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Volume 56-B, Issue 3 August 1974

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Cedric Prys-Roberts
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THE FAT EMBOLISM SYNDROME Pages 408 - 416
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Alan R. Gurd R. I. Wilson
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1. A distinction must be made between the fat embolism syndrome, a clinical entity, and fat embolism demonstrated pathologically, which may be found after death following fracture with no prior evidence of the syndrome.

2. One hundred cases of the syndrome encountered over a period of four years have been studied in detail and the diagnostic criteria have been defined. These include one major feature, four minor features and fat macroglobulaemia.

3. Sixteen of the patients died–eight from severe pulmonary insufficiency of the syndrome, eight from other traumatic causes.

4. The prevention of shock is the best measure for prevention of the syndrome. The role of proteases in the production of shock and the place of protease inhibition in treatment of the syndrome are briefly discussed.

5. For the established case the aim of treatment is to ensure an adequate pressure of arterial oxygen.


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W. J. Nolte T. Olofsson T. Scherstén D. H. Lewis
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1. Blood from forty-one healthy volunteers, seventy-one patients with fractures but without symptoms of fat embolism and seven patients with clinical evidence of fat embolism was examined microscopically for fat droplets and chemically for triglycerides.

2. Fat droplets, after Millipore filtration of the blood, were seen evenly distributed in all three groups.

3. There was no significant difference in triglyceride concentration between serum and filtrate in the three groups.

4. The results do not support the thesis that the Gurd test is a reliable aid in the diagnosis of fat embolism.


A. M. Rennie D. Ogston R. J. Cooke A. S. Douglas
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The changes in a number of haemostatic factors after fractures of the tibia or femur were compared with those observed in patients with fat embolism complicating such fractures. After fractures uncomplicated by fat embolism there was a rise in the fibrinogen, α1-antitrypsin and serum activation inhibitor. The plasminogen level and platelet count initially fell, but later increased to above the initial levels. Patients whose fractures were complicated by fat embolism had the same pattern of changes but quantitatively greater.


B. B. Porter C. Richardson K. Vainio
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1. One hundred and twenty-three patients with rheumatoid arthritis who had synovectomy and excision of the head of the radius performed on 154 elbows have been reviewed one to six years after operation.

2. The severity of the disease process at the time of operation was graded radiologically and an attempt made to relate this to the results.

3. Overall, the clinical results were most satisfactory; more than 70 per cent of the patients were pleased with the outcome. When radiographic deterioration of the joint was taken into account, however, only 54 per cent achieved a "satisfactory" result.

4. Clearance of the synovium through combined medial and lateral incisions gave better results than a lateral approach alone.

5. When the disease was far advanced by the time of operation any good results were likely to be short-lived.

6. The indications for synovectomy of the rheumatoid elbow are discussed in the light of these findings.


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B. McKibbin Z. Ráliš
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1. The findings in a femoral head obtained at necropsy on a boy aged nine suffering from Perthes' disease are described.

2. The findings revealed that there had been avascular necrosis of the epiphysis followed by revascularisation and healing, and there was evidence to suggest a second episode of infarction.

3. The findings provide strong support for the suggestion that Perthes' disease is the result not of one but of more than one episode of major infarction.


I. Suramo J. Puranen E. Heikkinen P. Vuorinen
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1. Intra-osseous venographs have been obtained in twenty-eight hips affected by Perthes disease and in twenty normal hips after the injection of opaque medium into the femoral neck.

2. In the normal hips the contrast medium drained rapidly into the local veins; none flowed distally into the diaphysis.

3. In the initial and in the fragmentation stages of Perthes' disease some contrast medium always flowed into the diaphysis and the flow into the local veins was greatly reduced.

4. In the restitution stage the venographs approached normal.

5. The implications of these findings are discussed.


S. L. Weissman
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1. A case of osteochondritis dissecans of the hip in a young girl who at the age of one and a half years underwent open reduction of congenital dislocation of the hip, is reported.

2. The possible relationship between this condition and the osteochondritic changes which followed the reduction is discussed.


W. J. W. Sharrard J. Webb
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1 . The indications, technique and results of supra-malleolar wedge osteotomy of the tibia in the management of valgus or varus deformity of the ankle in children with myelomeningocele are described.

2. This operation should not be performed until as much correction as possible has been obtained by soft-tissue release and muscle balance has been restored by tendon transfer.

3. In sixteen feet satisfactory correction was obtained and maintained in fourteen, one of which had required revision for over-correction.

4. A closing-wedge osteotomy is recommended ; the two failures occurred after opening-wedge osteotomies.

5. In the fourteen feet with satisfactory correction the complications were negligible, deformity has not recurred and epiphysial growth has been well sustained.


Danilo Goncalves
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Dysfunction of the distal radio-ulnar joint caused by traumatic, congenital and inflammatory onditions is usually treated by excision of the head of the ulna. This operation can induce ulnar carpal shift, with complications such as instability with poor grip, pain and clumsiness of the wrist, if the lower articular surface of the radius is normally inclined, or overinclined towards the ulna.

These complications can be avoided by use of an operation producing pseudarthrosis of the distal part of the ulna, with fusion of the radio-ulnar joint (Lauenstein) if there is dislocation, radio-ulnar discrepancy or arthritis, or without fusion (Baldwin) if the joint, in spite of keeping normal articular surfaces, has its movement blocked by malunion of a radial fracture.


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Robert M. Pringle Keith Protheroe Sadhan K. Mukherjee
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1. Four cases of sural nerve entrapment lesions in the ankle and foot are reported.

2. All the patients gained complete relief of symptoms following neurolysis.

3. The presence of a ganglion in relation to the sural nerve in the ankle and foot is a helpful sign in the diagnosis of this condition.


J. E. M. Smith
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1. The results of internal fixation are described in 470 tibial shaft fractures.

2. The immediate internal fixation of compound fractures was followed by so high an incidence of serious complications that the use of this method is not recommended. The immediate internal fixation of fresh closed fractures was also followed by many complications.

3. Delayed rigid internal fixation proved satisfactory for difficult fractures in which an acceptable reduction could not be obtained by closed means ; skeletal traction was of value in such fractures until the skin was soundly healed.

4. Delayed internal fixation reduced both the healing time and the complications.


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J. J. Rombouts C. Rombouts-Lindemans
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1. Eleven patients with juvenile rheumatoid arthritis, most of them young adults at a terminal stage, were found to have structural scoliosis with curves measuring between 20 and 80 degrees.

2. The common feature was severe and protracted rheumatoid disease.

3. The characteristics of the spinal curves are analysed; the longer curves may have been caused by muscle imbalance and the shorter curves possibly by asymmetrical involvement of the inter-apophyseal joints.

4. It is suggested that juvenile rheumatoid arthritis is an unusual etiological factor of scoliosis.


R. J. Crisfield
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Four cases are presented of a syndrome of progressive external ophthalmoplegia and scoliosis occurring within one family. These patients were extensively investigated but no biochemical abnormality was detected.


J. V. Fowles M. T. Kassab
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Displaced extension supracondylar fractures of the elbow 1. One hundred and ten children were treated by reduction and stabilisation by two pins inserted laterally at an angle of 30 degrees to one another.

2. The complications before and after treatment included fifteen nerve lesions in thirteen patients. The ulnar nerve was involved on one occasion only. Solitary radial nerve injuries occurred with postero-medial displacement of the distal fragment, while median nerve and brachial artery injuries were associated with postero-lateral displacement. All the lesions recovered spontaneously.

3. There were no ischaemic complications after treatment, despite the ligation of one ruptured brachial artery.

4. The average stay in hospital was four days, compared with twenty days for thirty-two other patients treated in traction because of gross oedema.

5. Of eighty patients seen six months to five years after the fracture, seventy (or 87·5 per cent) had excellent or good results, seven patients with marked varus deformities had fair results, and two patients had poor results with very stiff elbows.

Displaced flexion fractures 1. The clinical features, complications and treatment of seventeen cases are described.

2. There were no complications involving the median or radial nerves or the brachial artery, but three patients had a lesion of the ulnar nerve.

3. Nine children had closed reduction and fixation by two lateral percutaneous pins.

4. Reduction was difficult and the results poor compared with extension fractures. Closed reduction failed in one-third of the children, and the functional and cosmetic results were unsatisfactory in over half the patients reviewed.


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J. J. Wiley John Pegington J. P. Horwich
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1. Isolated dislocation of the radius at the elbow occurs most commonly as a pronation injury, associated with slight elbow flexion and a varus strain. Disruption of the radio-ulnar articulation occurs primarily because of tearing of the annular ligament, which is the most important reinforcing structure of this joint. The tensing of the interosseous membrane through neutral into supination, and consequently the approximation of the radius to ulna, supports the recognised supination manoeuvre to reduce such an injury.

2. It is suggested that this injury may be more common than previously appreciated. It may be not diagnosed, it may be over-diagnosed as total dislocation of the elbow, or it may be belatedly diagnosed as a congenital dislocation of the radial head.


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A. J. Miller
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1. A method of treatment of posterior malleolar fracture is described which restores the proximal surface of the ankle joint to its normal position.

2. Reduction is achieved with a special clamp and the position held with a strong plate. Early ankle movements may therefore be encouraged without fear of redisplacing the fracture.

3. Perfect reduction is necessary to avoid the later onset of arthritis, and this was achieved in five of six patients reported.


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M. Aufdermaur
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In the necropsy material presented there were, among 100 spinal injuries occurring during the past eight years, twelve in juveniles up to eighteen years of age. In all cases, the growth zone of the cartilaginous end-plate of the spine was fractured. The special histological architecture of the growth zones with their loosened fibrous lamellae might play a decisive role in the localisation of the lesions. The clinical importance of this type of injury and the radiological findings are discussed.


M. A. Leonard
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1. A clinical and radiological survey has been made of the families of thirty-one patients with peroneal spastic flat foot and tarsal coalition (twenty-seven calcaneo-navicular, four talo-calcaneal).

2. Thirty-nine per cent of ninety-eight first degree relatives were found to have some type of tarsal coalition.

3. A surprise finding was that not one of the first degree relatives had ever had symptoms referred to the tarsus.

4. No case of "ball and socket" ankle joint or of carpal coalition was found in this series.


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Michael S. Watson
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1. Thirty-eight patients with sixty-two forefoot arthroplasties have been followed up from two to thirteen years after the operation. Eleven were free of pain, thirty-eight had some pain but were improved, and the rest were worse.

2. Patients over the age of fifty or with rheumatoid arthritis did best.

3. Kirschner wire fixation of the great toe often caused late painful stiffness of the metatarsophalangeal joint.

4. Previous interphalangeal fusion of a lesser toe was often the cause of metatarso-phalangeal dislocation of that toe and callous formation.

5. Arthrodesis of the metatarso-phalangeal joint of the great toe gave a high proportion of painless feet, apparently because it prevented both painful stiffness at that joint and dislocation of the same joint of the lesser toes.


Sven-Erik Larsson Ronny Lorentzon
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1. The incidence of osteogenic sarcoma, chondrosarcoma and Ewing's sarcoma in relation to age, sex and site is analysed in a study of 832 malignant primary bone tumours diagnosed in Sweden in 1958-68. The results are compared with those in other series.

2. The adolescent incidence peak for osteogenic sarcoma is caused by tumours localised to the long bones of the lower limb. The peak incidence occurs at a mean age of twelve years for girls and sixteen years for boys and is associated with the maximum growth velocity for the adolescent growth spurt.

3. Ewing's sarcoma, showing no sex difference with regard to its incidence peak, seems not to be associated with bone growth.

4. In the adult, the incidence of osteogenic sarcoma parallels that of chondrosarcoma, thus showing a successive increase with increasing age. In Sweden, where Paget's disease is uncommon, the incidence of osteogenic sarcoma over the age of thirty is only one-third of that during adolescence.

5. In osteogenic sarcoma and chondrosarcoma but not in Ewing's sarcoma, the characteristic predominance of males over females is valid only for localisations to the long bones of the lower limb, the pelvis and the spinal column and not for other sites. Internal factors such as age, sex, bone growth and maturation and also weight-bearing seems to be of importance in modifying the response of the tissue to a causative external factor, like a common virus.


R. E. Page
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1. An enterogenous cyst lying in the cauda equina opposite the third lumbar vertebra, and associated with spina bifida occulta of the fifth lumbar vertebra and spondylolisthesis of the fifth lumbar on the first sacral vertebra, is described in a man aged thirty-five suffering from chronic low back pain and sciatica.

2. Current embryological theories concerning the formation of intraspinal enterogenous cysts from primitive gut cells are further substantiated by the features of this case.


THE LAMINECTOMY MEMBRANE Pages 545 - 550
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Henry LaRocca Ian Macnab
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1 . Standard lumbar laminectomy was performed at multiple levels in thirty dogs, and manipulations were carried out in the spinal canal to observe their effects on periradicular adhesion formation. The canal was scarified, packed with Gelfoam, or treated with three varieties of Silastic membranes. The results were serially assessed from three days to twelve weeks by gross observation, nerve conduction studies, histological examination of transverse sections of the spine, myelin study of lumbar roots and micropaque study of the arterial supply to the roots.

2. The results were consistent biologically. The principal source of scar is dorsally in the fibrous tissue elements of the erector spinae muscle mass. This scar, the laminectomy membrane, covers the laminectomy defect and extends into the canal bilaterally to adhere to the dura and nerve roots.

3. Gelfoam does not contribute to scar formation, but instead acts as an effective interposing membrane. Silastic membranes are capable of providing protection against nerve root adhesions without interfering with the anatomical or physiological integrity of the nerves.

4. Certain clinical implications of the study are discussed.


S. M. Tuli Carl T. Brighton Harry E. Morton Larry W. Clark
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1. Chronic tuberculous osseous lesions were induced consistently in eight- to ten-week-old unvaccinated guinea-pigs by the insertion of Gelfoam impregnated with mycobacterium tuberculosis into the metaphysial region through a drill hole in the distal part of the femur. Typical tuberculous lesions developed by three weeks and many of them were followed for twelve weeks or more.

2. This experimental model establishes a reliable method of producing a localised lesion at a predetermined site without early death of the animal. The model is sufficiently similar to the human lesion, and may offer a reliable system for further investigations.

3. It was observed that streptomycin penetrates readily into tuberculous osseous lesions. The concentration of streptomycin found in the tuberculous lesion after a single intramuscular injection was much higher than the concentration considered sufficient to have an inhibitory effect on the human type of mycobacterium tuberculosis.


BRYAN TOBYN KEON-COHEN Pages 560 - 561
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W. E. S. J. C.
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ABDEL HAY EL-SHARKAWY Pages 561 - 561
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K. Z.
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W. J. W. Sharrard
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Karl Nissen
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R. O. Murray
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Scoliosis and Kyphosis Pages 595 - 596
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Robert Roaf
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B. McKibbin
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P. H. Newman
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R. I. Wilsonb
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Pseudarthrosen Pages 597 - 597
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J. G. Bonnin
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J. Hambury
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A. H. C. Ratliff
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Martin Birnstingl
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A. Graham Apley
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