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.

The Neck of Femur Fracture in an Elderly Patient with Schizophrenia and Parkinsonism Managed with Dual Mobility Total Hip Replacement- A Rare Case Report.

Introduction: Neck of femur fractures is the most common fractures in elderly people as they present with osteoporosis. There is a higher chance of proximal femur fracture in a schizophrenic patient as there is a loss of bone mineral density due to a drug-induced increase in the level of prolactin and immobility. Patients with Parkinson's disease were at higher risk for the development of hip fractures due to gait disturbances and instability. Case Report: A 63-year-old male patient presented with complaints of the right arm pain, swelling, deformity of the right arm, and difficulty in extending the wrist for 3 days. The patient had a history of falls and trauma to the left arm at home. X-ray right arm showed distal one-third spiral humerus fracture for which intramedullary nailing was done. X-ray of the pelvis with both hips showed right neck of femur fracture with associated greater trochanter (GT) fracture. We managed with total hip replacement using a dual mobility cup and tension band wiring for GT fracture. Postoperatively, the patient has a good range of motion at the hip. The functional outcome is good as per Harris's hip score. Conclusion: Neck femur fractures in elderly patients with associated comorbidities such as schizophrenia and parkinsonism are best managed with total hip replacement using a dual mobility cup. It avoids the risk of dislocation in high-risk patients and prevents secondary procedures. Careful clinical and radiological examination of the pelvis is very essential even in asymptomatic patients with a history of trauma to prevent delayed diagnosis of these types of fractures in patients with schizophrenia and parkinsonism.

Neurobehavioral effects of liraglutide and sitagliptin in experimental models.

Glucagon-like peptide (GLP-1) receptor agonists and dipeptidyl peptidase 4 (DPP-4) inhibitors are two currently approved therapies for type 2 diabetes mellitus (T2DM). Present study evaluated the effect of liraglutide (a long-acting GLP-1 agonist) and sitagliptin (a DPP-4 inhibitor) on nociception, anxiety, depression-like behavior and cognition in rats or mice. Nociception was assessed using tail-flick test; anxiety-behavior in open-field test and elevated plus maze (EPM) test while depression-like behavior was evaluated in forced swim test (FST) and tail-suspension test (TST). Cognition was assessed in EPM and Morris water maze (MWM) following memory deficit induced by pentylenetetrazole (PTZ) or scopolamine. In tail-flick test sitagliptin (6 mg/kg) produced transient nociceptive effect. Liraglutide (200 µg/kg) reduced peripheral square crossings by rats in open field test as well as reduced closed arm entries in the EPM, indicating a decline in exploratory behavior. In FST and TST models for depression, the duration of immobility with sitagliptin (6 mg/kg) was reduced significantly in comparison to control group suggesting its antidepressant effect. Liraglutide did not show any antidepressant action. In EPM test for cognition, liraglutide and sitagliptin ameliorated the increase in transfer latency caused by PTZ in a dose-dependent manner. In MWM liraglutide and sitagliptin prevented the scopolamine-induced increase of the escape latency. This study shows that sitagliptin has mild antinociceptive effect and anti-depressant effect in the animal models of depression while liraglutide did not have such an effect. Liraglutide showed anxiogenic effects in the animal models. Both liraglutide and sitagliptin produced cognitive improvement in the animal models.