1. A course of treatment is suggested for patients with stove-in chests based on experience with seven patients, only one of whom died from his injury.

2. The literature on this subject is reviewed and it is suggested that treatment may be undertaken by an accident surgeon without recourse to intermittent positive pressure respiration inmost instances.

1. Three cases of fracture of the manubrium are described.

2. Two of these cases are very unusual in showing fracture of the manubrium caused by indirect violence.

3. The literature is reviewed and methods of treatment are discussed.

4. The mechanism of fracture of the sternum by indirect violence is discussed.

1. A case is reported of a Jamaican boy of fifteen months with typical and florid manifestations of dysplasia epiphysialis hemimelica associated with a number of atypical features not previously recorded.

2. The progress of the disorder over a limited period of two years is described and the development of the atypical features is discussed.

1. A series of twenty-three compression arthrodeses of the shoulder are reviewed.

2. The review demonstrates compression arthrodesis to be an excellent method of obtaining bony fusion of the shoulder.

3. The consistent success in achieving arthrodesis, in what is to be considered a difficult joint to fuse, is significant in the theory of compression arthrodesis, because the shoulder offers a more perfect example of compression arthrodesis than the knee in that the element of absolute fixation is less obvious.

1. Practical experience has shown that subcapital fractures of the femur unite freely if reduction is stable and fixation is secure.

2. Stable reduction is obtained when the muscular and gravitational forces tending to redisplace the fracture are opposed by equal and opposite counterforces, and inherent stability is believed to depend upon the integrity of the flared cortical buttress at the postero-inferior junction of the femoral neck and head.

3. In the stable subcapital fracture a state of equilibrium is reached when the forward and upward thrust of the fixation appliance in the femoral head is opposed by the counterthrust of the closely applied and cleanly broken fragments at the postero-inferior aspect of the fracture. When the postero-inferior cortical buttress is comminuted, inherent stability is lost, lateral rotation deformity recurs and the fixation device is avulsed from the cancellous bone of the head.

4. Stability may be restored by reduction in the "valgus" position, by various forms of osteotomy, by refashioning the fracture fragments or by a postero-inferiorly positioned bone graft. Theoretically, stability may also be obtained by a double lever system of fixation in which an obliquely placed fixation device or bone graft is combined with a horizontally disposed wire, pin, nail or screw crossing it anteriorly. Multilever fixation by three or more threaded wires or pins inserted at different angles and lying in contact at their point of crossing may likewise provide stability.

5. Fixation by two crossed screws has been chosen for clinical trial in 100 displaced subcapital fractures. Imperfect positioning of the screws in seven patients has been followed by early breakdown of reduction and non-union, but satisfactory positioning has been associated with radiological union in fifty patients who have been observed for twelve months or more.

6. Ultimate breakdown in some of these fractures is certain to follow avascular necrosis, and this complication has already been seen in a few patients treated by cross screw fixation more than two years ago. It is also expected that non-union will occur in some of those patients still under observation for less than a year. Even so, these preliminary findings indicate a percentage of union far greater than that obtained by previous methods of treatment, and, although statistically inadequate, they are presented in support of the belief that it should no longer be considered impossible to achieve the same percentage of union in subcapital fractures of the femur as we are accustomed to expect in the treatment of fractures elsewhere. It is not implied, however, that this ideal will be reached merely by the adoption of some form of double or multilever fixation, and much will continue to depend upon the quality of the radiographic services, the precision of reduction and the perfection of operative technique.

7. Every advance in our understanding of what is meant by "perfection of operative technique" lends increasing support to the ultimate truth of Watson-Jones's (1941) dictum: "A perfect result may be expected from a technically perfect operation; an imperfect result is due to imperfect technique." But the simple and foolproof method of fixation which will end the search for technical perfection in the treatment of the displaced subcapital fracture has yet to be evolved, and many questions remain to be answered about this injury. Nevertheless, it is clear that the surgeon should now be prepared to attribute early mechanical failure in the treatment of femoral neck fractures to his own shortcomings, and the temptation to blame capital ischaemia for every disaster should be resisted.

1. A review of 195 patients with displaced intracapsular fractures of the femoral neck treated by a sliding nail-plate appliance has been presented.

2. The highest failure rate was evident in fractures in women over seventy-five with Grade 4 displacement.

3. The effect of various concomitant factors has been analysed in relation to the end results.

4. Observations have been made on avascular necrosis, its incidence amongst the failures and its association with late segmental collapse after fracture union.

1. A method of internal fixation of displaced subcapital fractures of the femoral neck is described, and a consecutive series of seventy-one patients whose fractures were treated by this method is reviewed.

2. It is claimed that this method gives better mechanical fixation than a trifin nail and that the operation is less formidable than the insertion of a pin and plate.

3. It is suggested that with improved fixation the avascular head can be supported while revascularisation occurs.

1. A technique of transarticular nailing for subcapital and transcervical fractures of the neck of the femur is described.

2. Forty-four operations have been done, and twenty-one patients have been under observation for periods of from one to six years. In one of these pseudarthrosis has developed; in two others there has been delayed union.

3. The method gives sound fixation by a "squeezing effect" on the proximal fragment, which is enhanced by the locking of the adjacent articulation.

4. It is presented as an alternative to prosthetic replacement for treatment of femoral neck fracture in the aged. The nail damages the articular surface of the acetabulum but not the femoral head.

5. The importance of care after operation is stressed.

6. The advantages of the method, the role of circulatory changes in the femoral head and the mechanics of transarticular fixation are discussed.

1. Forty-five patients with monarthritis of at least six months duration have been reviewed. Arthrotomy and synovial biopsy were carried out in every case. The period of follow-up varied from two to eight years from the time of biopsy. A re-examination of the biopsy material was made at the time of clinical assessment.

2. Twelve patients (27 per cent) were diagnosed as having definite or probable rheumatoid arthritis. Four patients (9 per cent) had psoriatic arthropathy and six (13 per cent) had a persistent monarthritis of undetermined type. A further four patients (9 per cent) had polyarthritis of undetermined type, ten (22 per cent) were diagnosed as having osteoarthritis and seven (16 per cent) were completely normal (self-limiting joint disease).

3. There was a moderately good relationship between biopsy findings suggestive of rheumatoid arthritis and the eventual clinical outcome.

4. Monarthritis of the wrist was followed in every case by the development of significant disease, either rheumatoid arthritis or psoriatic arthropathy.

5. Rheumatoid arthritis may remain monarticular for many years.

6. It is concluded that thorough investigation of patients with monarthritis is of considerable help in diagnosis and prognosis.

A case of salmonella osteitis of the spine is described. It is thought to be the first case reported due to the serotype Salnionella muenchen.

1. Two cases of an unusual forefoot injury are recorded in which dislocation of the base of a metatarsal bone is associated with, and tends to perpetuate, dislocation of the metatarsophalangeal joint of the adjacent toe.

2. The anatomical and mechanical relationships between these linked dislocations are discussed, as are the principles of treatment.

3. The concept of segmental injuries to the forefoot is introduced.

1. Two cases of post-traumatic osteolysis of the outer end of the clavicle are reported.

2. The essential features of the lesion are summarised.

3. The possible medico-legal importance of the condition is mentioned.

1. Excision of the proximal row of the carpus is a useful procedure, with a limited application in patients with ununited fractures of the scaphoid, Kienböck's disease, dislocation of the lunate bone, unreduced mid-carpal dislocations and similar injuries which do not respond to conservative management.

2. It is an acceptable alternative to arthrodesis, even when the wrist is likely to be subjected to heavy use.

3. In the event of failure arthrodesis can still be carried out.

4. Advanced degenerative changes are a contra-indication but mild to moderate changes do not appear to affect the results.

1. A large proportion of fractures were poorly reduced in this series either because the method used was inadequate or because it was inexpertly applied. At first it was thought that immobilisation in plaster gave adequate fixation but it was impossible to be certain that the reduction was not sometimes lost in the interval between manipulation and the check radiograph taken immediately after plaster had been applied. This suggested that in some cases fixation might be lost early although late redisplacement was not seen.

2. The late subjective results in patients with unreduced fractures were good, but there was some loss of thumb mobility partly due to varus deformity of the metacarpal bone and partly due to incomplete compensation for generalised stiffness in and around the joint.

3. Since loss of movement caused little disability and joint involvement rarely produced symptoms due to osteoarthritis, it seems doubtful whether the use of complex methods of treatment is justifiable.

4. Women seem to be predisposed to painful symptoms at the carpo-metacarpal joint of the thumb whether they occur after fracture or in association with non-traumatic osteoarthritis of the joint.

Two cases are described of exostosis of the anterior inferior iliac spine after traumatic avulsion of the apophysis at this site by the rectus femoris muscle.

1. Two cases are reported in which reappearance of an osteochondroma after excision was shown to represent a second independent lesion and not a true recurrence.

2. The significance of this observation is discussed in relation to the pathogenesis and prognosis of this lesion.

3. A plea is made for greater discrimination in using the ominous description "recurrence," because the rare true recurrence must strongly favour a diagnosis of malignancy.

1. Two cases are reported in which there was diffuse fibro-fatty overgrowth or tumour formation involving the adipose tissue of the median nerve. In each the diagnosis was confirmed by operation and histological examination.

2. The first case is an example of the developmental abnormality usually referred to as "macrodystrophia lipomatosa." The second case should be termed fibrolipoma.

3. The literature is reviewed; no case of fibrolipoma has been recorded.

1. Three cases of fatty infiltration of the median nerve are reported.

2. One patient had symptoms of median nerve compression.

3. The intimate association of fibro-fatty tissue within the nerve precludes enucleation of the swelling.

1. Three patients are reported in whom a sudden acute internal derangement of the knee was caused by torsion of a pedunculated portion of the infrapatellar fat pad.

2. The symptoms and signs are described.

3. The pathological changes and the pathogenesis are discussed.

1. The risk of injury to the sciatic nerve during closed ischio-femoral arthrodesis by nail and graft has been assessed on the basis of clinical evidence and of anatomical studies in the living and in cadavers.

2. The margin of safety for the nerve is nearly always small.

3. The risk of injury to the nerve is prohibitive when there is marked deformity or hypoplasia of the pelvis. The risk is also increased when the buttock is compressed against the table and, because of the technical difficulties that are entailed, when the hip is in marked flexion. The risk is probably greater in children than in adults.

4. In properly selected cases in which none of these adverse factors is present it is submitted that the risk of nerve injury can be eliminated by proper attention to surgical technique and by the observance of certain definite precautions.

5. When there is doubt in the surgeon's mind about his ability to complete the operation without injuring the nerve the closed technique should be abandoned in favour of the open posterior approach.

1. The effect of immobilisation on bone formation has been investigated in the rat. As chlortetracycline has the property of being deposited preferentially in areas of newly deposited bone, its uptake can be used as a reflection of osseous formation.

2. One hind limb of albino rats was immobilised either by section of the second, third and fourth lumbar nerve trunks or by section of tendo calcaneus and ligamentum patellae. The incorporation of chlortetracycline was determined quantitatively in the femur and tibia of both hind limbs at intervals after immobilisation.

3. Tetracycline uptake is expressed in terms of bone weight, this being most important in order to obtain correct values.

4. A comparison between the tetracycline uptake and the weight of the bones gives information about the rate of bone destruction.

5. In animals immobilised by nerve section three phases can be distinguished: a first phase with diminished bone formation, a second with increased formation and increased destruction and a third phase with diminished bone formation. Both mechanisms, decreased formation and increased destruction, are therefore important in the production of immobilisation osteoporosis; their relative importance depending upon the duration of the immobilisation.

6. In animals immobilised by tendon section the mechanical function becomes restored in the second week as a result of healing: this explains the rapid compensation for the initial loss of weight of the bones accompanied by a marked increase in tetracycline uptake.

7. These results are discussed and compared with information in the literature. Variations in bone formation and destruction rates with time could explain the varied results reported by other authors.