IntroductionCoronavirus disease 2019 resulted in postponing non-emergency elective surgeries beginning in April 2020. Our hospital successfully restarted elective orthopaedic surgery during the pandemic to help improve the quality of life of patients with chronic disabilities.This study describes the development of local protocols and pathways to allow for a safe restart of elective orthopaedic surgery in a COVID-19-free 'green' site. It includes the morbidity and mortality outcomes of those patients who underwent non-emergency orthopaedic operations during this time. MethodsThis is a prospective cohort study over an eight-week period evaluating 104 patients undergoing nonemergency orthopaedic procedures through a COVID-19-free surgical pathway. The primary outcome measure was 14-day postoperative mortality. The main secondary outcome measures were the development of a COVID-19 infection in the hospital and 14 days postoperatively as well as the need for intensive care unit admissions. ResultsNo patients developed a COVID-19 infection. There were no intensive care unit admissions or postoperative deaths during our study time frame. There was no statistical difference seen for age (< 70 or > 70), gender, body mass index, or American Society of Anesthesiologists (ASA) grades in the development of postoperative complications. ConclusionsThis study describes a roadmap to setting up a protocolised elective operating service for orthopaedic surgery. It has shown that standardised protocols in a COVID-19-free 'green' site, preoperative COVID-19 testing, and adherence to national guidelines on self-isolation can help prevent developing COVID-19 infection postoperatively and reduce the risk of postoperative mortality.

Associated fractures of the atlas and axis are frequent, particularly in the elderly patients following a simple low-energy fall. This injury can be easily misdiagnosed on initial plain radiographs, and therefore computed tomography scan is a useful adjunct in patients with a degenerative spine. There is still no consensus as to the optimal treatment of combined axis-atlas fractures, and the majority of authors propose a therapeutic strategy dependent on the odontoid fracture pattern. We describe a combined atlas and axis fracture in a 92-year-old patient who was managed with nonoperative treatment in a rigid collar. The association of C1 anterior arch with a C2 type II odontoid fracture is a rare combination, which to our knowledge has never been reported following nonoperative treatment. There was a good functional outcome at 1-year follow-up with the fracture progressing to a fibrous nonunion of the odontoid process.

BACKGROUNDTypically, greater tuberosity fracture of the humerus are described in combination with proximal humeral fractures or in association with shoulder dislocation. 1 -4 According to the AO statistics, less than 2% of all operatively treated proximal humeral fractures were isolated, mildly to moderately displaced fractures of the greater tuberosity. 5 However, undisplaced greater tuberosity fractures of the humerus may be under-diagnosed and therefore be more common than suggested in the literature. 6 Very few similar cases have been reported. More specifi cally, Kaspar and Mandel 7 reported the fi rst case of a full-thickness tear of the rotator cuff associated with an extensive cavitary bone defect in the superolateral proximal humerus. This case was described as "acromial impression fracture of the greater tuberosity with rotator cuff avulsion". More recently, Dodson et al 8 reported complete rotator cuff tendon avulsion and glenohumeral joint incarceration in a young patient. CASE PRESENTATIONThe patient was of 47-year-old, right hand dominant male weighing 70 kg. Other than having tablet-controlled diabetes mellitus, he was fi t and healthy. He was ex-army personnel, having left the service about 17 years previously and experienced nightmares related to his previous army placement. One night, dreaming he was being chased by enemy troops trying to bomb his base, he jumped off his bed and landed with his body weight onto his right upper extremity. Trying to protect his head, he hyper-abducted his right shoulder and as a result, hit his right shoulder against the wall. The next morning, he experienced severe Other full case Acromial impression fracture of the greater tuberosity with massive rotator cuff tear: this need not be a nightmare!

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