Abstract Chronic skin eruptions may follow the acute reaction to envenomation by some jellyfish, the incidence and management of which are not well described. We describe management with topical tacrolimus of a chronic eruption following envenomation by Pelagia noctiluca (‘mauve stinger’), one of the most common stinging jellyfish in the Mediterranean Sea. An 8-year-old girl was stung on the arm by a P. noctiluca in Menorca, Spain. First-aid measures with vinegar and topical antihistamine were administered, and the discomfort settled within 24 h. Five days later, the sting site became increasingly painful and itchy, with superficial ulceration and arm swelling. A second sting site on the lower leg reacted in a similar manner. She was systemically well. She was treated with oral co-amoxiclav, fusidic acid and betamethasone valerate 0.1% cream, and nonadhesive dressings. She initially responded well, but was required to continue the use of potent topical steroid after 3 weeks, as the symptoms recurred within 48 h of halted application. The use of topical tacrolimus cream 0.03% achieved symptom control when used in a slowly weaning regime over 3 months, with a brief flare of skin symptoms around the time of contracting COVID-19. She has now been asymptomatic for 12 months, and the sting site is a maturing scar. Envenomation reactions to jellyfish of the phylum Cnidaria (including P. noctiluca) are the result of varying pathophysiological mechanisms. The tentacles and bell of P. noctiluca carry toxin-releasing epithelial organelles called nematocysts. When triggered, the stinging apparatus fires, injecting thousands of mineralized spine-covered tubules and toxins such as porins [Yanagihara AA, Wilcox C, Smith J, Surrett GW. Cubozoan envenomations: clinical features, pathophysiology and management. In: The Cnidaria, Past, Present and Future (Goffredo S, Dubinsky Z, eds). Cham: Springer, 2016; 637–52]. Acute tissue damage and inflammation are caused by physical trauma and venom effects. Vinegar used at the time of a sting may permanently prevent discharge from unfired and noninjected nematocysts. Hot-water immersion for 30 min inactivates venom, and topical steroids reduce inflammation. The delayed and prolonged skin response (presenting after the primary reaction to envenomation), as in our case, is likely to be an immunological response to the retained, embedded nematocyst structures and may include granulomatous reactions, and eventually scarring. Optimal acute first-aid measures (as above) are thought to reduce incidence of late skin sequelae. This report highlights the successful use of topical tacrolimus immunomodulation for an established delayed reaction.

•Modified application of heel external rotation test detects deep deltoid instability in AAFD.•Spring ligament sectioning causes non-significant increase in tibiotalar external rotation.•Deep deltoid is the only medial ligament, when sectioned, to cause significant tibiotalar external rotation.

Objectives: While operative fixation is the current recommendation for treating significantly displaced tibial plateau fractures (DTPFs) in elderly patients, our research suggests that non-operative management may also be a viable option as the primary treatment for these individuals. Our study aimed to evaluate the clinical outcomes of patients with complex DTPFs who received non-operative management as their primary management. Methods: Our study involved a retrospective analysis of non-operatively treated DTPFs during the period of 2019 to 2020. We included all patients for the evaluation of fracture healing and range of motion (ROM). Additionally, we conducted functional outcome assessments on all patients, utilizing the Oxford Knee Score (OKS) both before their injury and at the 10-month mark after their injury. Results: The study included 10 patients, comprising two males and eight females, with a mean age of 62.9 years (range: 46-74). Among them, four patients had Schatzker Type III DTPFs, two had Type V, and four had Type VI. Non-operative management was administered using hinged-knee braces, and patients progressed to weight-bearing gradually, with a minimum follow-up period of 10 months. The average time to bone union was 4.3 months (range: 2-7). The mean Oxford Knee Score (OKS) after the injury was 38.8 (range: 23-45), with an average reduction of 16.9% (p = 0.003). The average fracture depression was 11.41 mm (range: 4.2-29), and the average fracture split was 14.03 mm (range: 5.5-44). Conclusion: Based on our study, it appears that elderly patients with significantly displaced tibial plateau fractures (DTPFs) can be treated non-operatively as their primary management, despite the current consensus suggesting otherwise. Level of evidence: IV

Background: Calcium sulphate is a recent alternative for delayed antibiotic elution in infected bones and joints. The purpose of this study is to evaluate the use of antibiotic impregnated calcium sulphate (AICS) beads in the management of infected tibia and femur, with regards to patient outcomes and complication rates (including reinfection rate, remission rate and union rate). Methods: Searches of AMED, CINAHL, EMBASE, EMCARE, Medline, PubMed and Google Scholar were conducted in June 2020, with the mesh terms: "Calcium sulphate beads" or "Calcium sulfate beads" or "antibiotic beads" or "Stimulan" AND "Bone infection" or "Osteomyelitis" or "Debridement" AND "Tibia" or "Femur". Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of interventions (ROBINS-i) tool, and quality assessed via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. Results: Out of 104 relevant papers, 10 met the inclusion criteria for data extraction. Total infection remission was 6.8%, which was greater than that of polymethylmethacrylate (PMMA, 21.2%). Complication rates varied. The main issue regarding AICS use was wound drainage, which was considerably higher in studies involving treatment of tibia alone. Studies using PMMA did not experience this issue, but there were a few incidences of superficial pin tract infection following surgery. Conclusion: Where AICS was used, it was consistently effective at infection eradication, despite variation in causative organism and location of bead placement. Wound drainage varied and was higher in papers regarding tibial cases alone.