The simultaneous exposure of tissue and bone poses specific management challenges. Patients with extended soft tissue damage and high-grade compound fractures present a demanding clinical challenge, requiring a complex approach and multiple orthopaedic, plastic, and vascular-reconstructive procedures. Management involves combinations of wound debridement and closure by secondary intention, use of vacuum-assisted closure (VAC) devices, and various reconstructive plastic surgery methods. We present three consecutive complicated cases, involving compound fractures of the lower limb with massive soft tissue damage (Gustilo-Anderson type IIIB) that were managed with debridement, application of external fixation and VAC device. The mean wound size was 24 cm in length and 12 cm in width. The aim of treatment was to cover the bone with soft tissue and achieve healing of the fracture without persistent infection. Wound healing was achieved in all three cases within 30-42 days (mean 34). In one case, the skin graft was applied on day 33. Utilizing this method as part of a multi-directional approach, the VAC system helps the patient recover faster. Moreover, it acts as a feasible and valuable method to treat compound fractures with massive soft-tissue defects. VAC can replace microsurgical soft-tissue transfer, reduce the risk of infection and allow salvaging the limb.

Femoral nerve palsy secondary to iliopsoas non-traumatic haematoma is a scarce complication with a treatment approach that remains controversial between conservative and surgical intervention. We present a case of a 64-year-old male patient under warfarin medication, who developed severe left hip and anterior thigh pain and femoral nerve palsy with no history of trauma. Laboratory studies revealed a prolonged international normalized ratio level of 4.5, and imaging studies revealed a large haematoma surrounding the left iliopsoas muscle (35 cm x 9 cm x 6 cm). The patient was treated conservatively with discontinuation of his anticoagulation remedy and vitamin K administration and recovered almost fully after eight months, following a rehabilitation programme. Patients who are on anticoagulants should raise a high index of suspicion. Conservative management can provide a good outcome; it requires, however, a long period of rehabilitation.