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I never liked being asked questions as a registrar, not particularly. And so these are sort of my ramblings through my thoughts rather than a um a question and answer session. Some of you have been to the West Suffolk will be used to my ramblings. Um But they are really to try and get you to think from basic principles because that's the way to pass the exam and that's the way to approach most problems in foot and ankle, especially in trauma. Um is trying to break, break things down to simple principles. Work from that if you do that in the, examine your past and then once you, once you go through that and actually the more difficult decisions become a bit more logical. Uh So I will go through ankle fractures, which can obviously be a really boring presentation or could. So I've tried to think of a way of uh just making it about the mechanism and the basic principles of what you need to think about what I try and think about when it in an ankle fracture. So did I, I think I won't be able to see you so shifted. I've never done this. So if I do this and then do this and then I think you should be able to see it. Can everyone see that, Maria? Can you see that? So we're gonna do ankles. So this is my brain. Um So we're all aware of the boast guidelines, which if you read them are a bit bland, but when you try and read them and then pick out some salient points, number eight, number nine mentioned the word stable or stability. And when you're trying to decide whether you should or how you should treat an ankle fracture or whether you should admit them or whether you need to do or not or not, you need to think about whether it's stable or indeed the stability of the factor because if they're stable, you might not need to do an or if and if they're unstable, uh you might need to. So making a decision about stability is the primary thing you need to chart to try and do. So that leads me on to thinking what is stability? So I could ask one of you to try and define stability. Um And you all have your own thoughts as to what that might be and why I've shown a picture of some building blocks and one of my kids are small with a small truck running into them. Uh huh. Stability is the ability to withstand physiological force. So then when you think of stability in terms of the ankle. Well, you still got to be able to allow movement. Um, but you're still at this with that, you need to be able to, you want to prevent the taylors from moving from side to side. In other words, having Taylor shift because we all know that from those original papers, which I put the reference there, um, you only need a millimeter of Taylor shift and you change the contact pressures in your, in your Taylor's more likely to get arthritis. So we're pretty into the Taylors is pretty intolerant of shifting. So stability is massively important. So when you're talking about the stability of the ankle, what what gives it that stability and it's the same with any joint, you're really going to talk about the shape of the bones uh and the ligaments which attached them together and then the muscles and the neuromuscular control of the tissues around it. So remember that the Taylors is not a cube, well, not, it's not a equal sided block. It is triple trapezoidal. I don't know how to say there is a mortise, a bony mortars with the medial malleolus, the lateral malleolus, and also the poster malleolus. And that mortis like a mortise lock gives it some of the stability for those bones are held together by the deltoid on the medial side, the lateral ligament complex, not just the ATFL and also the sindhis notice. So all of these factors are involved in the stability. And therefore when you apply a pathological force, not a physiological force, some of those, one of those things gives up one or more. So that made me think what actually is an unstable ankle fracture? How would you define it? So, to me, it's two fractures or more, well, it's one fracture and a ligament rupture. But unfortunately, x rays which you'll love to do on that good at showing us what a ligament rupture is unless it's displaced. So we use things like Taylor shift of a millimeter or medial clear space or tip tip overlap, but sometimes you can't see it. So people say, well, should get an ultrasound, should get an MRI scan, which is maybe uh something which would all love to do, but it's not very practical. So then what you've got to think about is the pattern of fracture and to some extent that can predict whether something stable or unstable. So when you're a first year or a ST one or two, you might think that this is the way to define ankle factors, whether it's a weather A or B or C, but it's pretty basic, doesn't, it doesn't really tell you anything about what happened to the soft tissues and then you try and get your head around this, the log handsome classification, which can be a bit mind blowing the idea that you have some, where your foot goes. The super nation are you when you land and then what happens to the afterwards. So what I've tried to do is combine the weather and this large hands and classification. Because if you do that, then you start to get an idea of what's actually stable, what's unstable and that fits into the patterns of our clinical practice every day. So combining the two, if you have a weather. So what a large Hanson classification does it say on the previous slide when you land your supinated and then you a deduct your foot, essentially go through a stage one and stage two, the Super Nation external rotation injury, you go 34 stages, 1234 ATFL, 1st 3 to 4 plantation abduction, three stages. So when you uh when this uh mechanism happened, you go through one of these stages with each one. So when you have an X ray with the weather, a fracture, that is a stage one. So that's why it's stable because it's only injured one side of the joint. It could be that you don't have a web of a fracture with a Super Nation abduction injury, you just have an ATFL injury and again, that's stable. So if you have a Weber a or an ATFL injury, it's a stable injury. Therefore, you can be mobilized and discharged, which is what you're doing the VFC. But as soon as you have an X ray with a vertical medium malleolus fracture to get that, you've either got an ATFL injury or whether a injury as well because it's a stage two of the Super Nation abduction injury. So as soon as you the a vertical medium malleolus fracture, it's unstable and that's where the Irish law just to highlight unstable one. So therefore you, they need an operation because it's an unstable fracture or would it be? So whether we subornation, external rotation injuries are about 56% of what we see in a fracture again. And you got to whether it be that external rotation process gives you a fracture stage two. So first of all, you, you do, you do the 80 fo second, you do the, then you do your fibula fracture. So they're both on the same site, it's still stable. So what you need to decide is whether you've got a type three post area, either ligament or the bone or a medial fracture or a deltoid injury, you've got a medial fracture, you'll see that on your X rays. So you've got a stage four, we know it's unstable. The problem with these Super Nation external rotation injuries is that you sometimes just get soft tissue at the back and soft or soft tissue at the medial side. So you can't see it on an X ray. So the other people that you need to bring back to clinic for a weight bearing actually, because you need to tell between this type Super Nation external like type two, I just above the be fracture on its own or a type three or four, which may just be a soft tissue injury because once you've got a three or four that's unstable, you need to fix them and you do that. So with the weight bearing actually, and you get your Taylor shift. So you're looking for Taylor shift. What about actually with the weather, see fracture on it? Uh to get a web, a C fracture, you have a pronation, external rotation or indeed a pronation, a rotation, abduction injury injury. So this just shows external rotation. It's all about the pattern of the weber see fracture, whether it's a short oblique or whether it's a long spiral, essentially get a very similar picture in the two types of injury with urination. So stage one, you get a medium money on the strange or just a deltoid injury. Stage two ATFL and then you get your weather seafront. So when you get a weather see fracture on an X ray, it's unstable and that's why we fix weather seat. You can even go onto a type four, which is when you get upholstery of monuments. So that might be a bit confusing those three slides. So, but that's essentially chose to narrow down what we do, but he doesn't really tell us much about Malleolus fractures which have become a bit sexy as a fix over the last 5, 10 years so that they've got their own classification unfortunately, but they're all to do with external rotation. The type ones are a small fragment. The type twos are a lateral fragment and or a medial fragment which I think Rachel talked about just before. Then. The type threes aren't really external rotation injuries, their actual load injuries a bit like the Park pill in some charity was showing this is the Mason and Malloy classification. So weather sees and also Weber classification. And Lord Hanson gives you most fractures. Obviously, he's a posterior malleolus fractures. So if we try and summarize that in one slide, Weber a factors, they are stable, we don't need to fix them vertical medium, malleolus factors are unstable as there are super nation reduction type two where the bees with no Taylor shift, rser type two. So they're stable once you've got Taylor shift with a better be and or a medium malleolus and or upholstery malleolus, that's a three or four. Therefore, it's unstable. Weather sees are always unstable but medium molly or wrist fractures are usually unstable because you're likely to have a lateral ligament injury as well. And poetry and molecular structures are always unstable because of the mechanism. So this fits in with what we do most days, whether it was sent home a vertical medium Aaliyah issued, want to fix whether these are the ones you see in clinic. You do weight bearing actually to try and see if the type two or type three. Whenever sees, we always assume a deltoid or syndesmotic injury. So you tend to fix them medium malaria's fractures. They're the ones that you look at and think. Well, it's just a medium malleolus. But if they're starting to have lateral tenderness, our lateral signs or lateral swelling, you should consider with it, even if it's isolated, try and fix it, given doubt, fix those ones. And then the posterior miles, they normally represent a type three or type four of a more serious injury and therefore, should consider fixing them. So then briefly, what do we think about where we want to acceptable? You want to restore its length and its rotation. That's what the lag screws for, isn't it? When you try and put that clamp on and lengthen it and then rotate it internally and you're trying to correct this talocrural angle, which is this angle between these two lines and it's supposed to be about 8 to 15 degrees. But I think that's a little bit hard to judge in theater, but it's just this idea that the figure is slightly longer and then converge a dime sign is another thing I found on the internet, which is this idea of a curve down the bottom of the, of a lateral process of the table. You're always going to put your leg script scrutiny. If you can, if you can't, obviously, you might want to use a neutralization plate. Uh sorry, a bridge plate, not a neutralization plate is a vogue towards using locking plates because they're nicer shape. Um, and you get more screws in distantly, but you have to question in a young person whether that's useful or not. Obviously, there's been a couple of, there's a recent broad study on that. Anyone who's worked at West Suffolk knows that we sort of try and avoid using lock inflicts unless you really have to. Um, but there's some advantage in the osteoporotic group, the diabetic group or indeed, if you're in the um uh trying to mobilize them early group, I've used a couple of 3 billion nails. The ones where you get the locking screws in distantly are slightly better than the old fashioned rush pin type things where it's just essentially a pin up the fibula. Um But it is quite hard to get an anatomical reduction. Although I don't think there's any obvious difference in the outcomes because it's probably hard to measure the difference, but you can use one and I think acumen do the most commonly used one again. Proteus screws are a love of mine. Um As we talked about with the pill on fractures, you're trying to think about the angle of or the direction of which the fracture might fail. And so when you've got a community fibula, uh especially in the elderly or a diabetic, then the idea of using what we would call pro tibia screws. In other words, Syndesmotic type screws running into the tibia to get a hold because you're trying to prevent the foot and a fracture failing. And valgus, you can use as many as you want. 3456 screws. It's about getting good hold in the, in the tibia and the tibial cortices to, to stop the fibula failing. These are those ones that are just the bones really soft and you can't get any hold. Um, one of the things that some people sometimes do with these things because they're often in the elderly is use a hindfoot nail, but hind foot nails do have their problems. Yes, they give you good stability. But the idea of an unprepared uh ankle joint and a handful nail, the patient's hated normally, especially if the foot's in a slight uh Equinix position. So this is a more achievable uh way of fixation from most surgeons. And I think it's, I've never really seen this method fail whereas I've, I've seen a lot of problems with the hand foot nails, triangle front. So what about that? Medium malleolus? Uh This is on the, but from the bow fast website, but we're all aware that you can get different side fragments of the medium malleolus. Uh Sometimes people think it's uh cleverer to use a small incision, but that's associated with a slightly poor outcome. There's no harm in making a proper incision. Um You don't have to be, it doesn't have to be huge. But the idea of visualizing the fracture, making sure you've got a proper reduction, looking over the front of the medium area list towards the Taylors looking at this corner here. But there's different ways of fixing fragments of different sizes for these B and C one, you'd use one or two screws, depending on the size of the, these little abortions you'd normally try and leave. Unless you thought after fixing the fibula, there's still some tilt of the tables and these des, these sort of almost vertical medium malleolus, they're the ones that need the anti glide plate than syndesmosis. You need to make sure that you fix your fibula first and then you can assess uh and also maybe the poster malleolus because that's really the main way of getting your centers motions reduced because of those post your ligaments. Um But if you confirm it's under stable by a hook test or an external rotation test, um or just by your original X rays where you can uh measure the tip tip overlap or the tailor shift or the medial clear space. Then if you, if you decided that you're gonna fix it, Howard, how did I do that? But I would put a clamp on, I don't tend to use two screws and I tend to do four cortices. Uh Some people use tight rope, that's fine, that's a bit tricky to start with intended of the learning curve. And they are more expensive. This idea of not over tighten in the club, you can't over reduce a Cinders notice. So I think it's got hard to judge, um, what's too tight. Uh And so there'd be, I don't think there's any great way of not. I don't, I don't know, there's any great way of judging what's too tight and what's tight. So I think it's quite a tricky one but trying to think about not over clamping it. In other words, you're not trying to squash the shit out of it. Uh And then the clamp itself needs to go on the ridge of the fibula and the ridge of the media tibia just so that it's got good hold and it's not trying to translate the fibula pressure anti. Uh and then last but not least. So this Mason and Malloy classification, this is a team from Liverpool and so in a type one that's small thin fragment, we're really talking about this idea of it, ignore the size of the fragment. You don't have to do a post your approach. Just think about syndesmotic fixation in whatever way that you would normally do, most fractures would fit into this 2 a.m. or to be. Uh And again, you then have to choose whether you're going to do a pressure lateral or a poster lateral and or poster medial. There's a bit of a move these days in the especially the Liverpool group about doing most of these factors through the post remedial approach and choosing a window. So somebody can recently talked on the a a faculty course and it was very much about the pastry immediate approach to the tibia and the Liverpool group of highlighted it with a lot of the cat of Eric studies that you can reach the entire back of the tibia at the ankle from the post remedial approach. But I think that's quite a big learning curve, not something I do very commonly, the type threes, these post reappeal. And again, it's suggested that Mason Malloy suggest that you do these poster immediately. But I think most of us would feel probably most comfortable doing these posters. Actually, that's just a idea. Again of what uh verity was talking earlier about. If you go immediately, you can go to the side of the tendon and then you really come up right down on the bed of FHL if you go medial post remedial, so more around towards the medium malleolus. Again, you have to choose your window or you gonna go between the tendons, you're gonna go back at the FDL and you obviously get given your vascular bundle. So you have to choose your window in that one where you maybe like Maria was talking about where you've got a medium malleolus, but you kind of want to sneak around the back to get part of the to be fractures. Um Then maybe you could just go between tip posts and FDL. You don't have to go in this zone here. So that, and then you could probably use, just still use the same incision to sneak around for your medium. Mario does fracture if you've got sort of two parts. This one, it's not something I've done very often. I tend to go from here and from this side. But again, why not? Just go down the side of the media side of the tendon and then you, you, you hang onto FHL belly and then down towards the joint, towards the back of the subtalar. Don't you're going to get the FHL tender post your natural approach, we're all used to. You got the nerve and you got the post uh toenail artery, right? That's the end of that one. Let's talk about it. If I quit that, I think that will work and then if I go back to stop showing, there you go. So a bit of me talking, I suppose. Um So are there questions? Is anyone confused? Uh Is it too much? Are we not bothered? That was awesome, Mr Von. Thank you. So, to me, it's about if you understand the mechanism, which is really the large handsome classification and then a bit of understanding postrema liotta's fractures in terms of the classification of the mechanism of either external rotation.