayed union or non-union of fractured tibiae is described together with the results in twenty-nine patients. This procedure when performed early even in the presence of mild sepsis makes it possible to shorten the time of healing without any undue risk.
1. A series of fractures of the forearm has been treated by exceptionally rigid internal fixation with a special plate and screws.
2. The plate and screws are described.
3. The results of rigid fixation are found to be: i) reliability of union, and ii) good final function.
4. The lessons learned regarding the application of the plate and the after-treatment of the forearms are recounted.
1. Avascular necrosis of the bony epiphysis or necrosis of the articular cartilage of the hip joint–without bony necrosis–can occur after a slipped upper femoral epiphysis.
2. In avascular necrosis of the bony epiphysis the prognosis depends upon the degree of revascularisation that occurs and upon survival of the articular cartilage. The articular cartilage can survive and a good functioning hip result especially if aided by mobilisation without weight bearing.
3. The prognosis after necrosis of the articular cartilage is poor. This complication occurs more often when conservative treatment is used.
4. A certain number of hips will show poor results no matter what treatment is used.
5. Nutrition of the articular cartilage is probably by the synovial fluid.
6. Strong traction may damage the soft-tissue structure of the hip joint.
7. It is not advisable to perform an osteotomy soon after a slip of the epiphysis. It is better to wait until good function is assured in the joint.
1. The widespread deformities commonly associated with diaphysial aclasis have been studied in seventy-six patients. Apart from the adaptations of growth due to pressure by neighbouring exostoses, all the deformities of the tubular bones can be explained in terms of the same underlying factor–diminished length of the bones affected by the disease.
2. When the condition first manifests itself the future pattern of bone growth is completely unpredictable except in so far as it is known that the more actively growing ends of the long bones are the more severely affected in each case. It has also been shown in this series that, in general, the bones with the smallest cross-sectional area at the epiphysial plates (such as the ulna and the fibula) are the most severely shortened of all.
3. The cause of this disturbance of growth is still unknown, but there is an undoubted relationship between the presence of exostoses or thickening of the metaphysial region and shortening of the bone involved.
4. The phenomena of migrating exostoses and disappearing exostoses are also described and are shown to be examples of the normal process of bone modelling applied in special circumstances.
5. Although the importance of the cartilage-capped exostoses is not underestimated, it is hoped that this study will stimulate further work on what is probably the basic defect in this disease–namely, the disturbance of bone growth.
1. The tibialis posterior tendon was transferred in twenty-eight congenital club feet to maintain the correction obtained by serial wedge plasters.
2. There has been no relapse in twenty-seven of the twenty-eight feet in the period under review–namely, one to three years from operation.
3. The technique of the operation is described.
4. It appears that this operation should not be attempted when a soft-tissue correction has been done previously.
1. An operation which can correct congenital club foot deformity in older children is described.
2. The operation is based on the assumption that the essential element in a complex tarsal deformity is a displacement of the navicular bone on the talus and that all other elements of the deformity are secondary and adaptive.
3. The results of the operation are noted and the implications of some of its effects are discussed.
1. The radiographic appearances are no guide to prognosis or treatment of peroneal spastic flat foot.
2. Only 10 per cent of peroneal spastic flat feet are likely to cause severe persistent disability.
3. Severe symptomatic tarsal arthritis is exceptional in this condition.
1. Anterior segment injuries are shown to be more dangerous than lateral segment injuries, and an explanation for this is offered.
2. A common pattern in anterior segment injuries is described.
3. When this pattern is present the application of a plate to the sternum is a useful procedure.
4. Six cases are quoted in which the application of a plate to the sternum was effective.
5. A plate has been designed for the purpose.
1. The results are presented of upper tibial osteotomy carried out in ten patients for osteoarthritis of the knee associated with lateral deformity.
2. The operation is indicated when there is severe pain, valgus or varus deformity, and a range of flexion of at least 90 degrees.
3. In every case pain has been relieved, and recovery of movement after operation has been easy.
1. Chondromalacia of the patella starts most frequently on the medial facet.
2. The anatomy of the medial femoral condyle is described, including the rim at its superior border, and the different arrangement at the upper border of the lateral femoral condyle.
3. Rubbing of the medial patellar facet on the rim at the upper border of the medial femoral condyle can explain in part the etiology of chondromalacia.
1. The clinical, radiological and pathological features in seven cases of subchondral bone cyst are described.
2. Various hypotheses on the etiology of the lesion are discussed.
3. Although the hypothesis of vascular disturbance is thought to be the most attractive one, it is concluded that study of material from much earlier lesions than that hitherto available is essential if any justifiable theory is to be propounded.
1. A case of solitary plasmocytoma of bone with survival for twenty-two years after amputation is described.
2. Recent follow-up of a previous tumour reported from this department by Stewart and Taylor in 1932 has shown survival for thirty-five years after amputation.
3. These two instances of long survival, together with three culled from the literature, substantiate the hitherto doubted concept of a true solitary plasmocytoma of bone.
1. Five cases of locked metacarpo-phalangeal joint are described.
2. The anatomy of this joint is described and its bearing on the mechanism of locking discussed.
3. A method of treatment is suggested.
1. Three cases of ganglion of the lateral popliteal nerve are reported, all of which were treated by resection of the nerve.
2. In none was a connection between the ganglion and the superior tibio-fibular joint seen.
3. A careful histological study suggests that the condition is one of simple ganglion arising in the supporting tissues of the nerve.
4. A search of the literature has revealed twelve reported cases. The clinical and operative findings, together with the results of treatment, have been reviewed.
5. The treatment of choice is dissection of the ganglion from the nerve. If this proves difficult because of the multiplicity of cysts, incision and evacuation of cyst contents should be performed, although recurrence is possible after this procedure.
6. The prognosis for recovery of function is good when paralysis has been present for less than one year. Recovery of motor function is unlikely to be complete if there has been a longer duration of paralysis, though sensory recovery is usually good.
1. Eight cases of intraneural ganglion of the lateral popliteal nerve seen at operation within a period of six years are described.
2. In seven of these a pedicle was found arising from the superior tibio-fibular joint–it was probably present in the remaining case.
3. The essential step at operation is to find and extirpate the pedicle.
4. The implications of these findings are discussed.
1. A method of recording changes in bone blood-flow using a heated thermocouple is described.
2. Occlusion of the femoral artery or aorta decreases the blood-flow in the femoral metaphysis.
3. Occlusion of the femoral vein and intravenous injection of adrenaline, nor-adrenaline, acetylcholine, histamine or hexamethonium bromide increase the blood-flow in the femoral metaphysis.
From this work it may be concluded that persistent compression affects the growth plate by interference with the blood flow on one or both sides of the growth cartilage.
Despite exertion of the same pressure upon both sides of the growth plate, only the metaphysial side was readily affected in the early stages, for, as long as no damage was caused to the epiphysial side of the growth cartilage, the lesions were fully reversible.
Interference with growth was directly proportionate to the damage caused by compression to the epiphysial side of the growth plate and, in general, to the duration of compression.
The first signs of interference with the metaphysial side of the plate were the lack of vascular progression and concomitant retardation of calcification.
When severe degeneration was not present the growth cartilage recovered within four days.
The matrix was ready for calcification all the time, as shown by the extremely rapid calcification occurring soon after the compression had ceased and the vessels were able to reach their proper place.
It seems justified to believe that the first hypertrophic cell not to be calcified after removal of the clamp is the one around which the matrix has not yet changed sufficiently to have an affinity for the apatite crystals. As in moderate compression, the division of the proliferative cells continues and it seems it must be the age, or even more likely the distance from the transudate coming from the epiphysial side of the growth cartilage that conditions the maturity of the cell, which prepares the field for calcification and thus initiates the osteogenic process.
Views similar to this have been advanced by Ham (1957) and his school.
1. An immunological examination of the sera of thirty rabbits which had received primary and secondary homografts of cancellous bone into a subcutaneous site did not reveal the presence of circulating precipitins, haemagglutinins or passive haemagglutinins. These findings are consistent with the observations of Bonfiglio and his colleagues (1955).
2. Electrophoretic examination of the serum of four rabbits receiving primary and secondary homografts of bone into an intramuscular site did not reveal any change in the serum protein fractions.
3. A search for auto-antibodies produced by primary and secondary autografts of cancellous bone was unsuccessful in fifteen rabbits.
4. The multiple injections of saline extracts of bone into four rabbits did not evoke the production of demonstrable circulating antibodies, results which are in accord with the findings of Bonfiglio and colleagues (1955) and Curtiss and colleagues (1959).
5. For the first time the production of classical antibodies in response to injections of extracts of heterologous bone has been recorded. The repeated injections of a saline extract of rabbit bone intraperitoneally into ten mice produced demonstrable precipitins and passive haemagglutinins both to protein and polysaccharide fractions present in the bone extracts.
6. Knowledge concerning the production of humoral antibodies to transplants and extracts of bone has been reviewed.
1. The effects of the insertion of pieces of fresh cancellous bone into the subcutaneous tissues of the ear upon lymph nodes and spleens have been investigated in seventy rabbits.
2. The main immunological response is found to occur in the first regional nodes draining the sites of insertion of homografts of bone, which show a considerable increase in weight compared with nodes draining autografts of bone.
3. An increased number of large and medium lymphoid cells occurs principally in the first regional node of the homografted animals, as Scothorne and McGregor (1955) observed using skin as the homografted tissue.
4. The large and medium lymphoid cell response is found in both the cortex and the medulla of the lymph nodes. In the cortex a sectoral distribution of the cellular response is observed and the name reactive cortex is given to these sectors. Evidence is presented to show that the sectoral pattern of reactivity is probably determined by the localised entry into the node of iso-antigens through lymphatic vessels draining the bed of the graft.
5. We have made a quantitative analysis of the large and medium lymphoid cell response in the reactive parts of the diffuse lymphoid tissue of the cortex. The mean maximal large and medium lymphoid cell response occurs five days after the insertion of bone homografts.
6. The origin and fate of the large and medium lymphoid cells and their role in the production of antibodies is reviewed in the light of recent work.
7. A correlation is made between the maximal production of large and medium lymphoid cells in the first regional lymph node, the invasion of the graft bed with small lymphocytes and the inhibition of new bone formation in the homografts.
