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Morel-Lavallee lesion has been described as a post-traumatic soft tissue degloving injury. It is commonly seen in association with road traffic accidents or sports injuries where there is separation of the hypodermis layer from the deeper fascia caused by a shearing force. These injuries occur around the mid-torso, specifically at the flank, lumbar spine, scapula, buttocks and the knee but are most commonly seen over the greater trochanter. There is a complex serosanguinous fluid collection containing blood, lymph and necrotic material within the separated tissue planes. Various treatment modalities like compression bandaging, sclerodesis, percutaneous aspiration, open debridement, quilting sutures and VAC (vacuum assisted closure) therapy have all been described in literature, however a clear consensus on the management protocol does not exist. Herein we reported a 45 year old gentleman who presented with a persistent fluctuant swelling over his left thigh following a motor vehicle accident. He had a history of multiple aspirations of the collection. Upon presenting to our Institute he underwent incision and drainage with sclerotherapy followed by open drainage and debridement with low suction drains. However on follow up visits there was recurrent swelling over the inferior most dependent aspect of the lesion which was finally managed by VAC therapy. The patient eventually returned to normal activity after 4 months from the initial injury with no residual loss of function. The clinical significance of this case is to emphasize that a high degree of suspicion and early use of imaging modalities like MRI in suspected patients are essential to provide timely and appropriate treatment. We also aim to discuss the efficacy of various forms of treatment as per the available literature which shows that a low threshold for operative management is associated with lower recurrence and complication rates.

Background: A prospective comparative study carried out to compare the efficacy of intramedullary nailing and plate fixation, for displaced midshaft clavicular fracture, over each other.Materials and Methods: 62 patients with midshaft clavicle fracture were randomly divided into the plating group (31 patients) and the nailing group (31 patients). Post operative assessment was done and outcomes were compared between the groups throughout the follow up period of 1 year in terms of union rate, cosmesis, functional score and complications.Results: Incision length (p=0.008), operative time (p=0.02), blood loss (p=0.003) and hospital stay was significantly less for the nailing group as compared to the plating group. Implant failure, non union and hypertrophic scar was more prevalent in the plating group. The Constant Murley score was significantly higher for the nailing group (p=0.04) in the initial 6 months of the follow up, however there was no statistically significant difference in the DASH score (p=0.42) and Constant score beyond 6 month follow up.Conclusion: Intramedullary nailing is a superior alternative to plate fixation for clavicle fracture because of less complications, less hospital stay, better cosmesis and functional outcome.

Background: Sickle cell (SC) disease leading to endarteritis induces skeletal changes in the form of osteitis, sclerosis of femoral canal and osteonecrosis of the femoral head. All these make total hip arthroplasty (THA) difficult and prolonged. There is increased risk of infection, SC crisis and increased complication rate. Our paper aims to highlight preoperative, intraoperative and postoperative hurdles encountered in performing THA in sicklers and the short term outcome using cementless implants. Materials and Methods: Thirty-nine patients with SC disease, who had osteonecrosis of the femoral head, were operated between 2007 and 2011. The mean age of patients was 22 years (range 13-49 years). There were twenty eight females and 11 males. Bilateral cementless total hip replacement (THR) was performed in 11 patients (22 hips) and in the rest unilateral (28 hips). Preoperative and postoperative modified Harris hip score was evaluated. The average followup was 3.8 years (range 2-6 years). Results: The average operating time was 96 min (range 88-148 min). The average blood loss was 880 ml (range 650-1200 ml). The average intraoperative blood transfused was 2.3 units (range 2-5 units). All patients showed an improvement in Harris hip score from 42 points preoperatively to 92 points at latest followup. Intraoperatively, one patient had a periprosthetic fracture. Six patients developed acute SC crisis and were managed in intensive care unit. Three patients developed wound hematoma. Three patients developed limb length discrepancy less than 1 cm. None had early or late dislocations, infection, heterotopic ossification, sciatic nerve palsy and aseptic loosening. Conclusion: THA in sicklers involves considerable challenge for the orthopedic surgeon. Management requires a multidisciplinary approach involving the anesthetist, hematologist and the orthopedic surgeon. Contrary to previous reports, THA in sicklers now has a predictable outcome especially with the use of cementless implants.

Pantoea agglomerans infections in humans are uncommon. Most common infections reported are septic arthritis or synovitis. We report the case of a 25-year-old, healthy male, who presented with indurated swelling over the posterolateral aspect of his right thigh, associated with pain for one month. Magnetic resonance imaging (MRI) revealed muscle edema with cystic areas in the posterior-most part of the vastus lateralis of the right thigh. The condition was clinically diagnosed as a right-sided benign tumor of the vastus lateralis muscle. However, Pantoea agglomerans was isolated on a culture of the excised muscle tissue. On the basis of the awareness of the common association of Pantoea with penetrating trauma by vegetation, the patient was asked to recollect any prior such injury. He then gave a history of a fall in the field and a plant thorn prick in the thigh four years back, when he was an agricultural worker. We emphasize the importance of Pantoea agglomerans infection of the soft tissues that can have an atypical presentation as a non-suppurative, indurated, muscle cyst in our case. Thorn injuries are usually ignored as trivial incidents, however, Pantoea infections should always be borne in mind when encountering soft tissue lesions, as antibiotic treatment is required for complete resolution of the lesion.