ILIACUS A Common Complication of Haemophilia

ILIACUS
JOHN
GOODFELLOW,
From
This
but
not
paper
the
A Common
Complication
C. B.
FEARN
Nuffield
describes
exclusively,
HAEMATOMA
and
D’A.
Orthopaedic
seeks
and
J. M.
Centre
to explain
as a complication
of Haemophilia
and
the
MATTHEWS,
Oxford
Haemophilia
a clinical
syndrome
of haemophilia.
The
by Bulloch
and
Fildes
in 191 1
(Gunther
1924, 1935 ; Seddon
1953; Douglas
and McAlpine
of forty
patients
fifteen
had suffered
haemorrhage
intramuscular
We have
Department
We have
.
found
of Orthopaedic
Surgery
for
treatment
had been treated
elsewhere
results
from haemorrhage
fourteen
of the
syndrome
published
cases
since
Miller
and
Taylor
(1949)
syndrome
has usually
been
The
following
was
known
case
history
to suffer
from
is in many
Christmas
onset the pain became
worse
Two days later hypoaesthesia
of this
CASE
ways
disease
then
Lucia
1944 ; Weil 1946 ; Lyons
is common
in haemophiliacs:
syndrome
from
and were examined
by one
into the iliacus
muscle.
ILLUSTRATIVE
day after
ofplasma.
characteristically,
features
by marked
flexion
deformity
nerve palsy.
since the publication
of Getting’s
1930 ; Tallroth
1939 ; Aggeler
and
1956; Hall 1961).
The syndrome
studied
by Davidson,
Epstein,
at least one such episode.
The
occurs
main
no less
attributed
into the psoas
muscle,
and Weil (1946)
considered
this the commonest
haemorrhage
in haemophilia.
studied
twenty-four
patients,
eleven
of whom
were admitted
to the
other
thirteen
the syndrome
who
only
ENGLAND
Centre
which
are the sudden
onset
of severe
pain in the groin
accompanied
at the hip, followed
by a mass in the iliac fossa and femoral
Episodes
of this sort have been reported
in the literature
case
OXFORD,
1962
to
of us.
We
1962
a boy
than
to
site
of
Nuffield
1965.
The
believe
that
REPORT
typical.
In October
complained
of pain
in the
left
of sixteen
hip.
On
the
and he was admitted
to hospital
and given transfusions
in the distribution
ofthe left femoral
nerve and weakness
of the quadriceps
muscle
were noticed,
and a mass was
transferred
to the Nuffield
Orthopaedic
Centre
the same
iliac and lumbar
regions
and held the left hip flexed to 30
30 degrees
and there was a fairly free range
of abduction,
sensibility
was impaired
in the area of distribution
of the
felt in the left iliac fossa.
He was
day.
He had severe
pain in the left
degrees.
It could
be flexed a further
adduction
and rotation.
Cutaneous
femoral
nerve ; there was paralysis
of the quadriceps
muscle,
and the patellar
tendon
reflex was absent.
Deep
in the left iliac
fossa a tender
mass was felt extending
laterally
along the iliac crest.
In the past he had suffered
numerous
haemarthroses
and two episodes
of haematuria.
Both knees and both elbows
lacked
full movement.
Treatment-He
of Christmas
activity
equivalent
concentration
the
following
controlled
was
factor
from
day.
by large
treated
in bed
(factor
IX) concentrate
to
six
litres
nothing
Pain
doses
of
with
normal
to 1 18 per
was
the
cent
left thigh
supported
in flexion
and
were given by intravenous
infusion.
plasma,
and
of average
persistent
and
severe
of pethidine,
after
which
raised
normal.
for the first
it slowly
his
plasma
Christmas
A second
twenty-four
dose
hours,
diminished.
500 millilitres
This was of
For
two
was
factor
given
on
being
poorly
weeks
he had
intermittent
discomfort,
but the size of the mass in the iliac fossa remained
unaltered.
A month
after
the onset
he got out of bed and the next day the pain returned
and the mass
became
much
larger.
Two separate
swellings
could
now be felt ; a rounded
one filled the cavity of the
748
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
ILIACUS
inner
aspect
of the
ilium,
ofthe
psoas
muscle.
The
nerve
palsy
was
flexed,
and
further
HAEMATOMA
749
and a fusiform
one was felt medially,
extending
upwards
combined
swellings
almost
filled the lower left abdomen.
complete.
The
Christmas
patient
factor
was
was
put
given.
on
a Robert
The
pain
Jones
rapidly
frame
in the
The
with
subsided
and
line
femoral
the left
in two
hip
weeks
the mass was much
smaller.
A month
later he was taken
off the frame
and the joints
were
mobilised
in the swimming
pool under
cover
of Christmas
factor
and plasma
transfusions.
At that time the mass had almost
disappeared
but the femoral
nerve palsy was still complete.
Fifteen
months
later the quadriceps
femoris
muscle
had regained
full power,
but the patellar
tendon
reflex
was
was
palpable
The
following
mass
absent.
Sensory
in the
loss
was
limited
to a small
area
over
the
patella
and
THE
description
of the
SYNDROME
syndrome
is based
on observations
made
on the
twenty-
have examined
and on fourteen
case histories
published
by other
All but one of these patients
suffered
either
from classical
haemophilia
or Christmas
and had suffered
previous
bleeding.
Most
had had many
haemarthroses,
particularly
knee.
One patient,
not a sufferer
from a bleeding
disease,
developed
four
patients
haematoma
phenindione
and
syndrome
Presenting
started
thigh.
Onset
the
In
none
believe
in the
was
than
groin
sudden
this
in one
always
was
and
of the
Flexion
therapy
report
anticoagulant
that
is
spread
in some
the
first
of the bleeding
the presenting
to the
patients
intensity
steadily
increased
until
did severe
trauma
precipitate
patients
the onset of pain followed
several
twist
complicating
we
occurring
other
symptom-Pain
usually
but
and
of
with
the
diseases.
syndrome.
lumbar
It
region
insidious
or the
in others,
it was severe
and constant.
the haemorrhage,
but in
strenuous
use or a minor
limb.
contracture
of the hip-The
hip
was
always
held
and usually
in lateral
rotation.
The patients
assumed
posture
in bed, lying curled
up, often
on the affected
hips
and knees
flexed.
Extension
of the hip made
but other
movements
were present
sign distinguishes
iliacus
haematoma
suppurative
arthritis
of the hip.
in flexion
a characteristic
side, with the
the pain worse
if extension
was avoided.
from
haemarthrosis
or
This
acute
Fenzoralnert’epalsy-Haemorrhage
into the iliacus
muscle
is usually
followed
by femoral
nerve
palsy,
but not always
(Tallroth
1939,
Weil 1946); we have seen one patient
in whom
an undoubted
iliacus
The
haematoma
thigh
extent
and
of
The
shaded
the
the
cases
after
did
not
cause
nerve
lesion
development
was
of
.
nerve
afterwards.
nerve
not
the
.
compression.
Nerve
In
detected
until
haematoma,
many
several
but in
.
reported
days or weeks
our experience
the onset
of pain
to the distribution
usually
is paralysed
the
degree
complete.
and the patellar
in one of our
loss
sensory
becomes
of overlap
tendon
patients
by adjacent
well
evidence
cases
accompanied
49 B,
VOL.
K
the
of
other
NO.
lateral
of nerve
by
4,
NOVEMBER
surface
lesion.
an
isolated
1967
with
of us
of the
We
believe
femoral
but
the
femoris
Figure
The
skin
thigh
after
that
nerve
the
lateral
two
a
iliacus
palsy,
“
the
the
area
palpable
is
aboye
crestand
on the
surof the iliacus
which
was
wall
tl
the
inguinal
iliac
ligament.
muscle
1 shows the distribution
area of total anaesthesia
over
palsy of the
has examined
area
haematoma
.
quadriceps
reflex absent.
and is typical.
nerves
Lyons
(1953)
reported
a patient
as the femoral
nerve.
One
anaesthesia
The
on
leg anaesthesia.
shows
skin
face marking
or very soon
of the femoral
.
and
shaded
abdominal
.
begins
with
palsy is limited
compression
nerve
authors.
disease,
in the
we
iliacus
an
no
abdomen.
patella
haemorrhage
haematoma
that
was
cutaneous
haemophilic
of cutaneous
varied
with
always
anaesthetic.
nerve of the thigh as
patients
who had
in the
is in the
it occasionally
groin
but
great majority
“
occurs
without
no
of
J.
750
GOODFELLOW,
nerve
compression
at all,
involved.
Mass
in the iliac Jbssa-There
and
C.
B. D’A.
that
rarely
was
tenderness
FEARN
the
AND
lateral
J. M.
MATTHEWS
cutaneous
in the
groin
and
nerve
of the
guarding
thigh
in the
iliac
may
be
fossa
in
all cases.
In some the greatest
tenderness
was about
the mid-inguinal
point and slight fullness
could
be felt there.
In others
the tenderness
was greatest
in the iliac fossa
next to the iliac
crest.
It was not possible
to feel the mass in patients
examined
soon after the onset of symptoms
the haematoma
difficult.
It always
takes
some time
became
palpable
as
to reach
its full size, and
after one or two days.
“ guarding
“
makes
60
65
palpation
11
10
9
8
Episodes
7
bleeding
of
6
5
4
3
2
0
5
10
15
20
25
30
of thirty
45
50
55
70
(years)
FIG.
The age at onset
40
35
Age
episodes
in twenty-four
receiving
anticoagulant
2
patients.
therapy.
The
patient
over
65 years
was
The mass
arises
from the lateral
wall of the pelvis
and makes
the normal
concavity
inner
aspect
of the wing of the ilium convex.
In three
of our patients
the tumour
iliac fossa
and a second,
discrete,
fusiform
tumour
became
palpable
medial
to the
with
a groove
between
the two.
This second
swelling
was caused
by blood
distending
psoas
sheath.
the
the
of
filled
first,
the
developed
a few days after the onset
of symptoms
but the blood loss was
never enough
to cause shock.
Constipation-Constipation,
abdominal
distension
and colic occurred
in most of our patients.
Bowel
sounds
were present,
but diminished,
and two patients
needed
enemas.
A degree
of
Anaemia-Anaemia
constipation
is to be expected
in a patient
in pain and lying motionless,
but it is likely
that a
large iliacus
haematoma
has a more direct
effect on the bowel.
Ecchymosis-We
have
not seen skin discoloration
in the vicinity
of the haematoma,
but
Tallroth
(1939)
mentioned
it.
Age incidence-iliacus
haematoma
appears
to be unique
among
the haemorrhagic
accidents
of the bleeding
diseases
as it occurs
mainly
in adolescents
and young
men (Fig. 2). It is strange
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
ILIACUS
that
the
are
complication
frequent
so
should
and
when
arise
in the
haematomas
so
rarely
intramuscular
ANATOMICAL
The
walls
syndrome
of
iliacus
which
muscle.
the
part
to the
inner
lip ofthe
margin
of
iliac
the
Over the upper
psoas
muscle
the
of the
ten
of life
years
at other
when
are common.
sites
haemarthroses
CONSIDERATIONS
described
posterior
transversalis.
first
is the result
of haemorrhage
into
are formed
by bone and fascia and which
contains
Figure
3 shows the iliac fascia in a fresh cadaver.
at its margins
to
751
HAEMATOMA
crest
inguinal
and
to the brim
ligament
where
a closed
compartment,
the
the femoral
nerve
and the
The fascia is firmly
attached
ofthe
true
pelvis.
it is continuous
and lateral
parts of the iliacus
fascia
is thin and translucent
It is connected
with
the
fascia
muscle
and over all but the lowest
but it is particularly
strong
over
iiiacus
muscle
cutaneousnerve
of
igh
FIG.
The
the
groove
running
the
parts
of the
fascial
Experiment-In
injected
When
fluid
occurred,
was
the
into
the
VOL.
similar
and
arching
over
cadaver
it
to
the
there
were
two
The
iliacus
49 B,
NO.
4,
of
NOVEMBER
1967
transverse
forms
was
found
a dense
nerve
that
are
thicker
and
in Figure
femoral
cadaver.
fibres
progressively
site
the
of a fresh
the
as it lies in the
very
large
which
distended
of the iliacus
it
passes
indistensible
4 shows
quantities
easily
muscle
by
reinforced
as
funnel
fibres
bundles
downwards
of
enclosing
the
lowest
intermuscular
of
groove.
water
in its upper
part
a tense
globular
could
be
(Fig.
5).
swelling
palpated
clinically
(Fig. 6).
When
further
fluid
psoas sheath,
which
then filled up from below
so that
with a deep groove
between
them (Fig. 7). The psoas
and
in separate
compartments
except
where
they
pass
together
the
into
swellings
its fascia
its
fossa
haematoma
“
muscles
lie therefore
the thigh.
In iliacus
haematoma
haemorrhage
parts
3
iliac
dissection
of the psoas
muscle
into the substance
iliacus
thinner
where
at this
sheath
sheath
injected
left
becomes
muscles.
in it “ overflowed
forced
eventually
ligament
of the
muscles
fascia
of both
a fresh
the
was
into
wall
two
The
inguinal
lower
part
these
longitudinally.
behind
the
between
posterior
and
the
occurs
rounded
into
tumour
the
iliacus
which
muscle
was
felt
causing
distension
of
in all our
patients.
As
752
J.
the
small
fibrous
sheath
related
yet
slow
and
distended
(1939)
on
AND
J. M.
blood
femoral
MATTHEWS
is forced
nerve.
a fusiform
Should
tumour
which
into
He believed
which
occurs
the
bleeding
was
felt
dense
funnel
continue,
in three
the
of our
of
psoas
patients.
the genito-femoral
nerve,
though
closely
and therefore
usually
escape
compression
haemorrhage
is usually
associated
record
of a psoas
abscess
which
this.
sheath
psoas
FEARN
of the thigh
and
the fascial envelope
iliopsoas
a single
remarked
of the
distension
D’A.
distensible,
the
producing
shown,
found
B.
is not
compresses
lateral
cutaneous
nerve
to the muscles,
lie outside
3).
As has been
we have not
Tallroth
compartment
below
becomes
The
(Fig.
iliacus
tissue
C.
GOODFELLOW,
with
caused
femoral
nerve
that it could
be explained
when a tuberculous
abscess
Psoas
nerve palsy;
compression.
by the
forms,
relatively
and that
muscle
iliacus
muscle
I
Fibres
FIG.
The
posterior
cadaver.
in
the
upper
surrounded
nerve and
inflamed
fascia
is eroded
and
wall
The
of
fascia
part
the
right
display
over
L4
muscle
and
iliac
fossa
dissected
the
of
a fresh
off the muscles
femoral
nerve
lying
by fat in the intermuscular
groove.
the iliacus and psoas muscles
pass
under a dense fibrous arch.
ruptures
long
nerve
4
has been
to
arch.ng
before
the pressure
The
below
within
the abscess
can
compress
the nerve.
However,
these
considerations
hardly
explain
the absence
of nerve
compression
when the psoas
muscle
is the site of an acute
non-tuberculous
abscess
as described
by Zadek
(1950).
His six patients
were found
at operation
to have tense
abscesses
within
the psoas
sheath
; yet none
suffered
a femoral
nerve palsy.
We
described.
believe
The
that
the
significant
whether
acute
or chronic,
which
may overflow
into
explanation
difference
is to
between
is that the former
the psoas
sheath.
be
found
an
in
the
iliacus
is primarily
results
of
haematoma
a haematoma
THE
JOURNAL
the
and
experiment
a psoas
of the
OF
BONE
AND
iliacus
JOINT
just
abscess,
muscle
SURGERY
ILIACUS
rise
fluid
Primary
distension
to
compression,
nerve
at
low
of
the
psoas
sheath,
because
the
thin,
753
HAEMATOMA
from
whatever
distensible
cause,
fascia
would
can
be unlikely
contain
a large
to
give
volume
of
pressure.
FIG.
Figure
iliacus
S
FIG.
5-Injection
of the psoas
muscle.
Figure 7-Further
6
FIG.
sheath.
Figure 6-Initial
effect
injection
produces
overflow
of injection
distension
7
of the sheath of the
of the psoas sheath.
PATHOLOGY
The
morphology
of iliacus
haematoma
is shown
in Figure
8.
The
specimen
consists
of
the left half of the sacrum
and a portion
of the ilium of a patient
of twenty-three
years with
haemophilia
who developed
bilateral
iliopsoas
haematomata
shortly
before
his death
(Hall
1961).
At necropsy
the haematomata
were found to extend
from the diaphragm
to the inguinal
ligament.
fibro-osseous
in
front
The
cavity
of the left haematoma
communicated
compartment
which
limits the haematoma
the iliac fascia,
are displaced
forward
by
of
It is difficult
section
clot.
The
to distinguish
any structures
that the femoral
nerve
confirmed
In this patient
iliacus
muscle,
destroyed
the haematoma
remnants
of
in the substance
of the haematoma,
but
traversed
the cavity,
completely
surrounded
had ruptured
which
are seen
into the
compressed
be supposed
to compressing
cases there
was
the nerve,
no evidence
that
haemorrhage
would
that
into
cause
ischaemic
this occurred.
the fascial
ofthe
muscle,
result
in addition
yet in our
which
is so
of spasm
of the muscle;
Later
the flexion
contracture
in two
was
great
distension
of the fascial
sheath
and not to ischaemic
contracture
of the
muscle,
for although
it persisted
for many
weeks,
full extension
was in every case
when the haematoma
finally
resorbed
and in no case was the power
of flexion
at the
impaired.
In nearly
VOL.
envelope
the
DIFFERENTIAL
age
and
bowel
and had become
infected.
against
the ilium,
was largely
necrosis
of the iliacus
muscle,
The striking
flexion
of the hip
characteristic
of the syndrome
in the early stages
is the
of our
patients
the hip extended
fully under
anaesthesia.
hip
histological
by blood
by infection.
It might
due to
contained
regained
with the lumen
of the colon.
The
is well shown.
The iliac vessels,
lying
the haematoma
but not compressed.
all
patients
the
presence
of three.
it follows
As has been mentioned,
that the patient
will
49 B,
4,
NO.
NOVEMBER
1967
of a severe
DIAGNOSIS
bleeding
iliacus
haematoma
be a known
sufferer
diathesis
is diagnosed
before
the
occurs
in adolescence
and adult
life
and will almost
always
show
some
754
J. GOODFELLOW,
C. B. D’A.
FEARN
AND
J. M. MATTHEWS
evidence
of haemorrhages
in the past, a fact which
should
make
misdiagnosis
unlikely
if the
clinician
is aware
of the frequency
of the complication.
The occurrence
of the syndrome
in
a patient
undergoing
anticoagulant
therapy
suggests
that the complication
should
be borne
in mind
in acquired
as well as hereditary
coagulation
defects.
Acute
haemarthrosis
or suppurative
arthritis
of the hip bears
a resemblance
to this
syndrome,
but
of a nerve
haemophilia.
lesion
should
the
demonstration
should
Retroperitoneal
be reserved
of tenderness
distinguish
haematoma
for bleeding
and
them.
iliacus
haematoma.
The
left
half
of
suffering
iliopsoas
fascia.
produces
an entirely
into
the
nerve
compression
When
it occurs
the diagnostic
and
loin,
This
but
space
different
it is not
like
in the
from
is potentially
clinical
the
well
made
space
hip
and
the
is
uncommon
presence
in
in haemophilia.
The term
which
lies anterior
to the
8
sacrum
and
large,
ilium
and
A diffuse
defined
does not occur
and there
on the right side, iliacus
error
may have dangerous
fossa,
of the
of 23 years
of a patient
haemophilia.
very
picture.
tense
the
iliac
haemarthrosis
is a diagnosis
commonly
into the retroperitoneal
FIG.
An
a mass
Acute
a true
mass
tumour
retroperitoneal
may
be palpable,
ofan
iliacus
is no flexion
contracture
haematoma
may closely
consequences
(Fraenkel
haemorrhage
often
extending
haematoma.
Femoral
of the hip.
mimic
acute
appendicitis
1957).
If there
is any
evidence
of femoral
nerve compression
(the earliest
sign being hypoaesthesia
of the skin over
the patella)
the possibility
of appendicitis
can be excluded.
If nerve compression
is absent,
or if its onset is delayed,
the diagnosis
may be in doubt.
Flexion
deformity
of the hip is more
severe
in iliacus
palpated
when
in
haematoma
than
is seen
in acute
appendicitis.
in the early
stages
because
of intense
“ guarding
doubt
the iliac tumour
is easily felt by examination
lliacus
“
of
the
under
THE
JOURNAL
haematoma
abdominal
anaesthesia.
OF
BONE
cannot
muscles,
AND
JOINT
be
but
SURGERY
ILIACUS
755
HAEMATOMA
TREATMENT
The
aim
nerve
damage,
Pain
that
of treatment
in the
by correcting
continues
acute
phase
the clotting
defect
in spite
of correction
is to stop
and
bleeding
and
by immobilising
of the
clotting
relieve
pain
the affected
defect
ceases
and
iliacus
when
lessen
muscle.
the
patient
is
immobilised.
The
patient
of human
with
haemophilia
antihaemophilic
is given
globulin
fresh
if plasma
frozen
plasma
or a more
potent
concentrate
proves
ineffective.
The patient
with Christmas
disease
is treated
with
plasma,
which
need
not be fresh
but should
be less than a week
old.
A concentrate
of Christmas
factor
is used in a few centres
for control
of persistent
bleeding.
Infusion
should
be continued
for at least four days to allow
some
organisation
of the clot
(Biggs
and Macfarlane
1962).
Bed rest, with pillows
to support
the affected
haemorrhage,
but when
bleeding
continues
and
hip
pain
in flexion,
is severe
may be adequate
immobilisation
in slight
should
be
complete.
A modified
Robert
Jones
frame
has been used with success
in several
cases.
Once the pain has subsided
the flexion
contracture
diminishes,
and its correction
may be
helped
by light traction
to the leg.
Protective
infusions
may be given
again
for a few days
when
mobilisation
and
weight
bearing
are begun.
When
walking
is allowed
it is important
to protect
muscle
has
knee
the knee
regained
with a caliper
full power.
is almost
inevitable.
disability
from
which
damaged
an iliacus
it beyond
We
and to continue
If this precaution
this protection
is omitted
have
many
examined
until
recurrent
patients
the
quadriceps
haemarthrosis
in whom
haematoma
was a disorganised
knee
repair
during
the months
of quadriceps
the
femoris
of the
only
from repeated
paralysis.
residual
haemarthroses
PROGNOSIS
In
the
published
unpredictable.
showed
cases
Two
patients
a considerable
haemorrhage.
numbness
muscle
for
but
nerve
In one
the
and
twenty
power
was
is
recovery
who
even
suffered
immediately
and
was
there
less than
excellent,
patients,
recovery
a complete
of femoral
was
in
Medical
severe
iliacus
treatment
the only
treatment.
patient
we have seen who escaped
This experience
suggests
that
avoided
or at least
function
marred
only
and
wasting
of the
Research
developed
a nerve palsy
if treatment
patients
or
while
signs
by
has
been
1953);
showed
a year
a small
three
none
or more
of
area
quadriceps
femoris
Council
scale.
The prognosis
if proper
treatment
is given.
in hospital,
it was possible
to
haemorrhage,
haemorrhage
he never
institute
in seventeen
complete
weakness
4 on the
nerve
recovery
(Seddon
1930, Lyons
1924, 1935; Weil 1946); and two
(Gunther
In five
not
studied,
McAlpine
1956).
cases of iliacus
haematoma
patella.
recovery
of our
made
In fifteen
over
have
improvement
(Tallroth
1939, Douglas
We have reviewed
after
we
of nerve
and the
is given
compression.
This
is
only patient
who got prompt
at once nerve
palsy
may be
diminished.
SUMMARY
I
Haemorrhage
femoral
nerve
into the
is a common
.
2. The iliacus
haematoma
thirty
episodes
occurring
3. The anatomy
of the
compression
4. Differential
explained.
diagnosis,
one patient
are
5. An instance
presented.
of iliacus
fascial
compartment
which
complication
of haemophilia.
syndrome
is described
and illustrated
in twenty-four
patients.
iliopsoas
fascia
is described
and the
prognosis
haematoma
is recorded.
VOL.
49 B,
NO.
4,
NOVEMBER
contains
1967
and
treatment
occurring
are discussed
as a complication
the
iliacus
from
the
mechanism
and
the
muscle
and
authors’
of
study
femoral
necropsy
of anticoagulant
the
of
nerve
findings
therapy
in
756
.i. G000FELLOW,
We
wish
clinical
were
to
record
our
indebtedness
manifestations
treated
under
to
Professor
of haemophilia.
in collaboration
the direction
both
in care
of
Lord
Mayor
Treloar
M. Heywood,
the necropsy
C. B. i)’A.
the
with
J. Trueta
Patients
the
Medical
patients
in preparation
Orthopaedic
Hospital
the
Council’s
We
of this
are
M.
MATTHEWS
inspiration
Blood
Our
thanks
given
are
to
the
study
of Orthopaedic
Research
Rosemary
several
Dr
has
Coagulation
to Dr
us to examine
Disabled
Boys.
The
illustrations
he
Department
grateful
paper.
who allowed
Headmaster
of the Alton
School
for
findings
of the patient
he reported.
J.
to the Nuffield
Research
R. G. MacFarlane.
AND
for
admitted
of Professor
and
FEARN
due
to
patients
Unit,
Biggs
Mr
M. R. Hall gave
are the work
of
for
Oxford,
her
advice
E. S. Evans
under
of
Surgery
his care,
of
the
and to Mr
us permission
to publish
Mr David
Drury
of the
Photography
Department,
by the Oxford
Regional
Blood
Products
of the
Medical
the Nuffield
Orthopaedic
Centre.
The fresh frozen plasma
referred
to was supplied
Blood
Transfusion
Service;
the human
anithaemophilic
globulin
concentrate
by the
Laboratory
of the Lister Institute,
and the Christmas
factor concentrate
by Dr E. Bidwell
Research
Council’s
Blood
Coagulation
Research
Unit,
Oxford.
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P. M., and
AGGELER,
and
Mental
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BIGGS,
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C. S.,
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Forschuizg,
H.
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G. J. (1957):
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FILDES,
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EPSTEIN,
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S. P. (1944):
LUCIA,
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;A
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THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY