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1. Four cases of true congenital vertical talus are described; in three of the four cases there were other major deformities of the skeleton. All were treated by open operation; the operation sacrificed part of the substance of the navicular bone, which was placed between the forepart of the calcaneus and the head of the talus.
2. The results five to ten years after operation show that stable reduction was maintained without any further treatment. They suggest, however, that more of the navicular bone could have been removed or that the whole navicular might be excised, at least in the more severe deformities.
3. Congenital vertical talus resembles club foot (equino-cavo-varus) in that difficulty in reduction and in maintenance of the reduction results from the tension in the medial pillar of the foot. Easing of the tension can result in recurrence of the dislocation or, alternatively, a reversal of the deformity.
1. Eleven cases of congenital flat foot were studied, five of which are illustrated.
2. Ten of these cases were treated in infancy and followed for at least three years. In two cases the follow-up period was ten years and fifteen years.
3. An essential component of the deformity is equinus of the calcaneus, and treatment consisted of correction of the forefoot deformity by repeated manipulation, followed later by elongation of the calcaneal tendon and capsulotomy of the ankle.
4. The importance of recognising the deformity and beginning treatment in infancy is stressed.
1. Eight cases of congenital vertical talus in infancy are reported. The principal differential diagnosis at this age is from talipes calcaneo-valgus.
2. The deformity is primarily a dorsal dislocation of the talo-navicular joint.
3. Closed reduction can be achieved if treatment begins at birth. Open reduction is indicated for the deformity uncorrected by the age of three months.
1. A method has been described whereby the disability of hip disease, bilateral or unilateral, can be graded, and the quality of result following arthroplasty assessed, on a scale of numerical values.
2. The grade expresses the condition of the entire patient, rather than that of the hip joint alone.
3. Certain clinical criteria and physical tests have been adopted as the bases for scoring. The calculation of the patient's total score has been weighted to emphasise mobility, and to provide a more critical measure of the success of arthroplasty. Subjective tests (aside from the patient's estimate of his pain) are avoided, to provide as objective and accurate a method of assessment as possible.
1. Eight cases of monarticular brucellar arthritis in children are described. They have been followed up from between one and six years and all are now fully active and clinically normal.
2. The history was usually short, with limp, swelling of the joint and pain as the presenting symptoms. Constitutional disturbance was slight in all cases.
3. Diagnosis was confirmed by high concurrent serum agglutinin titres which were not found in control children of the same age from the same areas. Mercaptoethanol resistant antibody (IgG) and complement fixing antibodies were also demonstrated in the sera of four cases. One child had a positive blood culture.
4. The condition responded rapidly to rest and splintage and, to date, recovery seems to have been complete.
1. A comparison of the results of sixty patients with Pott's paraplegia, half operated upon and half treated conservatively, showed that better results were achieved in a much shorter time in those treated surgically.
2. Extra-pleural antero-lateral decompression is the operation of choice in cases of Pott's paraplegia.
3. The operation should be done as soon as the general condition of the patient allows, and should not be left until the disease is quiescent.
4. The greatest improvement is found in those patients who are still ambulant.
5. Although the gain in patients with complete paraplegia may be small, relief from painful flexor spasms and the healing of bed-sores often justify surgical treatment.
6. Fusion of the vertebral bodies can be carried out at the same sitting using healthy ribs and sometimes cancellous bone, with satisfactory results.
1. The results are recorded of radical excisional surgery for spinal tuberculosis in eighty-five patients.
2. Clinically satisfactory results were obtained in 97 per cent of seventy-one patients followed up. Radiologically the disease was deemed to be cured in 71 per cent of cases.
3. The average period of rest after operation was three and a half months, and the average hospital stay was five and a half months.
4. Total recovery from paraplegia occurred in 84 per cent of patients so affected.
Early decompression in Pott's paraplegia gives encouraging results. It produces speedy recovery from paraplegia and ensures rapid healing of the lesion. Lateral extrapleural decompression without fusion for lesions of thoracic vertebrae is safe and satisfactory. It gives adequate exposure of the anterior and posterior parts of the vertebral bodies and of the theca, without endangering the stability of the spine. Age, sex and site of the lesion have no influence on the prognosis, whereas paraplegia of longer duration, paraplegia in flexion, and paraplegia presenting as a spinal cord tumour carry a bad prognosis. In early lesions there is reconstitution of vertebral bodies whereas in advanced lesions there is consolidation or bony fusion.
1. The long-term results in thirty-one cases of spinal tuberculosis treated by the ambulant method are reviewed. The method has been shown to be successful in early cases.
1. Twenty patients with congenital short tendo calcaneus are described.
2. All were treated by tendon lengthening and followed up for one and a half to seven years.
1. Tumoral calcinosis and lipocalcinoma-granulomatosis are synonymous terms for the same entity.
2. The condition justifies inclusion as an important type of calcinosis and is to be differentiated from calcinosis universalis and calcinosis circumscripta.
3. It occurs during the first or second decades, large dense nodular masses forming in the periarticular tissues at the hips, shoulders and elbows. Smaller masses may have a wider distribution.
4. It has been reported to be a metabolic disease of obscure etiology.
5. The course is benign but excision of the masses should be undertaken early to avoid operative difficulties and secondary infection.
1. A case of congenital indifference to pain in a boy aged fifteen years is described. The boy's sister was similarly affected.
2. Clinical features and treatment are described, and the features are compared with those in previously reported cases.
3. Causation is discussed in the light of the negative findings at necropsy on the patient's sister.
1. A series of 106 central slip injuries has been reviewed.
2. Although the boutonnière deformity in many cases may be no more than a cosmetic defect, this survey has shown that in some instances it can constitute a slowly progressive lesion, with considerable disability and gross deformity of a digit.
3. Conservative treatment seems to be superior to operation, at least in those patients seen within six weeks of injury. Treatment by splintage alone yielded in this series a 75 per cent success rate, whereas operation showed only 50 per cent success.
4. When a sizeable fragment of bone has been avulsed from the middle phalanx, suture of the fragment in position is indicated and gives remarkably satisfactory results.
5. Injuries with soft-tissue loss over the proximal interphalangeal joint may yield successful results after suture or plastic repair of the tendon, and wound closure by split-skin grafts or local rotation flaps.
6. Poor results tend to occur in cases complicated by phalangeal fracture or by multiple hand injuries, and it may be advisable to defer the repair of the central slip until recovery from the other injuries has been completed.
7. With gross disruption of the proximal interphalangeal joint primary arthrodesis is probably indicated.
1. In a series of seventy-one patients with wringer injuries of the hand three basic types of lesion were observed:
2. Treatment was guided by the following principles:
3. Surgical technique as applied in various typical cases is outlined.
1. The nature of paralytic deformity arising in poliomyelitis, cerebral palsy and spina bifida is considered and three types of deformity–acute contracture, postural contracture and deformity from muscle imbalance are described.
2. The place of physiotherapy, splintage and surgery in the management of these varieties of paralytic deformity is discussed and the overall results of treatment are reviewed.
1. Haemorrhage into the fascial compartment which contains the iliacus muscle and the femoral nerve is a common complication of haemophilia.
2. The iliacus haematoma syndrome is described and illustrated from the authors' study of thirty episodes occurring in twenty-four patients.
3. The anatomy of the iliopsoas fascia is described and the mechanism of femoral nerve compression explained.
4. Differential diagnosis, prognosis and treatment are discussed and the necropsy findings in one patient are presented.
5. An instance of iliacus haematoma occurring as a complication of anticoagulant therapy is recorded.
1. Two cases are described in which increased density of the lower femoral epiphysis was due to sarcoma.
2. In one of these, multiple sarcomata were present.
There is some radiological, clinical and histological evidence to show that a fibular graft inserted into the forearm may continue to grow.
Three cases are described of elbow injuries in infants, to illustrate the difficulty of differentiating a dislocation from a supracondylar fracture.
1. Telemetering electromyography has been used to investigate the pattern of activity of certain muscles of the lower limb and back while the subjects walked up and down stairs.
2. During walking up and down stairs each limb has a supporting and swinging phase in each complete step.
3. Walking up stairs revealed the following facts. Firstly, raising the body on to the stair above is brought about by the contraction of the soleus, quadriceps femoris, hamstrings and gluteus maximus; the gluteus medius at the same time prevents the body falling on to the unsupported side. Secondly, the tibialis anterior dorsiflexes the foot during the swinging phase and helps the limb to clear the stair on which the supporting limb is placed. Thirdly, the hamstrings flex the leg at the knee in the early part of the swinging phase and control the terminal part of extension at the knee at the end of this phase. Fourthly, both erectores spinae contract twice in each step and control the forward bending of the body at the vertebral column.
4. Walking down stairs revealed the following. Firstly, the body is lowered on to the stair below by the controlled lengthening of the soleus and quadriceps femoris; the gluteus medius at the same time prevents the body from falling on to the unsupported side. Secondly, the tibialis anterior inverts the foot at the beginning of the supporting phase as the toe is placed on the stair below and dorsiflexes the foot in the middle of the swinging phase. Thirdly, the hamstrings control the extension of the leg at the knee during the middle of the swinging phase. Fourthly, both erectores spinae contract twice in each step and prevent forward bending of the trunk at the vertebral column.
1. A detailed study of density variations with age in cortical bone samples from different areas of the femoral diaphysis has been carried out.
2. Bone of relatively high density and, conversely, of low density was found to have a spiral pattern along the bone shaft.
3. Moving distally along the femoral shaft there was a transposition of the greatest density from the anterior to the posterior aspect.
4. In the erect body posture the femoral inclination is such that areas of denser bone might be expected to be aligned vertically because of the weight-bearing characteristics of the femur.
5. Most areas of the cortex tended to decrease in density after the age of fifty, the less dense areas changing more than those with an initial high density. Thus, osteoporosis tended not only to maintain but to accentuate the spiral pattern of density distribution by increasing the difference between dense and less dense bone.
6. In the distal region of the diaphysis bone resorption was greatest anteriorly but hardly affected the posterior aspect. A densitometric comparison between these two sites provided a clear indication of the effect of osteoporosis.
