PATHOLOGICAL CONSIDERATIONSFRACTURES of the neck of the femur conform to the same pathological laws as fractures of any other bone. It is now recognized that even in old people there is a free supply of blood to the femoral neck. Every surgeon who has operated on recent fractures has seen the capsule of the joint filled with blood, and the old theory that bone absorption and non-union were due to the inadequate bloodsupply has been abandoned. The union of these fractures is governed by the rules of hyperaemic decalcification and ischaemic recalcification.ll When the fragments are imperfectly immobilized, the trauma of movement gives rise to continued FIG. 564.-High fracture of femoral neck after nailing operation. Antero-posterior and lateral radiographs show that the fracture has firmly united without shortening of the neck.hyperaemic decalcification. If there is no immobilization at all, this process goes on until the whole of the femoral neck has disappeared. If a plaster spica is used so that the fragments are fixed to some extent but without complete control of rotatory movement, there is a less severe degree of decalcification ; nevertheless union is delayed, and if the fracture does unite, there is shortening of the neck. On the other hand, if by operative measures absolute immobility is secured, the fracture unites firmly3 without decalcification and with minimal shortening of the bone (Fig. 564).Although the fracture is freely supplied with blood, the greater part of this supply is derived from the distal fragment. The bone absorption following hyperaemic decalcification occurs mainly, therefore, in the distal fragment, and the head 788 T H E B R I T I S H J O U R N A L O F S U R G E R Yremains practically unchanged. If the fracture is high enough to lie above all capsular attachments, the proximal fragment may be completely avascular, and in such a case there will be radiographic evidence several weeks later. The proximal fragment will retain its original density and will not participate in neighbouring decalcification1,4 (Fig. 565). The fact that a fracture of the femoral neck may reduce or even cut off the blood-supply of the proximal fragment has three important clinical applications. FIG.565.-Blood-supply after femoral neck fractures. A, The head of the femur is supplied mainly by vessels running up from the neck ; 6, A subcapital fracture may almost completely deprive the head of its blood-supply ' C If the fracture is not immobilized the vascular neck undergoes hyperzemic decalcification and absorphon.' The avascular head retains its original density and shows neither decalcification nor absorprion.I. slow Union of Subcapital Fractures.-In most fractures both the main fragments have an equally free blood-supply and both share in the development of a young connective tissue which will calcify to form callus. If one fragment is avascular, the whole of this new growth must develop from the other fragment, and union is correspondingly delayed. The urAon of high cervical and subcapital fractures of...

Summary—Fifty-two cases of exposure of the glenoid labrum are recorded. Fifty-one operations with anterior exposure, followed by capsular reefing and shortening of the subscapularis, were successful. One operation with superior exposure, and without capsular reefing or shortening of the subscapularis, was unsuccessful.

1. This is a simple clinical study of the end-results of arthrodesis of the hip joint in patients followed up and re-examined five to twenty-five years after operation. 2. The study was stimulated by our astonishment at recent reports which suggested that arthrodesis of the hip caused serious operative mortality, a high rate of wound infection, and failure of sound fusion in one of every two cases; and that even when sound fusion was gained there was always pain in the back and usually stiffness of the knee. To say that we were astonished puts it mildly. 3. This review includes 120 patients aged from ten to seventy years, treated for osteoarthritis of the hip joint by intra-articular arthrodesis with the internal fixation of a nail, usually with an iliac graft, and with immobilisation in plaster for not less than four months. 4. Of these 120 patients there was sound fusion of the joint, proved radiographically, in 94 per cent; a mortality of nil; and recovery of free movement of the knee joint to the right angle or far beyond in 91·5 per cent. Almost half of the patients regained normal movement, the heel touching the buttock. Only in eight patients was there less than right-angled flexion. 5. There was no pain in the back—none whatever—in 64 per cent of the patients. In 36 per cent there was some pain or discomfort. One alone said that the low back pain was worse than before the operation. Many others said that pain in the back had been relieved by the operation. 6. It is emphasised that these results were gained only from sound fixation of the joint in the mid-position with neutral rotation, no more abduction than is needed to correct true shortening, and no more flexion of the joint than that with which the patient lies on the table. The limb was immobilised in plaster for at least four months after operation. The stiff knee was mobilised by the patient's own exercise without passive stretching, force or manipulation. 7. Two other groups of patients are considered. There are fourteen treated by fixation of the joint with nail alone, an operation that was never intended to arthrodese the joint and which has long since been abandoned. The other small group is that of patients with old unreduced traumatic dislocation of the hip, a procedure in which the risks of operation are so great and the number of successful results so small as to dissuade us from attempting operative reduction. 8. After successful arthrodesis of the hip joint patients can return to every household activity and every recreation including ski-ing, mountaineering, rock climbing, or whatever else they want.

THE JOURNAL OF BONE AND JOINT SURGERY Lane had always believed that resorption of bone round plates or screws was a consequence of infection and he declared that "rarefying osteitis in plain English means dirty surgery." The non-touch technique he developed certainly gave him success far beyond that of others, MEDULLARY NAILING OF FRACTURES AFTER FIFTY YEARS 697 VOL. 32 B, NO. 4, NOVEMBER THE JOURNAL OF BONE AND JOINT SURGERY MEDULLARY NAILING OF FRACTURES AFTER FIFTY YEARS 699 VOL. 32 B, NO. 4, NOVEMBER 1950 THE JOURNAL OF BONE AND JOINT SURGERY MEI)ULLARY NAILING OF FRACTURES AFTER FIFTY YEARS 701 VOL. 32 B, NO. 4, NOVEMBER 1950 THE JOURNAL OF BONE AND JOINT SURGERY MEDULLARY NAILING OF FRACTURES AFTER FIFTY YEARS THE JOURNAL OF BONE AND JOINT SURGERY THE JOURNAL OF BONE AND JOINT SURGERY THE JOURNAL OF BONE AND JOINT SURGERY NAILING OF FRACTURES AFTER FIFTY YEARS THE JOURNAL OF BONE AND JOINT SURGERY MEDULLARY NAILING OF FRACTURES AFTER FIFTY YEARS NAILING OF FRACTURES AFTER FIFTY YEARS

1. Léri's pleonosteosis is characterised by broadening and deformity of the thumbs and great toes, flexion contracture of the interphalangeal joints, limited movement of other joints, and often a Mongoloid facies. Four such cases are described. 2. A review of the twenty reports in the literature, and the cases now described, shows that the deformities are due to capsular contracture rather than deformity of bone. 3. In one patient there was striking evidence of fibro-cartilaginous thickening of the anterior carpal ligaments. It is suggested that the primary pathological change in pleonosteosis may be in the joint capsules rather than in the epiphyses. 4. The patient with thickening of the anterior carpal ligaments had bilateral median palsy from carpal tunnel compression. 5. The causes of carpal tunnel compression of the median nerve are reviewed. Acute compression may be due not only to dislocation of the semilunar bone but to haemorrhage in the palm. Late compression by bone may occur twenty to fifty years after injury. Late compression without bone abnormality has been attributed to occupational stress, but it is suggested that pathological thickening of the anterior carpal ligament may be the cause. 6. The patient with pleonosteosis and bilateral median palsy had also bilateral Morton's metatarsalgia with large digital neuromata. 7. Plantar digital neuritis has already been shown to be an ischaemic nerve lesion preceded by degenerative changes in the digital artery. The significance of the fibrous tunnel through which the artery passes to reach the digital cleft is considered.