Hypothesis 3 Open fracture of left front metacarpal bones with extensive soft tissue interruption including tendon laceration and nerve damage The calf was large and necessitated forced extraction at the time of delivery. Improper application of obstetrical chains put abnormal forces on the calfÕs leg at the metacarpal bones resulting in fracture of the bone. There was also extensive soft tissue damaged adjacent to the fracture site where the bone penetrated the skin and the chains were applied. There were extensor tendon lacerations as well. The resulting instability (from fracture and tendon laceration) causes the calf limb to deviate laterally distal to the injury when weight is applied (valgus deformity). Any healing that has occurred has happened in this position (likely malunion of the bony fragments). Poor management prevented the proper healing of this fracture/tendon injury and resulted in infection of the injury. Sequestra should be considered considering the open nature of the fracture and draining tracts noted superficially. The tendons healed malaligned causing a contracture on the dorsum of the calfÕs foot (tight bands of tissue palpated connecting toes to foot dorsum). This occurred because the calf heel was allowed to sag down when bandaged and casted and fibrous adhesions formed under the pressure of the bandages. The now shortened extensor tendons also account for the limited range of motion at the metacarpal-phalangeal joint. The skin wound resulting from the open fracture has attempted to heal by second intention (pink epithelium over the fracture sight), however, there is evidence of significant infection. The calf has draining tracts and pus can be actively expressed through manipulation of the limb. The skin wounds and infection have been exacerbated by the heavy bandaging and casting. Crepitation noted can be explained by the skin damage (subcutaneous emphysema and remaining bony fragments rubbing together. There is also likely some degree of nerve damage. The calf is dragging its leg and seems relatively painless despite the severity of its injury. Systemic involvement of the local fracture infection is likely, evidenced by the calfÕs fever.