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1. The posture of deformed finger joints in rheumatoid arthritis needs close analysis in terms of disturbed muscle balance. Although disorganisation of the joint itself may be the primary factor in the development of deformity, the deformity is often secondary to an extrinsic disturbance of muscle balance.
2. The part played by tendon ruptures in producing such imbalance is discussed.
1. The treatment of two haemophilic patients with cystic haematoma by radical surgical excision is described.
2. Details are given of their management after operation with the successful use of animal and human antihaemophilic globulin to control bleeding.
3. The literature of cystic haematoma in haemophilia is briefly reviewed and the seriousness of this condition stressed.
1. Three cases of acute peptic ulceration are reported after cerebral fat embolism complicating skeletal injuries. In two instances death occurred after perforation of an ulcer, and in the third intestinal haemorrhage led to death.
2. Although intracranial lesions and peptic ulceration have been reported on many occasions, so far as we know cerebral fat embolism as a cause has not been previously recognised.
3. The possible pathogenesis is discussed.
At the time of publication sixty-three additional patients have been fitted with the patellar tendon bearing prosthesis. Twenty of these were new amputees, and forty-three were old amputees who had previously worn a conventional limb. Of this group, nine were considered failures. The contra-indications for fitting now include: 1) coincident knee derangement such as cruciate or collateral ligament laxity (the trauma that causes the amputation often produces knee injuries as well; in this event the side irons of the conventional prosthesis help to support the knee); 2) scars in the popliteal fossa, such as those produced by exploration of the popliteal vessels; 3) marked variation in stump size such as in rapidly growing children or obese people; and 4) labourers obliged to work on rough ground, which places additional strain on the knee.
1. The results of treatment of twenty-five disintegrated tuberculous hips by excision, arthrodesis and anti-tuberculous drugs are reported.
2. The methods used are described.
3. Sound healing and bony fusion was obtained in all but three of the twenty-five hips treated.
1. The skeletal changes in endemic fluorosis are described from an area of the Punjab where the fluorine content of water and soil is very high.
2. A detailed description of a fluorotic skeleton is given, with its various anthropometric measurements.
3. The vertebral changes demonstrated the pathogenesis of the neurological complications observed in this condition.
Thirteen patients with congenital hypoplasia of the carpal scaphoid and associated abnormalities have been described and the significance of the condition discussed.
1. A syndrome resulting from congenital lesions affecting the spinal cord and cauda equina, associated with spina bifida occulta, is described.
2. The syndrome consists of a progressive deformity of the lower limbs in children. One foot and the same leg grow less rapidly than the other. The foot develops a progressive deformity which begins as a cavo-varus and becomes a valgus one. Both lower limbs may be affected. There may be progression to sensory loss, trophic ulceration, disturbance of function of bowel and bladder and even paraplegia.
3. Methods of investigation including myelography are described.
4. Exploration of the spinal cord has been undertaken in twenty-four patients so affected. Extrinsic congenital lesions causing traction or pressure or a combination of traction and pressure on the spinal cord have been found in twenty-two of these.
5. In two-thirds of the patients some degree of improvement has followed operation.
1. A series of 328 cases of acute haematogenous osteomyelitis in children is analysed.
2. In the first group ofseventy-seven cases from 1944 to 1950 penicillin gave excellent results.
3. After 1950 the disease took on new characteristics in terms of frequency, severity and age incidence, with the appearance of a staphylococcus resistant to penicillin: 251 cases are recorded from 1951 to 1960.
4. The importance of the early assessment ofthe disease into degrees of severity is emphasised as the surgeon's guide in his form of management.
5. The value of operative decompression is discussed.
6. The frequent and dire consequences of hip joint involvement are analysed and draillage of the hip joint is described.
1. A method is described for determining the presence or absence of a circulation within the femoral head after fracture of the neck of the femur.
2. An account is given of the fate of nineteen femoral heads in patients who had sustained high femoral neck fracture and in whom these tests had been carried out.
3. A favourable prognosis as regards fracture union and viability of the head was found to be correct in twelve of fifteen patients.
4. Non-union and major collapse of the head occurred in four patients in whom a diagnosis of an anaemic head had been made.
5. The morbidity of the method is described.
6. An explanation is given why vascular assay has been carried out as a secondary procedure, and possible clinical applications are indicated.
1. The pathological anatomy of total rupture of the ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb has been studied at operation in thirty-nine patients.
2. It has been found that the ligament, when ruptured distally (the most usual type) is often displaced so that the ulnar expansion of the dorsal aponeurosis–here referred to as the adductor aponeurosis–becomes interposed between the ruptured end of the ligament and the site of its attachment on the phalanx; the ligament gets folded over to a greater or lesser extent and the ruptured end sticks out beyond the proximal edge of the adductor aponeurosis. Such displacement of the ligament with interposition of the adductor aponeurosis was found in twenty-five of the thirty-nine cases. The ligament may also be displaced without the adductor aponeurosis being interposed (with a gap between the ruptured end and the site of itsattachment on the phalanx).
3. Variations in the pathological anatomy are illustrated by more detailed descriptions of nine cases. In one of these the adductor aponeurosis had got caught between the two surfaces of the joint, and in another the adductor aponeurosis was found ruptured as well as the ulnar collateral ligament.
4. On the basis of dissection studies on forty-two fresh post-mortem specimens, a rational explanation is given of the pathological anatomy.
5. The results of the present investigation on clinical and anatomical material provide a strong argument in favour of operative treatment for total rupture of the ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb.
6. Aspects of diagnosis and operative technique are discussed.
1 . The bone changes in von Recklinghausen's disease of the nervous system are reviewed and the gross deformities that are sometimes encountered in the cervical region are illustrated.
2. A case is described in which, at necropsy, histological study of affected vertebrae revealed actual neurofibromatous erosion and infiltration.
A three-month-old girl presented with a massive abdominal tumour arising from the right lumbar region. Microscopic examination of a biopsy specimen showed a typical neuroblastoma. No treatment was given except that necessary symptomatically for paralysis caused by compression of the cauda equina. Spontaneous regression was accompanied by maturation to a small ganglioneuroma, found at necropsy examination at the age of ten years. Death was from urinary infection due to a persistent neurogenic bladder.
1. A case of acute streptococcal gangrene is discussed against the known background of the disease.
2. In management, stress is laid upon the necessity for early adequate surgery, backed by adequate supportive therapy.
1 . The extensor assembly of the fingers consists of the central tendon joined by three pairs of components:
2. The retinacular ligaments are relaxed in full extension of the proximal interphalangeal joints and are, in this position, unable to extend the distal joints fully. This is because the interphalangeal joint surfaces are eccentric.
3. The pull of the wing tendons alters the shape of the extensor expansion and transfers the pull of the long extensor tendon from the base of the middle phalanx to the base of the distal phalanx, thus enabling full extension of the distal joint to be powerfully achieved.
4. The action of the lumbrical muscle, as an extensor of the interphalangeal joint, is demonstrated by a diagram showing its site and length in the various positions of the finger, calculated from the known excursions of the tendons. This is consistent with the observations on action potentials.
5. The phalangeal tendons of the dorsal interossei have a bifid insertion,
Finally an explanation of the deformity of clawing in ulnar palsy is given.
1 . The concept of the capsular mechanism of the shoulder joint with regard to recurrent anterior dislocation of the shoulder has been defined and a survey of the literature presented.
2. An anatomical, including an embryological, investigation of shoulder joints with special reference to the structure and function of the glenoid labrum and to the variations in the arrangement of the gleno-humeral ligaments and the synovial recesses of the anterior capsular mechanism is reported. The labrum, which is generally believed to be a consistent, fibrocartilaginous structure, is shown to be a redundant portion of capsular tissue and a continuation of the capsule as it attaches to the osseous glenoid rim. The fibrocartilaginous element is confined to a small transition zone at the capsular attachment in the great majority of cases. The great variability in the arrangement of the gleno-humeral ligaments and synovial recesses is stressed, and it is shown that an anterior pouch of variable size is present when the middle gleno-humeral ligament is attached to the scapular neck and not to the labrum.
3. The basic lesions of the anterior capsular mechanism found at operation for recurrent anterior dislocation of the shoulder in twenty-five consecutive cases using a modified Bankart procedure with a standard anterior approach to the joint are reported, and the findings are correlated with the results of the anatomical investigation. In most cases the lesions were found to be of the Bankart type with or without avulsion of the periosteum of the scapular neck. In four cases, however, the soft-tissue attachment to the anterior glenoid rim was intact; in those cases a large synovial pouch was present and the middle gleno-humeral ligament was either not discernible or it arose from the scapular neck. In all cases a postero-lateral notch on the humeral head was palpable and laxity of the subscapularis could be demonstrated. When measured, the joint capacity was always greatly augmented.
4. The present work shows, from a basic standpoint, that Bankart's original idea that the recurrent state was due to the failure of healing of the fractured fibrocartilaginous glenoid labrum is no longer tenable.
5. Finally, the anomalous attachment or the insufficient development of the middle gleno-humeral ligament in certain cases of recurrent anterior shoulder dislocation is shown to provide the anatomical basis for the recurrent state in these cases; this is the weak area in the antero-inferior part of the capsule which has been described in the literature for the past hundred years. Thus we have returned to the original view of Hippocrates.
1. An experimental study of the healing mechanism in circumscribed defects in femora of albino rats of the Wistar strain is described.
2. Only the outer one-fifth of the defect is repaired by subperiosteal bony callus, the rest of the defect being repaired by endosteal callus.
3. Subperiosteal callus does not bridge the defect until endosteal callus is developed fully.
4. As peripheral callus matures the greater part of the endosteal callus is resorbed, with the exception of trabeculae attached to the margin of the defect.
5. The resorbed area in the medullary part of the defect is gradually obliterated by deposition of inner circumferential lamellae.
6. There appear to be differences between the mechanism responsible for repair of fractures of a long bone and that which heals circumscribed bone defects.
The history of surgery is to a large extent written around the record of its technical advances. A pneumatic tourniquet is a humble instrument, when compared with many of the more complicated mechanical devices in the modern operation theatre. Nevertheless, it has played a significant role in making possible the precise operations of present-day orthopaedics. Simple tool though the tourniquet may be, its application carries many potential dangers, and it should only he entrusted to skilled hands.
Professor Paul Brand draws attention to an error in the report of a meeting of the Orthopaedic Section of the Association of Surgeons of India submitted to this journal and published in our issue of May 1962. The observations then reported were not made by him but in his absence by another contributor. The particular paragraph to which Professor Brand wishes to draw attention read: "Lately he had been using a wrist flexor tendon as the motor unit for the transplant, instead of the extensor carpi ulnaris, and he felt that the flexor tendon was the better."
Professor Brand writes: "I have not been using a wrist flexor tendon as the motor unit. I used one many years ago, and found it is very definitely inferior. I have never used the extensor carpi ulnaris. I assume that the sentence should have read: ‘Lately he has been using the extensor carpi radialis longus as the motor unit for the transplant instead of the extensor carpi radialis brevis, and has taken the graft around the radial side of the forearm and through the carpal tunnel to reach the lumbrical insertions along the lumbrical canals. He found the results were better with this method.’"
We acknowledge with thanks receipt of:
Acta Chirurgica Scandinavica, and Supplements
Acta Orthopaedica Italica
Acta Ortopedica-Traumatologica Iberica
Annals of the Royal College of Surgeons of England
Archives of Surgery
Archivio dei Centri Traumatologici Ortopedici dell'Istituto Nazionale lnfortuni
Biological Abstracts
Boletin de la Sociedad de Cirugia del Uruguay
British Journal of Surgery
British Medical Bulletin
Canadian Journal of Surgery
Indian Journal of Surgery
Journal of Neurology, Neurosurgery and Psychiatry
Journal of the American Medical Association
Journal of the Royal College of Surgeons of Edinburgh
Lancet
Ortopedia e Traumatologia dell'Apparato Motore
Radiology
Revista de Ortopedia y Traumatologia
Revue de Chirurgie Orthopédique
Surgery, Gynecology and Obstetrics
Zeitschrift für Orthopädie und ihre Grenzgebiete
