Giant Cell Tumor of the Second Metatarsal Managed with Ray Amputation: A Rare Case Report and Review of Literature.

Introduction: The giant cell tumor of bone (GCTB), also known as an osteoclastoma or a myeloid sarcoma, is a benign local aggressive osteolytic bone tumor that primarily affects skeletally mature young adults typically 20-40 years of age. Giant cell tumors (GCTs) are usually solitary tumors and very rarely are found in the metatarsal bones. The characteristic histological appearance of GCT displays a high number of osteoclast-like multinucleated giant cells, which resulted in the classification "osteoclastoma" or "giant cell tumor." Case Report: A 38-year-old male presented to the hospital with a firm swelling over the 2nd metatarsal slowly progressing over a period of 4 months, initial screening radiological investigations included X-rays, X-rays showed a tumorous growth involving the shaft of the 2nd metatarsal of the right foot, and the X-rays showed a characteristic soap bubble appearance. Magnetic resonance imaging. On gross assessment, the intraoperative sample showed that the GCTB has a dark brown-to-reddish appearance that is friable in texture. The gold standard for diagnosing a GCT is based on biopsy histopathological findings. The key histomorphologic feature is multinucleated giant cells. Conclusion: Giant cell tumors are frequently locally aggressive with high recurrence percentage, hence, excision was done. Nowadays, early radiological screening techniques help early detection of such rare occurrence of tumors such as the GCT and appropriate management. In conclusion, the giant cell tumor of the bone is a unique presentation of stromal cell and hematopoietic interaction in the bone.

Morel-Lavallee Lesion Associated with Subtrochanteric Femur Fracture in a Young Female Resulting in Extensive Soft-Tissue Necrosis and Hypertrophic Non-union Managed with Staged Surgeries and Exchange Nailing: A Rare Injury Pattern and Review of Literature.

Introduction: Morel-Lavallee lesion is a closed degloving soft-tissue injury which occurs as a result of acute traumatic separation of skin and subcutaneous tissue from the underlying fascia and muscle layer. The most common sites include thigh (peritrochanteric region), abdomen, scapula, and paraspinal area. Early diagnosis and management of the lesion is essential so as to prevent complications such as infections or extensive skin necrosis. The management options include conservative or operative depends on extent, location of lesion, and duration since injury. For the management of underlying fracture, one should take into the consideration, the soft tissue compromises which can occur if lesion is large at presentation and plan accordingly for either primary definitive fixation or staged surgeries as necessary. Case Report: A 25-year-old female patient presented with pain and swelling over the anterolateral aspect of the right thigh after a traumatic road traffic accident 2 days back. On radiological investigation, there was subtrochanteric femur fracture with a butterfly fragment. The patient also had Morel-Lavallee lesion on local ultrasound. Emergency management was done for Morel-Lavallee lesion in the form of percutaneous drainage and compression bandage; fixation was done in the form of external fixator. The wound progressed into complete skin necrosis so external fixator was removed and thorough wound debridement was done. Fracture stabilized with four TENS nails (titanium elastic nail). Removal of the TENS nail and exchange nailing in the form of intramedullary interlocking nail was performed after complete soft-tissue healing. Bony union seen at the fracture site clinically and radiologically at 3-month follow-up. Conclusion: Initial screening of lesion is very important at time of presentation. Early definitive fixation should not be done if the lesion is large and one should fix the bone once the lesion is resolved.

Management of a Gap Non-union Patella Fracture Using Encirclage Wire and Tension Band Wiring with Quadriceps V-Y Plasty in an Elderly Patient: A Rare Case Report and Review of Literature.

Introduction: The management of gap non-union patella fractures continues to be a challenge in orthopedics. The incidence of these cases ranges between 2.7% and 12.5%. The quadriceps muscle attached to the proximal fractured fragment pulls it proximally leading to the gap at fracture site. If the gap is too large, there won't be any fibrous union resulting in failure of quadriceps mechanism and extension lag. The primary aim is to bring the fracture fragments together and restore the extensor mechanism. Most of the surgeons prefer single-stage procedure, in which mobilization of the proximal fragment, followed by fixing with the lower fragment is done using V-Y plasty or x lengthening with or without pie Crusting. Others use of pre-operative traction to the proximal fragment using pins or ilizarov method. In our case, we used single-stage procedure whose results were encouraging. Case Report: A 60-year-old male patient presented with pain in the left knee with difficulty in walking since 3 months. The patient had road traffic accident 3 months back and sustained trauma to left knee. On clinical examination, there was palpable gap of more than 5 cm between the fracture fragments, anterior surface of femur and condyles was palpated through fracture site and knee range of motion was between 30° and 90° of flexion, and X-ray suggests of patella fracture. Midline 15 cm longitudinal incision was taken. The insertion of the quadriceps tendon over proximal pole of patella was exposed and pie crusting was done on medial and lateral side and V-Y plasty was done. SS wire was used to hold the reduction of the fragments by encirclage wiring and anterior tension band wiring done. Retinaculum was repaired and wound closed in layers. Postoperatively, long rigid knee brace was given for 2 weeks and walking with partial weight-bearing started. After suture removal at 2 weeks, full weight-bearing initiated. At 3 weeks, knee range of motion started and continued till 8 weeks. At 3 months post-operative, the patient is able to do flexion up to 90° and no extension lag is present. Conclusion: Adequate quadriceps mobilization during the surgery along with pie crusting and V-Y plasty with TBW and encirclage combined gives good functional outcome in patella gap non-unions.