Background Pelvic fractures from high-energy trauma are frequently complicated by urethral injury. The World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) recommend retrograde urethrogram as the first-line diagnostic test for suspected urethral disruption, performed prior to any catheterization attempt. When urethral injury is confirmed, the American Urological Association advises suprapubic tube placement as the preferred initial management to avoid exacerbating injury, with endoscopic or fluoroscopic techniques reserved for select cases in which standard approaches fail or are not feasible (Coccolini et al., 2019; McCormick et al., 2023; Morey et al., 2021) [1], [2], [3]. Case presentation We report the case of a 43-year-old male involved in a high-speed motorcycle collision who presented in hemorrhagic shock with multiple injuries, including complex pelvic ring fractures and blood at the urethral meatus. A retrograde urethrogram demonstrated urethral extravasation near the pubic symphysis. During emergent operative exploration for associated thoracoabdominal injuries, the urology team performed intraoperative flexible cystoscopy. The disrupted urethral tract was identified at the 12 o'clock position, and a 0.035-inch guidewire was advanced into the bladder under direct vision. A 16 Fr council-tip Foley catheter was successfully placed over the wire, achieving urinary drainage and avoiding further urethral trauma. The patient subsequently underwent interventional radiology-guided bilateral internal iliac artery embolization for ongoing pelvic bleeding and staged orthopedic fixation of pelvic fractures. Urethral healing was supported with long-term catheterization, and the patient was discharged on hospital day 31with the Foley catheter in situ for continued urologic follow-up. Conclusion This case demonstrates that video fluoroscopy and flexible cystoscopy can facilitate safe guidewire-assisted catheter placement in complex pelvic trauma when conventional methods are unsuccessful. However, current guidelines from the World Society of Emergency Surgery, the American Association for the Surgery of Trauma, and the American Urological Association support suprapubic tube placement as first-line management, with endoscopic realignment reserved for experienced providers and specific indications (Coccolini et al., 2019; McCormick et al., 2023; Morey et al., 2021) [1], [2], [3].
Introduction:Acute closed trauma to the long fingers and thumb presents a therapeutic challenge. Ultrasound refines clinical examination and enables optimal management. This study aims to assess the role of ultrasound in the management of acute closed trauma of the fingers and the thumb during post-emergency consultations. Method:Patients were re-evaluated within 15 days of their initial emergency visit. The evaluation combined a clinical examination and a standardized ultrasound assessment. Based on ultrasound findings, initial management was either confirmed or modified. The primary endpoint was the modification of initial management. Secondary endpoints included the evaluating of PRWE-Fr and QuickDASH scores and assessing of changes in the work absence duration. Results:Twenty-seven patients were evaluated, with a minimum clinical follow-up of three months. The mean age was 33 years. The thumb and the proximal interphalangeal joint were the most frequently affected fingers and joints, respectively. Ultrasound led to modifications in initial management in 77.8% of cases. Return to work was accelerated by an average of 5 days. At three months, mean PRWE-Fr and QuickDASH scores were 12.9 and 9.42, respectively. Conclusion:Ultrasound is an essential tool in the evaluation and management of acute trauma to the fingers and thumb. It is accessible, easy to perform, and non-irradiating, enhancing the clinical examination by the hand surgeon and enabling early therapeutic adjustments. Level of evidence:Level III.
We report the case of a man in his forties admitted to hospital after being stabbed in the precordial region. The initial chest X-ray and FAST examination revealed nothing abnormal. Despite apparent haemodynamic stability, the patient developed progressive dyspnoea, diaphoresis and signs of circulatory compromise. Due to clinical deterioration, an emergency exploratory thoracotomy was performed. Intraoperative findings revealed haemothorax, haemopericardium, and a perforation of the right atrium associated with pericardial rupture. The cardiac injury was successfully repaired, and the patient recovered favourably. This case demonstrates that initial negative imaging does not rule out significant cardiac injuries in penetrating chest trauma. Careful clinical reassessment and timely surgical intervention remain critical for patient survival.
Posterior hip dislocations with simultaneous femoral head and neck fractures are extremely rare, usually after high-velocity trauma, and demand urgent surgery to prevent complications. A 40-year-old woman sustained a posterior dislocation with femoral head fracture after a low-energy twisting fall. A forceful closed reduction without relaxation caused an iatrogenic femoral neck fracture (Pipkin Type III). She underwent open reduction and internal fixation within six hours of presentation (28 h after injury). Redislocation occurred on day 20 due to unrecognised labral avulsion and acetabular dysplasia, later addressed with labral repair. At two years, she remained pain-free with good functional scores, although the femoral head was not perfectly concentrically reduced on final radiographs, a finding attributed to the underlying dysplasia; she was subsequently lost to follow-up. This case illustrates that good short-term function can be achieved despite imperfect radiographic congruency, while underscoring the importance of recognising dysplasia and labral injury and of considering arthroplasty as an alternative in this fracture pattern.
Introduction High-energy trauma can result in complex orthopedic injury patterns. The “floating shoulder” and “floating elbow” are distinct, severe injuries involving serial fractures of the upper extremity, disrupting adjacent joint function. The simultaneous ipsilateral occurrence of both, further complicated by a pelvic fracture, represents an exceptionally rare and challenging clinical scenario. Case presentation We present the case of a 45-year-old male with a history of schizophrenia who sustained multiple fractures after a fall from a height during a psychotic episode. He was diagnosed with an ipsilateral left-sided floating shoulder (Neer Type I distal clavicle fracture and a surgical neck of humerus fracture), a floating elbow (open Type I Gustilo-Anderson supracondylar and intercondylar distal humerus fracture with metaphyseal comminution, and fractures of the distal radius and ulna), and a non-displaced anterior column acetabular fracture. This report details the single-session surgical marathon performed hours after admission, which included intramedullary nailing of the humerus, open reduction and internal fixation (ORIF) of the distal humerus, and external fixation of the wrist, alongside non-operative management for the clavicle and acetabulum. Conclusion This report describes a unique and previously unreported combination of injuries. The patient's successful outcome depended on collaboration between multiple specialties, decisive surgical planning, and a single, extensive operation to stabilize his fractures. The patient's psychiatric condition added a significant layer of complexity to his perioperative care and rehabilitation. To our knowledge, this specific combination of ipsilateral floating shoulder, floating elbow, and acetabular fracture has not been previously reported in the literature.
Case 64-year-old woman's closed right ankle fracture was temporized with an ankle external fixator. She developed a simple pin site infection treated with oral antibiotics. However, the local infection progressed to systemic infection. Pin removal, formal operative debridement, and ICU admission were indicated. Blood and tissue cultures yielded MRSA. Advanced imaging identified septic emboli to lungs, brain and eyes. The patient responded to antibiotic therapy. Operative fixation was delayed until resolution of bacteremia. The ankle fracture united with no symptoms after completing antibiotic therapy. Conclusion Surgeons should be aware of technical and patient factors that contribute to pin site infection.
Background Blunt abdominal aortic injury (BAAI) is rare but carries high mortality. Traditionally, hemodynamically unstable polytrauma patients are rushed directly to the operating room; however, because BAAI is frequently missed during exploratory laparotomy, definitive diagnosis requires computed tomography (CT). The Hybrid Emergency Room System (HERS), which integrates resuscitation, surgery, interventional radiology (IVR), and CT imaging, enables rapid CT scanning even in hemodynamically unstable patients. Nevertheless, the risk of missing BAAI persists when resources for image interpretation are limited. To address this, CT screening AI software “ERATS” (ER Automated Triage System) was deployed at Osaka General Medical Center in September 2025. Here, we report a case demonstrating the utility of this AI system. Case presentation A 29-year-old female presented in severe shock following a collision with a train. Initial resuscitation with resuscitative endovascular balloon occlusion of the aorta achieved transient stabilization, permitting CT scanning. Imaging revealed multiple life-threatening injuries: epidural hematoma, hemopneumothorax with multiple rib fractures, vertebral fractures, and pelvic fractures with active bleeding. A left chest tube was inserted, and pelvic transcatheter arterial embolization (TAE) was initiated. Immediately thereafter, ERATS alerted the trauma team to an abnormality in the abdominal aorta that was overlooked in the preliminary judgment. Re-evaluation confirmed an infrarenal abdominal aortic dissection with active extravasation. Emergency Endovascular Aortic Repair (EVAR) was performed immediately following the successful pelvic TAE, achieving hemostasis. Conclusion In the management of a severely injured polytrauma patient under resource-limited condition, AI-assisted CT diagnosis successfully identified an initially missed infrarenal abdominal aortic injury, enabling rapid hemostatic intervention.
Proximal humeral nonunion remains a challenging condition, particularly after failed plate fixation, because of the compromised bone stock within the humeral head and loss of medial calcar support. Under these conditions, it is often difficult to achieve sufficient mechanical stability while preserving the humeral head. We report a case of proximal humeral nonunion successfully treated using the nail and plate combination technique. A 61-year-old man sustained a high-energy proximal humeral fracture in a motorcycle accident and underwent initial plate fixation at a different institution. The plate failed subsequently, resulting in varus displacement of the humeral head fragment and nonunion. Revision surgery was performed using an antegrade intramedullary nail combined with an anatomical proximal humeral locking plate and cancellous iliac bone grafting. This strategy was selected to restore medial calcar support, enhance axial stability, and increase the number of screws engaging the humeral head fragment without interfering with the implant. Postoperative imaging confirmed satisfactory alignment and stable fixation at the nonunion site. Bone union was achieved without displacement, and solid union was confirmed at the final, 2-year follow-up visit. At the same visit, shoulder function was favorable, with a Constant–Murley score of 82 points and preservation of a wide range of motion. The nail and plate combination technique may represent a useful treatment option for proximal humeral nonunion in selected patients, providing complementary mechanical stability that is difficult to achieve with single-implant fixation alone while preserving the humeral head.
Introduction Post-traumatic radioulnar synostosis is a rare but severely disabling complication following forearm fractures, particularly after surgical fixation. It leads to loss of forearm rotation and major functional impairment. Management remains controversial, especially regarding risk factors, timing of surgery, and the optimal interposition material. Case presentation We report the case of a 24-year-old patient who developed post-traumatic radioulnar synostosis after plate osteosynthesis of both forearm bones. Radial fixation was performed through the Boyd approach and was complicated by transient posterior interosseous nerve palsy. The synostosis was classified as type II and IIIA according to the Vince and Miller classification modified by Jupiter. Surgical treatment consisted of complete excision of the synostosis and interposition of a fascia lata graft. Discussion The Boyd approach, fractures involving both forearm bones, and postoperative neurological complications are well-recognized risk factors for radioulnar synostosis. Surgical excision combined with fascia lata interposition provides reliable restoration of forearm rotation with a low risk of recurrence. Conclusion Excision of post-traumatic radioulnar synostosis with fascia lata interposition represents an effective treatment option in complex cases, particularly following osteosynthesis performed through the Boyd approach.
Background:Comminuted femoral shaft fractures present significant technical challenges in restoring length, alignment, and rotation. We present a case in which a nail-Schanz pin integrated external distractor was used to facilitate length restoration, controlled reduction, and maintenance of alignment. Case presentation:A 36-year-old male sustained a high-energy comminuted femoral shaft fracture with extensive posterior degloving injury following a motorcycle accident. Closed reduction and statically locked intramedullary nailing were performed using a nail-Schanz pin integrated external distractor. Gradual distraction allowed restoration of femoral length, and fine corrections of alignment and rotation were performed using a distractor under fluoroscopic guidance. Results:Radiographic union was achieved at 9 months postoperatively. Final assessment demonstrated negligible limb length discrepancy (+7 mm), 3° varus coronal alignment, neutral sagittal alignment, and no clinically significant rotational malalignment. The patient demonstrated a normal, pain-free gait and regained full range of motion of the hip and knee. Conclusions:This case demonstrates that a nail-Schanz pin integrated external distractor can be a useful adjunct during intramedullary nailing of comminuted femoral shaft fractures, enabling precise restoration of length and stable maintenance of reduction.
Background:Traditional Achilles tendon repair often requires incision of the paratenon, which may compromise tendon nutrition and healing. This report describes a novel paratenon-preserving repair technique that aims to maintain the biological environment and support functional recovery. Case presentation:A 41-year-old male sustained a complete Achilles tendon rupture while playing soccer. Surgery was performed within 24 h of injury. Intraoperatively, the paratenon was found to be completely intact. A locked cruciate suture technique was employed through the paratenon to repair the tendon without opening of the paratenon. The patient demonstrated uneventful recovery and returned to full activity by 6 months. Follow-up MRI at 3 months following surgery confirmed successful tendon healing within the preserved paratenon. Conclusion:Preserving the paratenon during Achilles tendon repair may promote biological healing and improve functional outcomes. This technique is especially useful in acute ruptures with an intact tendon paratenon.
We report a Gustilo-Anderson type IIIA open talar neck fracture (Hawkins type II) with medial foot dislocation after a fall from a ladder. Treatment consisted of single-stage surgical management including meticulous irrigation and debridement, anatomical reduction with screw fixation, combined with systemic antibiotics, local vancomycin application, plaster cast immobilization, and adjunctive hyperbaric oxygen therapy. Fracture healing proceeded without major complications, and screw removal was performed at 1½ years due to local irritation. At final follow-up, 3½ years after injury, the patient was pain-free in daily life and able to run up to five kilometers. Functional outcome was good, with an AOFAS (American Orthopaedic Foot & Ankle Society) hindfoot score of 87/100 and an FAAM (Foot and Ankle Ability Measure) activities of daily living score of 75/84 (89%). The patient remained active in sports but had limitations in squatting, jumping, and stop-and-go movements, reflected in the FAAM sports score of 17/32 (53%). This case report suggests that functional recovery can be achieved in open, dislocated talar neck fractures.
Background Isolated anterior wall acetabular fracture (AWAF) is a rare injury in adults and even rarer among the skeletally immature population. Case presentation We present the cases of two skeletally immature patients (a 13-year-old boy [case #1] and a 10-year-old boy [case #2]) with displaced isolated AWAF, surgically treated using the Smith-Petersen approach with osteotomy of the anterior superior iliac spine. Results The patients were closely followed up for an average of 18 months, presenting normal function and a concentric hip. Despite the good functional outcome, the latest hip radiographs of case #2 showed initial signs of a bony bar in the triradiate cartilage and the presence of avascular necrosis of the femoral head. Conclusion We emphasize the importance of long-term follow-up for skeletally immature patients with this type of injury, given the high potential for complications.
Introduction and importance:Cranial reconstruction after decompressive craniectomy is done usually at 20-25 per million people per year. The extra axial fluid collection is around 6% for subdural effusion and 6.1% for CSF leak and fistula. However, in Nepal, the overall complication of cranioplasty was 9% with collection of 4.1% and no any bone removal was done for epidural collection. Here I will be presenting a case that has rare complication of symptomatic epidural fluid collection after cranioplasty requiring removal of bone-flap. Case summary:45 years male underwent right Frontotemporoparietal Decompressive Craniectomy with Evacuation of Acute Subdural hematoma followed by lax duraplasty. After 2 months, he underwent autologous cranioplasty. On 5th POD, he had persistent headaches, became drowsy and GCS fell to 12 from 15. Immediate CT head revealed hypodense extradural fluid collection with midline shift and mass effect. Immediate removal of the bone flap was done and fluid was drained. He dramatically improved after operation and was discharged with GOS score of 4 after 10 days of hospital stay.Clinical discussion: Extradural fluid collection following cranioplasty is common complication but symptomatic fluid collection requiring removal of bone is not reported till date in Nepal. Conclusion:Cranioplasty is common but the rare complication of symptomatic epidural fluid collection causing mass effect and requiring removal of the bone flap may occur. Prompt investigation and urgent management are crucial for the good outcome of the patient. Preventive strategies for epidural fluid collection should be taken in all cases of cranioplasty.
Oropharyngeal impalement injuries in children are uncommon but potentially life-threatening, due to the proximity of vital neurovascular structures and the risk of airway obstruction. We report the case of a child who sustained an impalement injury from a reinforcement bar that penetrated the oropharynx, traversed the parapharyngeal space and exited near the preauricular region. Given the potential for disastrous complications, such as carotid artery blowout or need for surgical airway, the patient was managed by a multidisciplinary team including experienced anaesthetists, ENT, and vascular surgeons. Awake fibreoptic nasotracheal intubation was performed, followed by surgical removal of the object and primary repair of the oropharyngeal laceration under general anaesthesia. Despite the fact that the patient developed a transient grade III facial nerve palsy, which resolved over six months, no major structures were damaged. This case highlights the importance of early multidisciplinary involvement, advanced airway planning and awareness of neurovascular complications when approaching oropharyngeal trauma.
Background:Hair-thread tourniquet syndrome (HTTS) is an uncommon condition in which a strand of hair or fine thread constricts tissue, causing vascular compromise. Cervical involvement is exceedingly rare but can mimic intentional strangulation, leading to significant diagnostic and forensic challenges. Case presentation:A previously healthy 17-month-old boy developed apnea and transient loss of consciousness during co-sleeping with his mother due to accidental cervical HTTS. A tightly constricting strand of maternal hair was found encircling the child's neck, resulting in cyanosis and unresponsiveness. The hair was removed using scissors, and the child regained consciousness within five minutes. Forensic examination revealed a thin, circumferential erythematous mark and petechiae above the mark, with no airway compromise or neurological deficits. Whole-body imaging showed no fractures or additional injuries. The mother's long hair (40 cm) was confirmed as the source of the constricting strand. Multidisciplinary evaluation - including forensic assessment, scene investigation, police inquiry, and social service review - supported an accidental etiology. Discussion:Findings reported in the literature on pediatric HTTS have been summarized. Clinical findings consistently include a narrow ligature mark and facial petechia, reflecting vascular obstruction. Because these signs overlap with intentional strangulation, careful evaluation is essential to avoid both over- and under-diagnosis of child abuse. The pathophysiology involves rapid venous outflow obstruction and potential arterial compromise, with risk of cerebral hypoxia. Conclusion:Cervical HTTS is a rare but potentially life-threatening condition. Prompt recognition and removal of the constricting hair facilitate full recovery. Increased awareness among clinicians, forensic specialists, and caregivers is crucial to ensure appropriate investigation, accurate diagnosis, and prevention.
We report the case of a 19-year-old woman who experienced delayed hemorrhage 4 h after emergency liver repair for traumatic rupture. Digital subtraction angiography (DSA) confirmed that the source of bleeding was an anatomically variant right inferior phrenic artery (originating from the right renal artery), and the patient subsequently underwent successful hemostasis via transcatheter arterial embolization (TAE). This case reveals the masking effect of hypotension during compensated shock on vascular injuries and highlights the limitations of routine surgical exploration in identifying rare vascular variants. Furthermore, it emphasizes the necessity of a comprehensive management strategy based on preoperative imaging, dynamic intraoperative exploration, and multidisciplinary team (MDT) collaboration.
Background Kite flying in India and other South-East Asian countries is a significant cultural activity, especially during festive seasons. There is an increasing use of non-biodegradable kite strings like the Chinese manja has caused a rise in injuries not just to kite flyers but also to pedestrians and motorcyclists, sometimes even causing life threatening injuries. Case We present a rare case of a 27-year-old male patient who was injured by a kite string while crossing the road. He sustained a lacerated wound and a completely torn tendo achilles on the right side. Surgical debridement and end-to-end Krackow repair of the tendon was done using non-absorbable suture successfully. Functional outcome of the patient at 12 months follow-up was excellent. Conclusion This case highlights the rare but serious risk of Achilles tendon injury caused by kite strings. It emphasizes the need for public awareness, safety regulations, and enforcement regarding the use of hazardous kite strings. Early diagnosis and prompt surgical management are essential for optimal outcomes in such injuries.
Background: Bilateral upper limb superficial thrombophlebitis is rare in trauma patients and typically indicates systemic thromboinflammatory activation rather than localized vascular injury. Trauma-associated immunothrombosis is increasingly recognized as distinct from classical disseminated intravascular coagulation (DIC). Case presentation: A 35-year-old male presented with severe traumatic brain injury (TBI) following an unwitnessed fall. On hospital day six, he developed progressive discoloration of the left hand, rapidly involving the right upper limb. Doppler ultrasonography confirmed bilateral cephalic and basilic vein thrombosis without deep venous involvement. Platelet count declined from 40,000/μL on day seven to 10,000/μL on day eight, while prothrombin time and INR remained normal and fibrinogen levels were elevated. Admission chest radiograph was normal; however, repeat imaging on day eight demonstrated diffuse bilateral alveolar opacities. HRCT revealed extensive multilobar consolidation with surrounding ground-glass opacities, radiologically suggestive of severe diffuse alveolar injury with features compatible with alveolar hemorrhage. CTPA showed no large central pulmonary embolism. Repeat CT brain demonstrated stable extradural hematoma with resolution of subarachnoid hemorrhage and partial resolution of subdural hematoma. Anticoagulation was withheld due to intracranial hemorrhage and profound thrombocytopenia. The patient developed refractory hypoxemic respiratory failure and died on hospital day eight. Conclusion: This case highlights a rare and catastrophic systemic thromboinflammatory complication following TBI. Early recognition and multidisciplinary management are essential in similar rapidly progressive cases.
