Preliminary analysis confirms that delivering TES in inhospitable terrains in a Public Private Partnership mode is doable and is welcomed by the community.

Pretibial wounds are often associated with prolonged wound healing, particularly in the elderly female population. The wounds characteristically have either a proximally or distally based flap. Delayed wound healing has been attributed to flap necrosis and poor blood supply to this area. The aim of this review article is to examine the vascular anatomy, pathology and management options of patients with pretibial wounds.

A 46-year-old gentleman attended the emergency department with a history of blunt trauma to the right side of his chest allegedly from falling against a table the day prior to his attendance. He was complaining of shortness of breath and pain on the right side of his chest and a chest X-ray was performed to rule out a traumatic pneumothorax. The chest X-ray ( Fig. 1) revealed several fractured ribs on the right side in three different stages of healing. There was a new/recent fracture in the right tenth rib posteriorly which possibly was from the injury sustained the day prior to his attendance. There was another fracture in the right eighth rib, which had started healing with callus formation, the age of which was estimated to be within 4-6 weeks. There were two other old healed fractures in the sixth and seventh ribs on the right side. On further questioning following the X-ray examination, regarding the mechanism of the injuries, the patient reluctantly admitted that he was being assaulted (punched and kicked) on a frequent basis by his female partner. The patient was not willing to involve the police or the social services. DiscussionDomestic violence against men is much more common than it is perceived to be. There were an estimated 2.5 million incidents of domestic violence acts against men in England and Wales in 1 year according the recent British crime survey report. 4 According to the survey 2% of men (in comparison to 4% of women) were subject to domestic violence in a period of 1 year prior to the interview. Among men who suffered domestic violence, 14% suffered a moderate physical injury and 1% suffered severe injuries. Ninety-four percent of men subject to domestic violence did not think that what happened to them was a crime. Female victims are six times as likely as men to report that they were subjected to domestic violence. 5 Statistics from a survey in Canada reveal identical rates of spousal violence for men and women. 6 Rib fractures in children are due to high energy localised trauma and raise suspicions of non-accidental injury in the absence of an appropriate explanation of trauma. 2 A literature search did not reveal any reports of multiple rib fractures in adults as a presentation of domestic violence. Due to the variety of presentations, there is no fracture pattern considered pathognomonic of adult abuse. 3 As in the above cited case report, multiple fractures healing at different rates without an

Introduction: Blunt traumatic injury of innominate artery is uncommon and has been reported only in 132 cases. In the literature there has been a solitary case report of a stroke resulting from an innominate artery injury. We present a case of traumatic injury of the innominate artery resulting in an ischemic stroke.Case presentation: A 20-year-old gentleman ejected from a two wheeler and run over by a truck presented to us with multiple bleeding facial wounds and severe crush injury of his upper torso. Bedside chest X-ray revealed a widened mediastinum and multiple rib fractures with pneumothoraces bilaterally which were drained with intercostal tubes. An hour into his stay in the ED he developed left hemiparesis. CT brain showed infarcts in right temporo-parietal and occipital regions. CT angiogram of neck vessels revealed an avulsion injury at the origin of the right innominate artery with pseudoaneurysm formation.Discussion: The innominate artery is the 2nd most common site of great vessel injury after the ascending aorta. 71% die before reaching the hospital. Patients who present to the ED are often stable with associated major injuries including rib fractures, pneumothorax and closed head injuries. The diagnosis is aided by a thorough clinical examination or a chest X-ray revealing a widened mediastinum as seen in our patient.Lessons learnt: Severe upper torso injuries involving the clavicle and upper ribs with pulse deficits or unexplained neurology should always raise a strong suspicion of major vascular injuries warranting further evaluation.

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