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To start with our lesson of management of ankle fractures. Um Let me just check if the the screen is moving. Um Right. So ankle fractures are common and uh the these are one of the most common traumatic injuries that can occur in the lower limb, especially in young patients. Uh They're usually associated with uh traditional trauma which could mean uh force at an angle. The aim of treatment in these uh fractures is not only to restore the stability and the functioning of the joint, but also to maintain the neurovascular status of the ankle joint. Um because the foot is a relatively dependent area of the body and healing is not particularly ideal. Now, this manage uh this management of an ankle fractures is uh done to optimize functional recovery and also to reduce the chance of development of posttraumatic arthritis. Right. So the risk factors associated of course, are young, age, male, gender and uh smoking and alcohol consumption are generally factors which are associated with uh poor recovery following any injury. To discuss the anatomy of the uh ankle joint, please. Oh, wait, this is a video. So the you is not available to play unfortunately. Um but if we were to have a brief look, we can discuss it through x-rays, which are available to us in other slides. Um Generally, we have three bones that form the ankle joint. We have the tibia, the fibula and they are associated with the talar bone at the base. Uh the tibia and fibula together form a structure which is similar to mortis. Mortis is a wet shaped structure and at the base of it is the uh is the tenon, which is the talar bone um associated with the uh amorphous joint between the tibia fibula and the talar bone. Uh are the ligaments. Here, we have the uh superficial ligaments which is the superficial posterior tibiotalar ligament. The tibial calcaneal ligament, the tibial spring ligament and the tibial navicular ligament underneath them. The there are two ligaments. The anterior deep tibiotalar ligament and the posterior deep tar ligament ligaments of the uh ligaments still deeper to that. And also on the la uh lateral side is the posterior talofibular ligament. The calcaneofibular ligament and the anterior talofibular ligament. Uh along with the ligaments. We also have the syndesmosis. The syndesmosis are fibrous bands between the bones uh which essentially allow uh greater stability to the joint itself uh during ankle fractures. It is not uncommon for these syndesmoses to be torn along with the fractures of the bone. Uh important among these Syms is the interosseous membrane which runs between the tibia and the fibula. Um and this basically marks a five millimeter distance, less than five millimeter distance between the tibiofibular joint. There's the anterior tibiofibular ligament. Uh And along with that, we have the deltoid syndesmosis as well. Now, during this uh presentation, we will be including uh closed macular uh fractures and syndesmotic ankle injuries, but we will not be including depon fractures, open angle fractures, ankle and ankle fractures in immature patients. Uh ankle fractures can be classified based on uh two criterias. One is the Weber classification within the Weber classification. Um We look at the location of the fracture with reference to the physical distance it has from the ankle joint. So in Weber A which you can appreciate in this uh in this x-ray, just hold on a minute, please. Um Sorry, you're having a bit of technical difficulty. OK. That presentation which is basically you can access my neck, which this is supposed to be full, right? So Weber A would involve the uh fracture of the distal most part of the fibula. Um Weber B would involve the uh fracture of the fibula, which would also involve the uh rupture of the subotic joint, which is the anterior tibial fibular ligament between the tibia and fibula and Weber C which is over here, which would be a higher fracture of the uh fibula uh in relation to the ankle fracture. Uh The differentiation between these fractures can obviously be appreciated on looking at the location of the uh fracture. But also you can uh discern the level of fracture by means of the distance between the tibiofibular clear space. The higher the fracture generally, the greater will be the separation or the greater will be the clear space between the tibiofibular joints. Next, we have the leg Hansen classification. Leg Hansen classification has more to do with the uh nature of the injury and how the injury has occurred. Uh And it has 13 parameters by means of which we can classify the injury uh in different positions, which is supination, abduction, supination, external rotation, pronation. Uh to name a few here are a few of the examples with supination and induction. Uh You can see that the fracture uh would involve different syndesmotic uh fibers and uh bones. It can also happen in supination with external rotation, pronation with abduction pronation with external rotation. And once a fracture happens, it may present clinically with symptoms of swelling bruising. It can be, it can be associated with pain, uh especially if you touch or weight bearing. It is often associated with deformity around the ankle which is an emergency of its own kind. And it is often associated with difficulty walking or a limp uh ankle fractures present commonly with synostotic injury as we previously established. They can also come in the form of an open fracture because it is at the end of the day, a traumatic fracture and peritoneal tendon tears as well as chondral injuries, ok. When documenting a ankle fracture, it is important to note the comorbidities of the patient which can uh lead to decisions regarding clinical management as well as uh prognostic uh features of the injury. Uh It's important to note if the patient ha has any uh mobility impairments along with mobility is utilized. Uh if so, uh also it's important to uh determine the bone health. So it's important to ask about osteoporosis and renal disease. It's important to establish neurovascular integrity. So it's important to ask about peripheral neuropathy, diabetes, colitis, and peripheral uh and existing pad. And of course, as you mentioned, lifestyle factors such as smoking and alcohol abuse are also always prevalent and important questions when asking about any traumatic injury. So the investigation of choice uh in the diagnosis of an ankle fracture is almost always an x-ray. What's important in x-rays is uh de determine which kind of view you want in regards to the injury. And also the uh the second line of investigation that we usually do for ankle fractures is a CT scan which is done to determine the clinical uh uh to, to determine surgical uh o options or frequent options. Now, x-ray ankle series, according to both guidelines, uu utilize the true lateral and moist view. However, clinically, uh clinicians have been your uh surgeons have been prone to also order the AP view. Now, it's important to understand the difference between an AP view and aortic view, we already established that aortic uh the mortice joint or the ankle joint, it it is called the mortis because it resembles uh Amor antenna, which is, which is an uh a design use for stability generally in carpentry. So if you were to compare the AP view with the mortice view, you can appreciate that the tibiofibular overlap in AP view is greater as compared to the mortice view. In the mortice view, you can clearly appreciate the shin line. The shin line is an imaginary line that runs between the tibiofibular and the talar joint. Uh it has uh in the mortage view, there is no overlap between the bones, so it is clearly visible and if there is any uh displacement of the tibia with regards to the uh thus bone, it can be clearly appreciated in the mortage view. Uh Similarly, we can also appreciate the tibial fibrillar distance better in the mortage view as compared to the AP view. The difficulty generally arises in uh achieving a true mortage view because with ankle fractures, uh patients present with deformity and extreme pain, they're not able to weight bear and technicians often have difficulty in getting the right view. So the the uh gold standard for an ankle fracture is to order a mortage view as well as a lateral view. Now, there are a few things that you can appreciate when looking uh at a a mortage view for an ankle fracture. We already discussed the gentle line which is an imaginary line that runs between the tibia fibrillar and talar joint. Uh In case of a, let's say, if, if we were to look at the example, A, uh we can see that this would be classified as a Weber B fracture uh as the uh fracture in the fibula is above the anterior uh uh tibu fibular ligament and we can appreciate that the shin line has been interrupted. Another point of note is the dime sign. The dime sign is an imaginary uh dime or circle shape, uh uh circle shaped uh imaginary line that that basically occurs between the this uh the style process of the fibula and the talar bone. Uh in case of a fracture, there is deformity and you can notice an interrupted dime sign in the lateral view which we previously discussed, you can appreciate uh the position of the thus bone with regards to the tibia. And again, you can see in case of any fractures, they will be apparent on any, in case of any displacement, they will also be apparent on the lat of you. Um There is a third kind of view which is the dynamic stress view. Within the dynamic stress view, you want to cause external rotation of the ankle in order to get a very specific kind of view. So if you can appreciate uh this x-ray, you can see that the stability of the joint becomes apparent with a dynamic stress view. This is a kind of an ap view um with specific positioning which you have to often request for technicians. And you can see that if the tibia and thus bone are not well approximated, the joint is not stable. The patient is not able to bear weight and an and an unstable joint, often surgery and early surgery has uh is the most appropriate option. So again, this is from uh a treatment point of view in order to establish whether or not uh you need to intervene immediately or you can give a few more hours to the patient. One other kind of special fracture is the meenu fracture, excuse my pronunciation. I'm not uh not native for this uh language but the meenu fracture is a higher fibular fracture. In this case, there is a high fibular fracture which may or may not be associated with a distal fibula or distal fibular friar fracture. The hallmark sign of the fracture is the anterior uh the tibiofibular space is more than five millimeters and the displacement between the tibia uh tibia and the uh and the talar bone is more than one millimeter. So the management of ankle fractures can be operative and non operative as is the case of is uh as in the case of mo most orthopedic fractures for non operative management. Uh There is a very specific criteria. Uh the fracture has to be undisplaced. Uh uh the the fracture has to be of undisplaced of the media of the lateral mallear malleoli. Uh It can be the isolated lateral malleolar fracture which is less than three millimeter displaced and there is no talar shift or there is a posterior malleolar fracture with less than 25% of the joint space involvement or less than two millimeter step off. It is always important to thromb patients. So thrombo uh thromboprophylaxis, uh risk assessment or VD risk assessment should be done according to hospital protocols, pre op and of course, POSTOP for non operative management, start with analgesia. Uh The varieties we use for realignment of the joint and to increase comfort in patients is either a short leg ao splint, a short leg cast or a cam boot. Excuse the spelling of say, please in case of a deformity around ankle and assessing the neurovascular status. Like I said, if there is a deformity, there is a greater risk to the neurovascular integrity. In such cases, reduction and splinting should be done sometimes even before radiographs if they cannot be immediately done. Operative management of the ankle fractures include sp plating cal uh tous or Meller, screws, mallear screws, excuse me and tension band wiring. Now, when approaching uh the ankle fractures, you can take different approaches, medial posterior or lateral. Uh in a lateral approach, you would approach by way of the fibula. Uh you have to give us an incision 10 centimeter above the tip of the lateral medialis and superficially to the peroneal nerve. Uh Unfortunately, we were not able to play the video for the anatomical structures uh which showed the n uh nerves, uh nerve supply, the arterial supply as well as the presence of uh different bones in, in the ankle joint. Uh but upon a review, I I'm sure that you will find it very helpful and you will see uh in regards to the lateral meiosis and uh or other bones of the uh lower limb where exactly the superficial peri uh peroneal nerve is now the skin incision is slightly inferior to the eight la through insertion. And between Peroneus tertius anteriorly and per peroneous L and B posterity restore fibula lens to provide lateral but to LS through with neutralization plate, provides compression and per stability counters to increase area of contact between bone and through head. Uh You can use different kind of plates, the lateral plate, the anti light plate and the posterior little positioning of this plate. The middle me approach will be from the uh middle side and that which is the tullar side. Um Here, the cancellous leg screws are used preferably uh and anti plate is placed prior to joint, a vertical fracture and perpendicular if uh perpendicular to the fracture line, two K wires or mini fragment plate uh is used if the fragment is too small or is communed, we can also have the poster approach POSTOP management of uh ankle fracture patients. Uh basically involves management of orthopedics as well as physio. So the patients should be allowed to weight, bear as much as they tolerate um within the splint or cost unless there are specific concerns regarding the stability of the fixation or contraindications such as peripheral neuropathy or particularly concerns about the status of soft tissue complications. Uh of ankle fractures, most commonly include swelling and numbness of the left limb. This is exacerbated with patient noncompliance or patients uh not keeping their uh lower limb elevated. Uh So this is extremely important to counsel them properly regarding it, infection, bleeding and pain are risks in almost all infec uh all surgeries, uh important complication include nonunion, malunion, POSTOP arthritis or POSTOP stiffness. Uh after surgery, patient should be followed up in fracture clinic within six weeks of surgery to detect complications and POSTOP x-rays should obviously done to confirm the maintenance of reduction on radiographs. Thank you very much. If there are any questions, please let me know so many people off. Um I how is, yeah, some people in your house 11 on online should be and then all questions at the hospital. You can, you and my knees are a great presentation and thanks a lot. Any questions in the room here. Uh II, do apologize regarding uh the technical issues. I think the video would have been extremely helpful. It was a 3d animation of where the neurovascular structures are in regards to everything and what was it from? Was it? Um, no, it was a, I don't exactly know which youtuber had put it up but I uh but I edited it so that it was uh relevant to our. Um uh no, it, it, it does not play and also, um I wish that but uh I had a note written out from the present which was not. Um OK. My question was regarding that we can and then here from observation, we see that mostly for that very strong feeling, a very from surgeon to surgeon. And it also depends on how happy you are with weight bearing and with your fixation. From my point of view, I, the reason for my philosophy on it is that if I'm fixing an ankle fracture, it is to give them an advantage to what they have before that advantage should be a being able to the b being able to wait down. So many advantages being a weight bearer, you get patient mobile, get out of the hospital quicker, less chance of DVT, better range of motion, ankle, better muscular control, all this kind of stuff. Um So that's why I fix the ankle fracture, but like why your hip fix the hip fracture, get your patient up and around. Otherwise, you know, if you fix it, then just say no, they're not much better than they were before in terms of the complications. So I always fix it. So ankle fractures, either stable or not stable. If they're stable, don't need an operation to get walking on it. They're not stable, fix it so that it is stable. So you can walk on it uh to reduce the risks of not so muscle waste dvts, chest infections, prolonged admission time, social admission, then go on to that bed sores, pressure sores from the plaster, they inevitably be et cetera, et cetera. That's my philosophy on others might have a different. So with regards to the guidelines, um they, they're available, it's a 16 point uh manifesto as regards to what one should do. Um their main concern uh is the post arthritis and stiffness in the ankle joint. And um because it's a dependent area and because it's a very sensitive area, they want early mobilization. Yeah. Um They talk common about weight bearing as well. Yeah. So they want weight bearing, weight bearing. Yeah. Yeah. I don't know what the evidence is suggesting. Postoperative uh posttraumatic arthritis versus weight bearing. All I know is weight bearing is better for the patient, uh early weight bearing. If you can do it, sometimes it'll just be horrendous and you sleep better and you have to do AF and N or N or whatever. And then in those rare cases, perhaps you be scared of weightbearing. Um But most of the time I think you should fix it with a construct that you are gonna be happy that they can work on, at least within the combines of the room uh and then come out of the boot while they're in bed and just get me out of the room cos otherwise, yes, you will get stiffness. You will get. Uh, that's why II don't like the glasses POSTOP either. I think that's what it is for me. It's just rude or nothing. Another one of the complications that's quite common we've seen in the wards as well is that oftentimes these injuries are um, uh they're associated with superficial injury as well, even though the fracture is not technically an open fracture, but the of the skin, there's confusion or a laceration. And over time, what happens is that uh because of the nature of the injury, um, blistering is a very, very common complication. Yes. And when we put them in boots for too long, especially can boots, what happens is that they start? I mean, again, uh these patients are often, well, the ones we receive, um, that are often a above 50 or your comorbid and we're seeing more and more involvement of PN because of associated, you know, discomfort because of the boot. So, yeah, it, it would, it would make sense to try to get them, get out of the boot while I'm in bed, get the ankle moving. Yeah, but for me, only for mobilize. No, when they're getting around. Oh, ok. Um And even technically speaking, if you fixed it as more confidence you have. It's, it's just comfort not for the actual stability of the fracture, which is interesting because we tell them that the boot is there to make, to keep it stable and to prevent soft tissue injury, I tend to use a lot more because I and then I find so tiss more with that. Don't take it off if you fix the construct as stable as you can, you can still plaster for two weeks. Just let the first two week, he, some people do that. Some people will plaster for the first two weeks just and then the and then I think I'm arguably a little bit more aggressive than, than most. Um And I, and I'm always more conservative. It's good to have one generation difference training 11 more. But it is so it is true to say the more um or will want to the, the for any, any loading fracture, make a construct or replace a bone to a level that they can fully wear down. Otherwise you're just decorating it with metal and there's still a lot of metal with pencils, um, and chest infection and all that. So for me, the, the boot is, you know, I don't, II don't even mind after the operation they're not in a boot, they just come back to the wall. I just have a boot by the side of the bed because for me, the boot should be uh superfluous to need and if you're relying on a boot for stability, you've not fixed it well enough. Mm. Ok. Another thing that I've noticed and this is very specific, you trust our department and our trust is that we, um, we don't really turn anyone away. So I've seen operative management of patients again for, for structure severity, for patients above 60. But according to both guidelines, they don't really recommend that every single time because um they prefer, according to them, they prefer for there to be treatment, a surgical treatment, uh preferably for patients who are more mobile, who are under 60 for the ankle for the ankle. Yes. I mean, ankle should be as high dependence. The fact it's stable or it's very stable or not stable, unable. I mean, old people say you can still keep them in a stable position and faster and stabilize. But then you really mold pass, you could do that but unsafe seven if it's stable or not stable, if unstable, fix it, so it's stable. So you can walk on it if it's stable, walk on it, either way, walk on it. It should be the product and we was in orthopedics. Um I if you read the book Principles of, I don't know if you've seen that one or you seen that one. It's, it's a really old tradition which it teaches how to put casts on and how to manage