We made a randomised prospective comparison of the Dynamic Hip Screw and the Gamma locking nail for the internal fixation of 200 petrochanteric femoral fractures in elderly patients. There was less intraoperative blood loss and a lower rate of wound complications in the patients treated by the Gamma nail. They had, however, a high incidence of femoral shaft fracture which we relate in part to implant design. We do not recommend the use of the Gamma nail for these fractures.

We present a prospective randomized trial of two groups of 50 patients each having complete zone 5 and 6 extensor tendon injuries. These were rehabilitated by the use of either a dynamic outrigger splint or a palmar blocking splint. The results were analysed using the Miller and TAM assessments. Good and excellent results were achieved in 95 and 98% of cases following dynamic outrigger mobilization and 93 and 95% of cases using palmar blocking splint mobilization, using the Miller and TAM assessments respectively. There was no statistical difference in the results obtained between the two groups. Therefore, we prefer the latter technique which is simple, cheap, more convenient and requires less therapy time.

We reviewed 41 patients over the age of 65 years (mean 76.5) who had suffered cervical spine injuries, 12 of them with neurological deficit. Eleven patients died during treatment, mostly from respiratory disease. Seven patients were treated by surgical stabilisation, five by halo traction, and the rest by rigid collars or halo-vests. The cervical injury was missed at the first examination in four patients. We conclude that most injuries can be treated by a rigid collar, and that the use ofa halo-vest or surgical stabilisation are effective alternatives. Bed rest and traction are poorly tolerated by old people. There should be a high index of suspicion that any elderly patient who presents with a history of a fall or minor trauma may have a cervical spine injury. J BoneJoint Surg [Br] 1994; 76-B:877--81.

The aim of this study was to assess the diagnostic value of combining single photon emission computerised tomography (SPECT) with reverse gantry computerised tomography (rg-CT) in the investigation of spondylolysis. Patient characteristics and imaging results in 118 patients, aged 8-44 years, with low back pain (LBP) were analysed. SPECT showed increased scintigraphic uptake in 80 patients, and spondylolysis was identified on rg-CT in 53. The Cohen Kappa ratio of 0.362 (95% CI: 0.198-0.526) suggests only fair agreement for the result of increased scintigraphic activity with the finding of spondylolysis on rg-CT. We conclude that these investigations give mutually exclusive information, which leads to four diagnostic categories. When there was increased scintigraphic activity on SPECT, 58.8% (95% CI: 48.0-69.5%) of patients had spondylolysis on rg-CT. With rest from provoking activities, these lesions may heal. We interpret the findings of increased scintigraphic activity, but no spondylolysis demonstrated on rg-CT as indicating a bone stress response. These also require rest from provoking activity to prevent a stress fracture developing. In this study, 84.2% (95% CI: 72.67-95.8%) of those patients without increased activity on SPECT had no spondylolysis identified on rg-CT. These patients may need further investigations such as magnetic resonance imaging (MRI) to diagnose pathology, which typically does not involve the posterior elements--but rest from sport may not be so important. There were five patients in our study, without increased scintigraphic activity, but in whom bilateral chronic-appearing (wide separation, smooth sclerotic bone margins) spondylolyses were identified at L5. These all were anticipated from previous plain radiographs or MRI. This group will almost certainly not heal, and if the spondylolyses are the cause of pain these vertebrae will need stabilisation by surgery if physiotherapy fails.

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