Background: Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tunnel beneath the pectoralis minor. With an ultrasound scan along the brachial line, the brachial plexus cords in the subcoracoid tunnel can be targeted using an in-plane needle approach. We describe this new approach to the infraclavicular block called the “subcoracoid tunnel block.”Case: Twenty patients were administered with the ultrasound-guided subcoracoid tunnel block for the below-elbow surgery. The contact of the needle tip with cords was visible in all 20 patients. With neurostimulation, the posterior cord was identified in 11 (55%) and medial cord in 9 (45%) patients on the first needle pass. The subcoracoid tunnel block was successful in 16 patients (80%). Conclusions: Our case series shows that the subcoracoid tunnel block is an excellent alternative technique for the infraclavicular block. Its advantages include better needle-cord visibility and easy identification of the brachial plexus cords.

This case series describes the use of ultrasound (US)-guided dorsal sacral foraminal block (DSFB) for providing postoperative analgesia in six patients who underwent foot and ankle surgeries under spinal anesthesia. Postoperatively, all of them received a US-guided DSFB at the level of the brim of the second sacral foramina (SF2). Needle placements were confirmed with fluoroscopic (FL) images and injected radiocontrast defined the diffusion with a postoperative CT scan. The images obtained depicted ipsilateral spread in the sacral epidural space, sacral nerve roots, and plexus. The US-guided DSFB could be effectively used as an alternative method for postoperative pain relief after foot and ankle surgery.

The most serious complication of Paget's disease is sarcomatous degeneration of pagetic bone. Multifocal sarcomatous degeneration occurs mainly in polyostotic Paget's disease. Paget sarcomas are the most threatening sarcomas of bone irrespective of the histopathology, their prognosis being far more negative than primary sarcomas. Paget's disease is a common entity but osteosarcoma arising in Paget's disease is an infrequent complication. The skull involvement is even rarer. We report a case of malignant transformation of a skull lesion in a patient of polyostotic Paget's disease. Skull radiographs, computed tomography and magnetic resonance imaging scans of the tumour area show interesting results.

 IntroductionRadiocarpal dislocation is an uncommon entity in traumatology. Proper management depends on the type of dislocation and the presence of concomitant injury (1) . Associated injuries are common with radial styloid, ulnar styloid and marginal avulsion fractures predominating. Open injuries with significant soft-tissue disruption can occur, leading to persistent instability (1) . The paucity of reported cases and incomplete understanding of the spectrum of associated injuries has not permitted a consensus on treatment recommendations.  Case ReportA 55 year old male sustained a fall from a height of around 5 feet on an out stretched hand at home in April 2015, with impact on the ulnar aspect of the right wrist joint. Following the fall he developed a wound which was around 4 cm x 3 cm. The wound was associated with pain, swelling and deformity around the wrist joint. There was loss of extension of the medial two fingers at the metacarpophalangeal joints. The ulnar artery pulsations were not palpable; however the capillary refill time was normal. The sensations were intact over the cutaneous distribution of the ulnar nerve.Pre-operative radiographs of the wrist joint including the forearm were obtained in the antero-posterior and lateral views. The x ray showed a fracture of the radial styloid process and radio-carpal dissociation with a dorsal and lateral displacement. Initial treatment was in the form of wound irrigation, sterile dressing and immobilization with an above elbow POP slab.After an informed consent, surgery was conducted 6 hours from the time of injury. Following through wash and debridement, the fracture and radio-carpal dissociation were reduced and stabilized with ligamentotaxis with Kirschner wire augmentation. Wound closure was done. Ulnar artery was found transected and the cut ends ligated, which was done as part of primary care outside our centre. There was no attempt at arterial re anastomosis as the capillary refill time was found to be normal. Tendon repair was also not carried out in the same sitting.Post-operative period was uneventful and the patient was followed up regularly. At 3 weeks following surgery the stitches and Kirschner wires were removed and the wound was dry and had no discharge. The external fixator assembly was removed 6 weeks following surgery. Following removal physiotherapy in the form of active and passive wrist mobilization was initiated.Twelve months following surgery, the patient was found to have good range of motion at the wrist. Flexion was up to 80 0 , extension was up to 50 0 . Supination was restricted by 30 0 with no restriction of pronation. However there was complete ulnar nerve injury distal to the wrist which was evident clinically by the presence of ulnar claw hand and wasting of the hypothenar eminence. This was further confirmed by nerve conduction velocity testing of ulnar nerve. The patient was given the option of tendon transfer but the patient party declined this plan of action.

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