Introduction: Scapulothoracic dissociation (SD) is a rare and potentially disastrous injury, characterized by a complete disruption of the scapulothoracic joint with lateralization of the scapula and intact skin, secondary to a high-energy trauma due to distraction of the scapular belt. It is associated to a wide spectrum of injuries and high mortality rate. Case presentation: A 20-year-old male, admitted to the Emergency Department after a car accident. He presented swelling of the left upper limb with signs of hypoperfusion. The X-ray and CT-scan showed a left SD (scapular index 1.36) with AC dislocation associated to humeral neck and Monteggia fractures. CT-angiography showed thrombosis of the left axillary artery. He underwent to AC fixation with 2 plates followed by stabilization of the proximal humerus with 2 Steinman nails and bypass of the axillary artery with reversed great saphenous vein graft. Radio-humeral reduction and osteosynthesis of the ulna with a plate were also performed. Intraoperatively, the presence of compartment syndrome in the forearm lead to the performance of decompressive fasciotomies. Results: After 4 weeks, the vascular perfusion of the limb was restored, but without motor function and reduced sensitivity. The patient was referred to hand surgery consultation to assess the viability of the limb and eventual reconstruction of the plexus. Conclusion: The authors report the unique case in the literature of SD with neurovascular injury associated to humeral neck and Monteggia fractures. A quick strategy between Orthopaedics and Vascular Surgery allowed the rescue of an already committed limb at an early stage.

The association between long bone fractures and the risk of developing Fat Embolism Syndrome (FES) is well established, with a higher frequency in patients with multiple fractures and open fractures. Early rigid fixation is a protective factor. In FES there is a greater involvement of the lung, central nervous system, and skin - constituting the typical triad of hypoxemia, neurological changes, and petechiae. Purtscher's retinopathy was reported in 50% of patients with post-traumatic FES, constituting a finding with high specificity when present. We present the case of a 21-year-old male patient who was admitted to the Orthopaedics Emergency Service, following a high-energy trauma after a motorcycle accident, which resulted in an open fracture of the left tibia grade I (wound <1 cm), according to the classification by Gustillo & Anderson. He underwent surgical washing and debridement with tibial nailing and intramedullary reaming on the same day. A few hours after admission, the patient developed temporospatial disorientation, followed by dyspnea and diminished bilateral visual acuity in the postoperative period. He was transferred to the Intensive Care Unit on suspicion of FES. After observation by Ophthalmology, he was diagnosed with Purtscher Retinopathy (RP), an occlusive retinal microvasculopathy, which reinforced the diagnosis of FES. The patient showed complete regression of symptoms with supportive care. This case intends to reinforce the need for a high degree of clinical suspicion of FES in patients with long bone fractures who present with organ failure and the relevance of ophthalmological findings in the diagnosis.

Background: Management of polytrauma requires a well-planned methodical approach which can be of utterly importance in the achievement of satisfactory functional outcomes. Case Presentation: 43-year-old male, farmer, runover by truck with subsequent polytrauma, resulting in posterior open fracture-dislocation of the right knee (bicondylar Hoffa fracture, tibial plafond fracture and popliteal wound), left acetabular anterior column fracture, left superior pubic ramus fracture, left trochanteric fracture and left lateral malleolus fracture. Clinical Outcomes: Initial orientation followed the ATLS principles. Primary surgical treatment consisted in damage-control approach with right knee osteotaxis, lavage, debridement, primary closure of the popliteal wound and application of transcondylar skeletal traction to the left limb.
11 days after admission, intramedullary nailing of the left femur and ORIF of the left lateral malleolus with plate and screws was performed. The popliteal wound was prepared so it could receive a skin graft later on.
18 days after admission, ORIF of Hoffa fracture with screws and tibial plafond fracture with plates and screws was performed. Furthermore, after wound preparation, an autologous skin transplant was achieved using full-thickness skin graft. At 1-year follow-up, he presented almost complete ROM of the left knee and no active limitation of mobility of the right limb. Discussion: Polytrauma poses an important challenge in the management of the various musculoskeletal injuries. The importance of timing, surgical preparation and daily evaluation played an enormous role. The present case is a demonstration of how adequate decision making and high-quality surgical treatment can be crucial in getting the best functional results.

This retrospective study aimed to assess the outcome of modified Stoppa approach using an anatomically precontoured plate in the treatment of acetabular fractures. Thirty patients (mean age 50.3 years) with acetabular fractures were treated between January 1, 2018 and December 31, 2019. In all cases, fracture reduction was performed through modified Stoppa approach and fixed with omega plate. In specific fracture patterns additional approaches were needed. Patients were assessed for restoration of the hip joint congruency, overall fracture reduction and complications. Quality of reduction was categorized based on Matta’s principles and for functional outcome we used Merle d’Aubigné and Harris hip scores. The average anesthesia time was 253.6 minutes, the mean intraoperative blood lost was 266.6 ml and the mean intraoperative fluoroscopy was 3.21 mGy. According to Matta criteria for reduction quality, we recorded anatomical reduction in 22 cases, imperfect reduction in 6 cases and 2 cases with poor reduction. The average follow-up was 22.5 months. We did not record any malunion, loss of reduction or implant loosening. Late complications included one case of avascular necrosis of the femoral head and posttraumatic arthritic changes in 5 cases. We recorded a mean Merle d’Aubigné score of 13.26±4.46 and a mean Harris score of 86.03±13.37. The possibility of anatomically precontoured plate with subsequent lower operative time combined with stable fixation of the primary acetabular fracture fragments and the quadrilateral plate makes the omega plate a viable option for treating acetabular fractures with good to excellent results in 89% of the cases.

Accidental burns in the operation theatre are very unusual. Burns due to electro-cautery and the use of alcohol-based antiseptics are well documented in the literature. Iatrogenic burns following prolonged exposure to light in microscopic surgeries are also reported. There has been an increase in the incidence of skin-related complications in patients undergoing surgery or getting prolonged exposure to light following photodynamic therapy or the presence of photosensitizing drugs in circulation. However, so far no such complication has been encountered during any orthopedic surgeries. We report a unique case of surgical site burn following prolonged exposure to operating light in an old neglected pelvic non-union surgery.

Purpose of the study: Modern minimally invasive methods of treatment of pelvic injuries are fundamentally distinguished by a more gentle approach to soft tissues and nearby anatomical structures, higher clinical efficiency of treatment compared to traditional wide surgical approaches. The aim of this study is to analyse, compare and evaluate the results of the above-mentioned surgical methods.
Materials and methods: in this retrospective cohort study the results of surgical treatment of 150 patients with injuries of the pelvic ring were evaluated. The patients were divided into 2 groups: 90 patients were included in the main group (minimally invasive surgical treatment) and 60 patients in the control group (traditional surgical treatment with wide surgical approaches). On average, among the main group of patients the duration of surgery was 67.6 minutes, intraoperative blood loss amounted to 57.5 ml, time from admission to the final fixation method was 7.5 days, length of hospitalization was 15 days. And in the control group on average the duration of surgery was 182.8 minutes, intraoperative blood loss amounted to 397.5 ml, time from admission to the final fixation method was 9.3 days, length of hospitalization was 22 days.
The obtained results and conclusions: the data obtained during the study indicate that in order to minimize the secondary surgical hit and to shorten the duration of hospitalisation the choice of minimally invasive surgical technics (if technically possible) is preferable.

Background
Locked symphysis pubis is an exceedingly rare pelvic injury especially in the paediatric population. This study is the first to describe this fracture in a skeletally immature patient.
Case report
We report the case of a fifteen year old boy who presented to the Emergency Department (ED) after being involved in a farming injury with a left lateral compression pelvic trauma. He sustained Locked Symphysis Pubis (LSP) and internal pelvic bleeding from the right Internal Iliac Artery (IIA). He was treated successfully by selective embolization of the ILA followed by closed reduction of the LSP and percutaneous fixation of the SI joint.
Conclusion
Locked symphysis pubis in the paediatric population is an exceedingly rare injury among lateral compression type pelvic fractures. Careful assessment and preoperative management planning are encouraged. Open packing of the pelvis in case of internal bleeding should be avoided in paediatric patients, only selective embolization is advocated. Closed reduction of the LSP by using the external fixator as a lever arm for reduction followed by percutaneous fixation of the SI joint. Moreover, changing the patient position to prone position followed by posterior lumbar spine stabilisation is our preferred method of treatment.

Introduction: Inter- and pertrochanteric femoral fractures are some of the most common fractures in old patients.
We report the case of a patient who developed an aneurysma spurium of the left profunda femoris artery after a reversed pertrochanteric femur fracture with a large displaced trochanter minor fragment.
History: A 74-year old man presented with a left displaced reversed intertrochanteric femoral fracture to our ER. Surgery was performed as half open reducation and fixation using a long PFN-a - Proximal Femur-Nailing System. Surgery was uneventful.
In the context of recurrent hemoglobin drops a total of 13 red blood cell concentrates were given before the diagnosis of the vascular complication was made.
CT Angio of abdomen and pelvis revealed acute bleeding at the origin of the left profunda femoris artery and the formation of an aneurysma spurium.
Retrospectively this was caused most likely by the rim of the fractured minor trochanter. After confirmation of vascular complication a saphenous vein patch was performed by our vascular collegues. The dislocated fragment of the minor Troch was removed.
Results: the patient ambulated without pain initial with partial weight-bearing,. Routine follow-ups remained uneventful. The angiologic control showed a stable situation.
There are no guidelines regarding the dislocated minor trochanter complications in the current literature.
Conclusion: When treating haemodynamical unstable patients or those with continuing low hemoglobin levels after suffering from comminuted fractures of trochanteric region especially with a dislocated minor trochanter or fragment look out for the uncommon event of major vascular complications.

Background: Around 1 in 3 adults aged 65 years and over will have a fall at home within a one-year period. Falls are estimated to cost the NHS more than £2.3 billion per year. The NICE guidelines recommend older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment which include a cardiovascular examination and review of medications. Orthostatic hypotension (OH) is a common cardiovascular disorder, with or without signs of underlying neurodegenerative disease. AIMS AND OBJECTIVES: This audit was carried out to assess the percentage of elderly patients admitted with a fall who had their LSBP measurements taken and recorded while on admission. METHODS AND MATERIALS: A prospective study of patients admitted with a fall between 14th of April and 25th of May 2020 in the Trauma and Orthopaedics department at Salisbury NHS Trust was carried out for the first audit and then A retrospective audit of patients admitted with a fall between 10th of July and 21st of August 2020 was done in the re-audit.
Results: Initial audit results showed 68% of patients were not meeting NICE guidelines on measurement of lying and standing blood pressures. The re-audit showed significant improvement in compliance

Introduction: Surgical site infection (SSI) is one of the most dreaded complications of an orthopedic surgery. It prolongs hospitalizations, cause functional limitations and adversely affects quality of life. Although the use of intrawound antibiotic powder is increasing especially vancomycin, there is little documented evidence of the same apart from the spinal surgeries. The aim of this study is to determine the efficacy of intrawound vancomycin powder as a prophylactic measure against infections in all types of orthopaedic surgeries. Methods: 75 consecutive patients who underwent orthopaedic surgeries were included in the study. Out of 50 patients with high risk factors, intraoperative local vancomycin powder was used in 28 cases (Group A) while in remaining 22 patients (Group B) no local antibiotics was used. For remaining 25 patients (Group C) with active infection at the operative site, surgical debridement was done and local vancomycin powder was used. For the above study, 2 gms of vancomycin powder was applied locally.
Results: 3 patients out of 22(13%)in group B had surgical site infection and needed reoperation whereas only 1 patient underwent reoperation in group A(3.5%) and Group C(4%). The incidence of SSI was significantly lower with the use of intrawound vancomycin powder as compared to patients in whom vancomycin was not used.
Conclusion:The use of intrawound vancomycin powder in orthopaedic surgeries decreased the risk of SSI and reoperation rate and hence it should be considered to prevent SSI. Its application is safe and can maximise patient outcome and reduce health care-resource utilization.

Background: The aim of treating acetabular fractures is achieving anatomical reduction and stable fixation allowing early mobilization and rapid rehabilitation. Column screw fixation has been used either alone or adjunct to ORIF in the fixation of acetabular fractures. Objectives: Assessment of the functional and radiological outcomes of acetabular fractures fixed with column screws. Patients and Methods: A prospective controlled case series study including 31 patients with 33 acetabular fractures fixed with column screws; either alone or adjunct to ORIF. Small fragment (3.5 and 4 mm) and large fragment screws (4.5 and 6.5 mm) were used in 16 and 18 fractures, respectively. One fracture was fixed using both types of screws. Results: The mean values of the initial and the maximum residual fracture displacements were 8.2 and 1.7 mm, respectively. 85% and 80% of the patients had excellent and good radiological and functional outcomes, respectively. Five patients developed complications (2 Advanced osteoarthritis, 2 iatrogenic sciatic nerve injury and 1 heterotopic ossification). There was no significant difference between small and large fragment screws regarding the functional and radiological outcomes (P-values 1). Age> 50 years, time delay to surgery> 7 days, initial fracture displacement > 10 mm and residual fracture displacement > 2mm were negative predictors of the outcome. Conclusion: Column screws can be used as a mini-invasive method of fixation either alone or as an adjunct to ORIF providing stable fixation allowing early mobilization and partial weight bearing post-operative. Keywords: Column screws, Acetabular fractures, Mini-invasive.