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Okay. Hi, everyone. Um Hope you're all doing well. Thanks for joining us again for our final session. Um We've got Rosie with Hackney with us today and she's the boat, a rep from Edinburgh and she's here to teach just about foot and ankle x ray interpretations and some common injuries that you might see. Um, while an orthopedics, if you have any questions during the session, just pop them in the chat box and I'll release the feedback from the end. Okay. So I'll hand over to Rosie and we'll get started. Great. Thanks very much. Um So we are going to talk today about foot and ankle, sort of common pathology. A few things I think would be interesting for you guys to know if at any point, as killer said, if you want to stop and ask some questions, I've allowed time in that in the presentation. Um And also just a huge thank you to Caitlin and the British orthopedic medical students associational bombs uh for having me today. So, a bit about myself. So I'm Rosie, I'm one of the S T four's in trauma orthopedics and the South East Scotland run through program and as Caitlyn said, I'm also the South East Scotland representative for Botha. So what we're gonna do today, so, um, we'll start off by with ankle fractures. So common things are common, but ankle fractures, I think can be quite daunting. Lots of people can spot an ankle fracture, but it's really what you're trying to spot when to worry and when to fix and when to refer up to orthopedics or indeed, when you're in orthopedics, when to refer to the operating room. Well, then talk about hallux valgus because it's a very common thing. And you'll often find lots of your family members shoving their toe in their face asking what's wrong with it. Liz Frank injuries fairly interesting and again, something not to miss achilles tendon pathology and then finally, compartment syndrome, we all know that's very important. Um Going through all of this seems a little bit daunting, but we'll just take it step by step. And as I said, at any point, if you want to stop, um and ask some questions, then please, please do. So. We'll start with the ankle really to cover the ankle properly. Want to discuss the anatomy first and foremost. So we often in orthopedics, we talked about the integrity of the ankle mortise, which I think sort of assumes knowledge that perhaps not everyone has, the ankle consists of three bones. So you've got the distal aspect of the tibia which the bigger thicker bone, the distal aspect of the fibula. On the lateral side, the outside of the ankle represents the lateral malleolus and then the taylors which articulates between the two of these. So they are the bony component of this ankle mortise. And with as with your bones, you got to have things that then join them together. And these are the ligamentous complexes. So they're all important syndesmosis, which you'll have heard a lot of people talking about. Um And that's the kind of inferior tibiofibular complex. So the thing that joins the fibula to the tibia um in that tibial incisura, you then got the lateral collateral ligament complex, which most people will have injured or will injure at some point in their life, going over on their ankle, off a curb. And then the medial collateral ligament complex, which you have heard as the deltoid ligament complex and the stability of the ankle firstly relies on the bony configuration. That's why it's so interesting fractures. But also on this ligamentous stability. And you've really got to have both to have a properly stable ankle. So if we just go a little bit deeper into these lateral collateral and medial collateral ligament complexes, so, the lateral ligament complex, that's the stuff running from the fibula onto the tailors and the calcaneus, there's three components. So at the front, you've got the anterior taylor fibula ligament, which you will hear people call the ATF L. And when you get a kind of boggy swelling there and tenderness just anterior to the distal aspect of the fibula. That's what people will often have as a result of an ankle sprain. So you damage that ligament. Inferior lee connecting the distal aspect of the fibula to the calcaneus as a calcaneofibular ligament and posteriorly, you guessed it is the tailor fibula ligaments in orthopedics, you know, anatomy, we tend to keep things nice and simple. Um So really just say what you see and um what joins what to what on the medial side of the ankle, the deltoid complex, you've got superficial part of that which runs from the uh tibia down to the calcaneum. So that's the tibia, calcaneal ligament and the deep part which consists of anterior posterior part which runs from the tibia and Taylor's and talotibial ligaments. Um So it's just worth noting where those are in relation to the bony anatomy when you're trying to consider soft tissue injuries where you're gonna palpate what on patient's um and what may well be swollen if they've injured them. So, the syndrome Asus. So syndrome assis is this tight elastic band that holds the distal tibia and fibula together. And it's uh really is the kind of a cornerstone of the ankle mortise. It's got three parts. So the anterior tibia fibular ligament joining the anterior aspect of the tibia, I think actually put a point of here. So let me just get that uh anterior aspect of the tibia to the fibula, you've got the posterior tibial fibula ligament which joins the posterior part of the tibia to the fibula. And then between it, you've got this interosseous ligament, which is a really sort of fibrous tissue that binds the fibula into the tibial notch, which is known as the uh incisura and it just keeps it in nicely there. So that's the syndesmosis, these two ligaments, anterior posterior and then the fibrous uh interosseous ligament between. So why do we worry about the ankle mortise? Well, if you have an injury to the bony component and the ligamentous component, then you will disrupt the ankle mortise, disrupt the mortise congruity, which is otherwise known as Taylor shift. And I can never run here someone what's calling it Taylor Swift. Hence, she will always feature in my foot and ankle slides. So essentially what happens is normally in the ankle mortise, you've got this lovely, fairly symmetrical space running laterally superior early and then immediately when this is disrupted, you get abnormal loading of the contact area of the taylors in relation to the tibia or the medial aspect of the fibula and you get abnormal loads to the articular cartilage. That's why we're so pedantic in orthopedics about having an adequate reduction. Um It's because we want this ankle mortise to be restored in order that there's not any abnormal load going through the tailors or the tibia. So how do we spot taylor malalignment or Taylor Swift? Taylor shift. So we're looking at this medial clear space and really just looking at the these parallel lines coming up and over the Taylors from the tibia remain parallel and not sort of sitting wonky indicating Taylor's may well be tilted. You can see here, it's narrower here and wider here because the tape Taylor's is tilted and then this medial clear space has increased. Generally, a kind of general rule of thumb is anything over four millimeters may well be pathological. What I tend to just compare it to the lateral clear space and they may well also have previous films or films of the other ankle, but also see here. So there's tilting of the taylors beneath the tibia. But also if you follow up the lateral aspect of the taylors and then look at the lateral aspect of the tibia, they have a normal ankle X ray which you can see here, they usually line up. But on this, you can see that there's a step there demonstrating that the joint is no longer congruent and this X ray really demonstrates well, why we're so bothered about this? You can see that will be really abnormal loading of that part of the talus as it hits up into the tibia. Does anyone have any questions about taylor shift malalignment, the ankle? Water before we move on, you can always ask them later. Yeah, there's no questions right now. Thank you. So if you're working in accident emergency I don't know what stage everyone is, whether they are medical students foundation your doctors. And if you're working in accident urgency, you will be the person decide whether someone gets an ankle X ray or not. And something I think is certainly covered in the Edinburgh and Curriculum Ottawa Ankle rules. And it's really just relying on your examination before, uh, just ordering an ankle X ray on anyone. Anyone. Obviously, if someone comes in with a pretty band or mechanism, injury, deformed ankle with gross swelling and they're not walking on it, you know, to get an ankle X ray. But if there's any do bitey, these rules are sometimes good to kind of hark back to. So it's any tenderness over the posterior aspect of the distal tibia. And that's um the medial malleolus, any tenderness over the posterior aspect of the distal fibula, which is the lateral malleolus can also palpate the base of their fifth base of the fifth metatarsal on the lateral aspect of their foot, which is often a commonly injured bone known as a Jones fracture base of fifth metatarsal fracture managed conservatively nine times out of 10 and also tenderness over the magnetic Euler as well, which is the bone on the medial side of the foot. So any tenderness there consider getting an X ray and that's bony tenderness rather than tenderness of any of those soft tissues that we discussed earlier. Little surround distant aspects of the tibia and fibula, but really can the patient walk. If a patient comes to offering into any still wearing their high heels, they probably not got an ankle x an ankle fracture. Okay. So things to consider, how do we know whether ankle is stable or unstable? So, we've obviously covered the medial and lateral malleolus as possible sides of pathology. But also the fact here we've got the posterior malleus malleolus. So these are your 3 may leola, posterior, lateral and medial. So we're considering the stability of it. I ankle fracture, we need to consider are the medial malleolus or posterior malleolus involved. Okay looking at the X rays. And if they are often they are unstable fractures, by definition, they are more than just a fibula fracture. They are a by or a trimalleolar fracture and they are something that needs referring up to the orthopedic service for considering a fixation and then the Weber or Veber or Webber classification. So this is where the fibula fracture is relating to the Cinders Maciste. And this is something I often will ask medical students if they're in the operating theater. Is this the weather A C or B or C and 3% of the time they get it correct that A is in prison. Syndesmotic. So distal to the uh syndesmosis be is at the level and see is super syndesmotic. So proximal, a good way of remembering and how I remember it is that whether a fractures represent generally an a version fracture of that lateral uh lateral collateral ligament complex. And therefore, it's just a small flake sometimes it's more, but it's just how I remember it just come here, just a small flake. And it's always interesting demotic then we got to think is the tailor city in the correct position, which is what we've covered when we've discussed the ankle mortise. So that medial clear space is the taylors lining up with the lateral aspect of the tibia. Um And whether or not it's looking tilted and is there a suggestion of a syndesmotic injury? So again, is there Taylor shift is they're widening of the Sindh osmosis. So just covering the vapor classification as well, we've got the type a infra syndesmotic type B at the level of the syndesmotic syndesmosis and type C which is above. And you're looking, some, sometimes people get confused. I think the spike here is above the level of the syndrome osis. You're looking at the medial cortex of the fibula from your considering whether it's whether B or C okay. And if that's uh the fracture is below, that's what you know, at the level of that. And it's a weather be so generally whether a fractures are stable. However, if they can be uh by mail Eola in nature, uh and that's where the ankle will have been pushed and punched out that medial side. And it's a Super Nation adduction injury, it's a pretty nasty injury and you need a nice big buttress plate there in order to fix the medial malleolus back into position. And generally, you can just leave this small avulsion weather a fracture to heal on its own. Don't need to fix those whether be these are the ones that uh you know, cause some discussion. So if they are you Neema Leola, just that weatherby fracture of the fibula, they can be stable or unstable. And that's really as to whether or not this deltoid ligament complex, which you'll remember is on the medial side of the ankle, the medial malleolus, whether that's intact or not. So on examination, you may well find that a patient has a really swollen, medial side. Um but really you're looking on the X rays whether or not the taylors is incongruent. So these are two basically identical fractures. You can see that this looks very similar to our example, fracture here, that long spike extending. And on this one, it's stable. You can see that the medial and lateral clear spaces are symmetrical, nice parallel lines running between the tailors and the distal tibia. Whereas this one, there's Taylor tilt, this line coming up here has shifted, it's no longer a straight line and the medial clear space is clearly widened. So there is an injury there to the Sindh osmosis and it will be unstable and therefore requires fixation. Uh Question is what do we do with these? Now, generally in most units. Now, if the fracture isn't obviously unstable on initial radiographs obtained in that emergency department and they look like that, then you put a patient in a weight bearing moon boot and you ask them to walk and you x ray them at one and two weeks. Okay. So that's basically if it's unstable, it will declare itself and you will see it on X ray. If it's stable walking on, it won't displace it and the patient's ankle will remain congruent and we'll go on to heal. This is a case where you've got a by mail Eola fracture here. So you can see that there's that sort of avulsion type fracture of the deltoid ligament complex. There's clearly something going on there and the medial side is disturbed, there's Taylor shift, there's um tilting of the talus and then that line there is also disturbed. It's unstable. It's by mail Eola. So you fix the fibula, put a syndesmosis screw across in order to restore the congruence of the ankle mortise and then put these screws in the medial mall and where necessary super syndesmotic that's above level of sin is Maciste. These are inherently unstable. It's a pretty impressive looking initial X ray here. And actually all it's all you do is fix it with a nice syndesmosis screw. In order to reconstruct that stabilizing some asthma assis in these. The general rule is anything more proximal than the distal third of the fibula. You don't fix. Okay. So that's why this fibula fracture has not been fixed. And the medial malleolus fracture you can see just here will have reduced nicely and therefore not needed fixation. Unlike this one, which looks like it probably didn't reduce very nicely and therefore was fixed. What about isolated medial malleolus fracture? These are often, often can be unstable. And the main thing and why I put this in my slide is these can still be by mail Eola fractures, but the fracture may not well be visible in just your plain radiographs you get in A and E and it may well be way, way, way up at the head of the fibula right up next to the knee. And that represents a mason nerve injury or mason nerve fracture, the proximal fibula, okay. And if there is amazing nerve fracture, that means that the the energy of the fracture has gone through the medial malleolus through the syndesmosis and disturb that and come out through the top of the fibula. And therefore, you can say safely say really that there is a syndesmotic injury that requires some fixation. Here's an example of a posterior malleolus fractures. This is a posterior mall here, see that there's a step in the joint there. We don't like steps in joints that represents joint incongruity who have abnormal wear of the articular cartilage there. And the patient will go on very rapidly develop post traumatic arthritis. Very occasionally, the posterior may Leola fragment. As with the as with a lateral malleolus fragment, you malleolar fragment may well just be an avulsion fracture. So small flake and they can be managed potentially nonoperatively providing that you reconstitute the damaged sin diagnosis, but larger fragments should be fixed. It's sort of an area of them constant discussion orthopedics at the moment because on a two D radiograph, can you really ascertain how large something is, you know, if it looks small, is it more, is it larger on the lateral side, etcetera? Um So most of these will go on to have a CT scan to try and assess the size of that posterior malleolus fragment and also plan how you're going to fix it. And this is one that's been nicely fixed here. So, still confused, I hope not. But it is a sort of challenging thing to, to learn in how many minutes we've been going for. Um But basically are the medial malleolus and posterior malleolus involved. These generally mean that they are unstable. You've got to check whether or not the fibula is intact approximately and you can do that on examination, you know, is the patient tender, but it's best to get an X ray because if you miss it, you know, you've missed an unstable ankle fracture, you've got to look is there Taylor shift and also look at what the size of that posterior malleolus fracture is as to whether or not you need to get that fixed from the back where in the fibula is an isolated fracture. So generally, these interests into asthmatic weather. A fractures are stable. We trial by walking for the weather B's and whether Cizar unstable, if the Taylors is in the incorrect position, the ankle factor is unstable and requires fixation. And is there a suggestion of a syndesmotic injury? I is it by Mallia trimalleolar has a mason nerve is a tailor shift. It is an unstable fracture. So I'm gonna be moving very quickly onto just touching on pelon fractures which are distal tibial fracture. But if anyone's got questions on ankle fractures, I can answer them just now. There's nothing on the track just yet, but I'll keep, I'll keep posted. Thank you. So, Pillon fractures. Um So the word Pillon or tibial platform fracture comes from the French word for pest all. And we think about pesto and mortar. You have a pesto going into the mortar and crushing anything that's in it with it. High energy force. And that's exactly what the Taylors does to the tibial platform, it smashes up into it secondary to an axial load. So you will often see uh tibial uh distal tibial pelon fractures in patient's who have, for example, have an attempt on their life and a suicide and jumped off a building or a tall wall or something. Um And they will have this smash of the Taylors up into their tibial performed and they get this distal tibial fracture with intra articular involvement. Okay. Now, as I've said, these tend to be high energy injuries. So your first and foremost thing you say when someone presents you with an X ray that looks like that is I would take an 80 approach in conjunction with my accident emergency colleagues, allowing an A T L S approach would ensure that their airway breathing circulation and any anything else um involved in the patient's uh systemic wellness is addressed first, before addressing the limb itself, this can often be open. So you need to have that circumferential assessment of the limb. You need to have a thorough assessment of the neurovascular status of the limb. Um And generally, these are not something that you can kind of just pull nicely and reduce in the emergency department as is the case with ankles. These are regarded as a soft, severe soft tissue injury really with a kind of mashed up bony component in them. So they are a real challenge to manage. Okay. Um A lot of them have tibial fracture, sorry fibula fractures associated with them around 75%. And so that's why a lot of people think it's an ankle fracture. It is not an ankle fracture there managed um you know, fairly differently and its high level of expertise in order to get them fixed. General management. Although where I work in Edinburgh, we tend to just fix them primarily and not do this um is to span them with an external fixator. And what that does is kind of restore any uh congruity of the fracture that you can, you then scan them with a CT scan, which is what this is showing here. And you can see, you know, that's articular cartilage really at 45 degrees to the joint, this kind of uh mush for lack of a better word. So, um it's a pretty, pretty smashed up pill on fracture and then plan, you've got a plan how you're going to address this multi fragmented uh fracture with open reduction and internal fixation. But you can't obviously just have multiple, multiple wounds around an ankle which has just had a high energy injury and that just results in misery, wound breakdown and infection. So span scan and plan, but ultimately a definitive fixation or unfortunately, in some cases, amputation. Hi, we're moving onto toes next. Any questions? Oh, yeah, we've got a question here. Um Somebody just asking how does diabetes and peripheral vascular disease affect the management of ankle fractures or sort of follow up? Yeah. So one of the issues with diabetes is obviously peripheral neuropathy. And you'll find unfortunately very often that patient's who have diabetes and poorly controlled diabetes also have to go to hand in hand with that often have a larger body habitus and therefore increased weight going through your ankle fixation. So, if I had a patient who had poorly controlled diabetes and who had peripheral neuropathy. Um First of all, most I would change how I fixed the ankle. So you can either do a big approach here which where you your incision is based from here to here in order to get your plate and screws in can change it to do what we call a fibula nail, which is what this is here. It's a bit more of a minimally invasive approach. So you just do a small cut here and a small cut here and a small cut here and I mean, small by sort of a centimeter to get this nail in and that just reduces the disturbance, too soft tissues. Um I'd also be a little bit more reticent about allowing them to wait there immediately. But that is also you have to balance that between not allowing them to wait there to protect your repair. Um whilst also allowing them to wait there, wait there because the morbidity associated with not weight bearing. Someone who is overweight, obviously with pulmonary embolus deep in thrombosis is great. And also a lot of people who are uh unwell with their diabetes and have peripheral neuropathy, etcetera, um can't get home if they're non weight bearing. So you're trying to just balance that out. If someone had a really, really smashed ankle where reconstruction would be, you know, multiple incision, prolonged approach, lots of soft tissue damage, then you would consider primarily whether or not doing what we call a hindfoot nail where you put a nail up through the taylors, through the calcaneus and in straight into the tibia to just fuse the ankle straight off the bat. Again, through a minimally invasive approach, whether that would actually be in the best interests of the patient in order to get them up and about walking immediately uh and also reduce the kind of operative time and disturbance, too soft tissues. Great. Thanks any other questions, the person who had asked that question also mentioned about pre assessment, but I guess you kind of covered that in terms of you plan your operation differently. Um You know, yeah, I think the pre assessment is something that's really reserved for elective surgery. We're talking trauma where someone has had a fall, they've come in with an ankle fracture and you aim to fix that ankle fracture within 1 to 2 weeks. So in terms of pre assessment and preoperative optimization, if someone comes in with an HBA, one C of, you know, we have them of 100 and 46 120 you know, we're talking really poorly controlled diabetes here. HBA one C only changes as you well know, six months, you know, your 120 day hemoglobin, it's not going to change in the time period that you have in the lead up surgery. Certainly, you can optimize their diabetic control perioperatively, but there's not a lot you can do uh in trauma in order to try and optimize these patient's soft tissues and their diabetes and things. Uh Thanks. Okay. So, moving on to Alex Valgus. Um So I thought before we discuss feet further, we ought to just do a little bit of a recap anatomy. So this is an ap radiograph of a foot here. We've got what you can see just the distal aspect of the tibia here. So that's your medial malleolus and then the lateral malleolus is kind of blurred out here. So your Taylor's and your Calcaneus Taylor sits as we know under the tibia and then the calcaneus beneath that, that's your heel on the medial side. You've got the navicular bone, which is the one that you're palpating in your Ottawa ankle rules. And then there are three bones that sit uh from medial to lateral and these rather unhelpfully. So in this diagram, they've been called 1st, 2nd and 3rd clean air form. In reality, they are called the medial clean air form, which is the one on the most medial side of the foot, the middle clean air form, which is one in the middle and then the lateral cuneiform, which is what's shown as the third Conair form here. So, medial and middle cuboid is in the big cuboidal shaped bone, which you can see uh what sort of blurred out here isn't it? It's just sitting there and then 54321 metatarsals and then 12345 phalanges in your great toe, just like the thumb. You've got 1st and 2nd phalanx. So a proximal and distal, whereas in 2345, you've got a proximal middle and distal phalanx. Okay. And these are sesamoids of the great toe, basically, just like the kneecap. Often people will get referred in with a query, fractured toe and actually, it's just, they're normal anatomy and the sesamoid bones. So, Alex Valgus is a K A bunion. Okay. A lot of people have them and we'll just go through who gets them, what we do with them. A couple of the measurements that we can obtain to try and diagnose them. So, Alex Valgus, as I said, is otherwise known as a bunion and it's the most common form of deformity each time covering it today. And you'll see lots of celebrities like our beloved Victoria Beckham have these bunions, uh Alex Valgus as you can see in her heels here. So it is a diagnosis, a clinical diagnosis, but you need an X ray firstly to confirm first and secondly, to grade it and plan your operation and also to assess whether or not there's any arthritis, any of the joints. So um the lines that you can draw on the X ray in order to diagnose it, diagnose it, you draw a straight line straight through the pole of the second metatarsal, a line straight through the pole of the first metatarsal. And then look at the angle between that. So normally it's about less than 10 degrees in Alex, how this, as you can see here, it's going to be greater than that. As that first metatarsal drifts immediately, you then draw a line straight up the pole of the proximal phalanx of the great toe and continue on that line that you've drawn previously along the pole of the first metatarsal. And that is your hallux valgus angle as that toe drifts in the way you can imagine that angle then starts to increase and the normal angle is S and 15. And you can clearly see here this person angle is going to be increased. Okay. So they've got hallux valgus compared to this foot where that will be normal and this will certainly also be normal. So 70% of people who have it, have a family history of it and I'll tell you that their grandma also had monkey toes. Um It can be secondary to ligamentous laxity as well. Um And also people who have flat feet, rheumatoid arthritis or neurological conditions such as has cerebral palsy. There's a kind of some do bitey as to whether or not shoes have an impact, but certainly wearing high heels with what we call a narrow toe box. So where your your toes are being squished distantly will not be helpful, just have a sip of cheese. So management sensible footwear and I'm sure most of the ladies that come into clinic wearing footwear like this originally and you try to give them a pair of these uses the looks that you'll get so no high heels and this lovely wide toe box, a nice square footage toes, uh shoes rather. Um, you also have to bear in mind. Is there any other pathology that's contributing to the hallux valgus or it's worsening things like pets, planus. So blackfeet do someone need orthotics in order to manage that our surgical management is not for esthetics. Um This is for people who have um you know, deformities that are causing them significant pain can often get fairly unpleasant, colossi teas or indeed kind of loss of skin overlying these and blisters, you know, overlying these, these deformities. Now, the corrective corrections of the deformity really depends on the severity, but generally, we do what we call a scarf aching osteotomy. This is scarf osteotomy where you can correct the pro nation of the toe because it prone eights when it moves out the way you correct the medialization of the first metatarsal uh and, and straighten that, that first metatarsal up and then an ache in osteotomy is where you basically take a wedge of cheese out of the proximal phalanx and do a closing austin osteotomy, put a screw in to fix it and straighten that up. Thus correcting the hallux valgus angle. If however, and I mentioned this very briefly before. If someone has got arthritis at the base of the uh, first metatarsal or indeed between their toes and they've got pain because of that, bringing their toes straight and thus making the joint more congruent and having more contact with that horrible arthritic joint. Um, you will not improve their symptoms. You might wear you, well, almost definitely make them worse. So what you do in that situation is put on a plate and screws and fuse the foot, the foot in a better alignment. So you're using the, using the toe into that position of uh more straight toe, but you're not doing the correct um osteotomy because you will just make their symptoms worse. So some, some people say they've had it corrected, some people say they've had their toes fused and that's why. So we're moving on to Liz Frank injuries. Next, happy to take some questions on Alex Valgus first. If there are any, I think someone might have had a question just about general trauma injuries. It's more. Um So is anti coagulation reversal an issue on those on the wax or Warfarin? Is it reversible? Did you say? Yeah, or is the reversal of those an issue with Korma? So if someone was to come in on Rivaroxaban, for example, which is a common know act that's used in my area, we there's no reversal agent really. Um I think you can give factor 10 A but I think it's only really if it's absolutely warrants it. Generally, we just allow the patient 24 hours, if their renal function's normal or 48 hours, if they're real function is abnormal just for the know act to get out of their system. And then it's not all that much of a problem for us, to be honest, because we use tourniquets in surgery, but for the anesthetist, certainly they would then opt maybe to do not do a spinal anesthetic with the risk of causing a dural bleed. And the patient may well get a G a general anesthetic because of that warfarin is reversal, reversible rather. Um And it certainly takes a while longer to get out of the system. So we give patient's vitamin K oral or IV in that situation, often patient's certainly you have ankle fractures. For example, if they say if they're on a warfarin on Warfarin and they're waiting 1 to 2 weeks, depending on, you know, who else is waiting for surgery. They can go home and we'll just say to them, stop your warfarin five days before surgery, things like clopidogrel and aspirin. Again, we don't really worry about too much and sort of half life for those is somewhere. Uh you know, well, over a week, um so we tend not to worry about stopping them. And again, it's just then up to the least tests about the appropriateness of doing spinal anesthetic for that. Great. Yes, thanks. So, Liz Frank injuries, I think it's something that people will have heard of and I just wanted to introduce you firstly to this chap. Um It is Doctor Liz Frank. So he was a French uh surgeon. He's actually a gynecologist in 18 15 who was trained up by a chapter called G on Jupiter. Jupiter, um who is the chap who founded, you know, Jupiter Arms Disease. And Jupiter Am's contracture uh is Frank uh doctor is Frank Cotton in his first name was, as I said, a gynecologist and he specialized in amputations. And so it's one of the first people to do a through shoulder amputation. And he also did an amputation through the foot and he performed the amputation through what we now know is the Liz Frank ligament uh and that area of the foot, which I'll explain to you anatomically and therefore, it's called the Liz Frank ligament after a, so a surgeon who served, I think in the Napoleonic Army and I've just put this here. So surgery is bright when operating, but it's still brighter when there is no blood and mutilation and yet leads to the patient's recovery, which I think is probably something all of us live by today as surgeons, but this is actually put on his tombstone when he died. So, something to leave and think about. So, Lisfranc injury is the anatomy. Uh So the list Frank ligament runs from the medial cuneiform, which as you will all remember is this bone here to the second metatarsal base. That's the Liz Frank ligament there. And it's a really important stabilizer of the mid foot. And if it's disrupted, and then you get widening of the list frank joint and all these toes can actually just head off that way and uh cause significant damage to the foot. I'm just looking at a little bit more closely. This is your medial cuneiform here and this is your second matter tassel here. You have a dorsal aspect of the ligament. You've got uh fibrous tissue in between. And then you've got the plantar aspect of the ligament. And these are all very strong stabilizers and kind of active that keystone of the foot, the mid foot in order to have it stabilized. So, Liz Frank ligaments presentation traditionally back in doctor lives next day was people coming off horses and their foot would be left in the stirrup. They would have a plantar flex foot which you can see that's happening with this chap uh foot here and then a torsion allow injury to the foot. It tends to be or traditionally is a high energy injury. So that's where you need to go in with your 80 approach, you know, make sure the patient as well before you go in and do your orthopedic stuff. However, increasingly we do see them as a bit of more of an insidious injury. So I had a lady once who got up out of bed to go to the toilet and her foot, she did sort of lost track of where it was beneath her apparently. And her foot, you can imagine she sort of stood on the top of her toes and her foot went underneath her and she sustained a lisfranc ligament injury. Um, and so in anyone who has a kind of unusual path of injury where the foot can twist underneath them or it's, it's been a twisting injury or a high energy injury, then you've got to be suspicious of the lids, Frank injury. So radio graphic changes could actually be really subtle, which is like this one. You can see that there is widening of the space there or they can be bond or obvious where all of these toes have gone off that way and you can clearly see there's something abnormal uh with this, uh I saw a young girl in clinic today with a foot like this and she'd come off the climbing wall, she jumped down about 5 ft. Um And she had a lisfranc ligament injury and her widening was just like that. Whereas people who uh involved in road traffic accidents where the floor of the car goes up into their foot injuries like this present with pain. And this plantar diagnosis which is bruising on the bottom of the foot, lisfranc injuries. You must obtain lateral films. Radiographers can be sometimes a little reluctant to, but that's so that you can see whether or not this um toe is popping up, whether it's displaced dorsally. So in terms of interpreting X rays trying to interpret whether or not um there's displacement, you first look at the first raise the next tassel and you're looking at the congruence see of this metatarsal cuneiform joint. Okay. Looking at whether or not this lines up nicely with, with the lateral aspect of the first metatarsal uh a nice area there, you're then looking at the second metatarsal. So this is this green line here. I'm looking at the medial border of the middle, clean air form or they've described it here as an intermediate cuneiform. Is that lining up nicely or is there a step just where that triangle is, is there a step in the joint there? And you can see on my previous slide, you know, is there a step there and then looking on the a brick, uh whether or not the third mess tassel lines up with the lateral cuneiform, that's the lateral aspect of it. And whether the fourth lines up with the medial aspect of the lateral cuneiform can also look for a flex sign, which is where this little piece of bone here has been avulsed. We're looking that word in today's lecture avulsed off the first metatarsal and it's a sign of a lisfranc injury. And here you can clearly see there's that step which we'll talk about here. The step between the intermediate cuneiform and the second metatarsal. This remains congruent. But certainly you can imagine all these lines, if you looked on the oblique would be abnormal management. 80 approach, as I've said, using a TLS principles, put the patient nonweightbearing because if the weight bear it will only get worse. Um and then fixation is reconstituting the anatomy bill is frank ligament complex. So that's reattaching your medial cuneiform with the second method tassel with screw fixation. If all of the lateral raise, fall off the side like this, you will meet them again. But in the same way in your hand, if you block the lateral aspect of your hand where your little finger is, that's um you know, it's got fairly um it's got a good amount of movement in it. In your fifth metacarpal, your fifth metatarsal as well, have a good amount of movement in it to allow you to walk on uneven ground. And that's why we fix them temporarily with key wires whilst the soft tissues uh repair and then we take those K wires out the later down the line. That's Liz Frank injuries. Any questions about those? We've got a question for back on Hallux Valgus. Um Someone's asking. So in the case is where you fuse the first MTP joint in a way. Um In your personal experience, you use plate and screw or do you prefer, I'll fix as a minimally minimally invasive procedure. So I think if you, I've only ever used plate and screws, but I have seen the, the memory staples used if that's what you mean by I affix, uh I think whatever in the hands of the surgeon they think is the best um technique possible. The main thing for doing any joint fusion is that you prepare the joint adequately. So I'm not sure it matters all that much how you then go on to fix the joint. The only thing with the plates and screws is they're pretty bulky and they need taken out later down the line. Whereas the, the memory staples do not, I don't think there's really an option to do real minimally invasive joint, invasive joint fusion surgery because ultimately, you're going to have to expose the joint enough so that you can adequately prepare it. I remove all of the remaining articular cartilage, get nice bleeding cortices that will then go on to fuse. And so, um you know that in itself is a fairly invasive procedure, no matter what metal work you then choose to put in. Okay. Great. Okay. It's Hilles tendon. So as we well know, uh this attaches are gastrocnemius, um celeste into our calcaneus. And as we well know, it can well rupture in some patient's. So generally, we see it in early or middle aged patient's have have to put early middle aged because a good friend of mine ruptured Cherokees tendon aged 34. So that counts as very young. And therefore, we just got to bear that in mind. It generally happens though with unaccustomed exercise. So I've listed the activities that my patient's have come in with over recent weeks. So squash returning to tennis mom's netball, someone went back to netball and first session, Hercules Tendon went and also a chap who thought that it would be a good idea to take up boxing. And the main thing that people say is I thought that someone had kicked me or if you're playing tennis or squash, thought that someone who whacked me in the back of the leg with their reckitt. Um, that's quite a kind of typical history that you get from patient's. So management of these is rarely operative. Okay. And there is, you know, you can do primarily, um, at least tendon repairs. However, you may well slightly reduce the risk by a couple of percent um, of rerupture, you're still going to need the same post operative protocol of a period of the mobilisation in a quickness, which is where your toes are pointing down. Um And you have a sort of 1 to 5% risk of infection depending on the patient. So certainly these diabetic patients' we were discussing, I would never offer an operation on them, but you know, any operation comes with risks if you can avoid an operation and then your best to, and that's coming from a surgeon. So in Edinburgh, we put people in an equinus air cast. So an air cast is basically like a moon boot and it basically allows the patient to wait there previously, people put in casts and they were non weight bearing for eight weeks, which is pretty brutal. So first four weeks, the patient's in full a quickness with their toes pointing down with a heel, raise about four wedges, then put them down to two wedges. And for the last two weeks there in neutral, remaining in this sequence, air cast, they have to stay in these air casts 24 7. So patient's be like, oh, I took it off to have a bath to have to have a shower, took off. Good bed. Know if you stop moving the foot around, then you will disrupt all that lovely healing. The achilles tendon is doing obviously, if people are immobilized in this a quietness, then their car pump, which is part of our natural body's DVT prophylaxis will be impaired and therefore having a frank discussion with patient's about the risk of DVT and offering DVT prophylaxis is a very important part of management. We also must bear in mind that our colleagues who work in the plaster room who fit these acquirers air casts, they see them every week actually to assess their skin. You can imagine having your foot in a sweaty boot for eight weeks. A lot of people do come even though they're sort of young, fit and healthy with fairly macerated heels after they use, it's their job to try and protect that this test will recognizes simmons tests. You ask the patient to get up on a chair, hang their heels off the edge, compare both sides, you can't do it just on one side, squeeze the calf. If their toes move, the achilles tendon is intact. If they don't, the achilles tendon is not intact, doctor can extend them ruptures, I'll rattle through compartments in the room and then we can have questions on both. So compartment syndrome, I did a quick Google um to look for some imaging and this came up immediately as the definition of compartment syndrome. So, pain, parasthesia, pallor paralysis, pulseless nous, this is not compartment syndrome. This is missed compartment syndrome. If you have pain parasthesia, pallor paralysis and pulseless nous, you have an ischemic limb because you have missed compartment syndrome. The piece of compartment syndrome are pain, pain, pain, pain, pain and pain. You can say, you know, pain on passive stretch, pain, on squeeze pain, out of proportion of injury. But ultimately, it's all pain. It's none of none of these. If you've got those, you've missed it. So what is compartment syndrome? So often follows a trauma, a crush injury or actually following surgery. So, an example of trauma would be um her patient who jumped off a very tall building and they unfortunately sustained a tibial shaft fracture. And she also had um you know, multiple injured limb on that side as well and went on to develop Compartment syndrome. So that was from her trauma. The high energy injury, crush injury once had a patient who had been squashed between a car and offense for around 45 minutes before they were extricated by emergency services. And so their leg was crushed between a car and offense for 45 minutes. They developed compartment syndrome and following surgery. So we put a tibial nail down someone's leg, a lot of swelling, inflammation, etcetera, etcetera that come as a result of that. And they can develop compartment syndrome. After that, it is a surgical emergency time is muscle in this case. And therefore they need to be taken to theater as soon as possible. So, the pathology behind the pathogenesis behind compartment syndrome is as follows. So you get these elephant elevated intercom compartment or pressures due to inflammation. So any muscular uh compartments, you know, surrounded by fascia, you get this elevated pressure due to inflammation, bleeding, you know all these um uh interleukins, etcetera floating around that cause all this information, you then get reduced venous returns. This is something that people often get confused about. They think that the intercom compartmentalize pressure raising causes them to have reduced arterial inflow. It's not that you get reduced venous return as these pressures increase. And the capillary bed becomes engorged. This then impairs tissue profusion. And then you get this vicious cycle where because there's no venous return, the capillary gets better is engorged. You can't have adequate gas in state exchange tissue gets uh poor profusion. It then um you know, releases cytokines and inflammatory markers, etcetera, etcetera, and the information worsens. And then you get more elevated intercom part mental pressure's less venous return and eventually the pressure will elevate above systolic pressure. I arterial inflow. But at that point, that's when you get the pulseless nous etcetera last year. That's your ischemic limb. This is the point where we can really do something about it. And what do we do? Emergency management of lower limb compartment syndrome is that of two incisions for compartment fasciotomy, ease. You obviously don't primarily close it. So your incisions are situated just lateral to the tibial crest, uh around sort of three fingers, breaths lateral and you're coming in your decompressed anterior compartment and the lateral compartment through that incision and then immediately you're coming just medial to the tibia, your decompressing the deep compartment, um posterior to the tibia and then the superficial compartment and with that incision as well. So two incision for compartment fasciotomy and you do not close them primarily, you plan to take them back to the theater at 48 hours in order to have a look, is there any more tissue that needs to bride it? Any dead tissue that needs to prided. And you can consider whether or not it's appropriate to start closing things up then generally lateral compartment, uh the best sorry medial come out with a first. Mhm. So what are we covered? Ankle fractures. What spot went to worry when to fix Alex valgus, lisfranc injuries, achilles, tendon and compartment syndrome. Any questions? Um There's one question in the chat here. Um Early, I don't know if you maybe want to come back on and just, just, just asking about profound and complex concentrate and if you put back on and I can upload three quiz uh and then closed my slides. Yeah. Yeah. Just to read the question because he's just detailed some of the, um, it's just the asking about the use of them prothrombin complex reversal of, of rock span, precipitated leading. Oh, okay. I'm back. Uh Let's have a look. How do you use? So it's just let me chat icon. So, um, if we, I mean, if we had someone who was bleeding out from a limb, it's going to be something that vascular surgeons are gonna be fixing and stopping the bleeding when you're talking about reversing Rivaroxaban with things like that. That would certainly be something. Firstly that the hematology's we're dealing with orthopods do not have access to drugs like that. That would be something that escalated up and generally would be something where they're having a life threatening bleed such as into the abdomen, chest pelvis that cannot be controlled or into their, into their head. So that might be something more than the neurosurgeons deal with. But that is not something that I've ever had to consider and certainly would not be something that would be within my remit to be prescribing or even considering that would be a kind of multidisciplinary team approach. Do we need hematology involvement? Okay. Um Does anyone if anyone has any more questions um just put them in the chat there? Um But for now me and Rosie put together a week quiz just on today's content. So if you'd like to join the quiz, just scan the QR code there and give us a thumbs up. So we know that people are on. Um And yeah, and then we'll get started on that in a minute. Mhm Oh And okay. So we'll start the instructions will stay at the top of this first question and but we'll just go on to the next slide. Um So I don't know if you uh everyone is everyone who wants to join the quiz onto the thing. Oh Yes. Oh Yeah, they're answering. Uh I okay. So yeah, this is really just, it's just whether or not you were listening to me. So where is the Taylors? Um Just to re orientate people who perhaps, I don't know, we're looking at the uh lateral malleolus of the fibula, medial malleolus, the tailors. And then if the tibia and then beneath the tibia is the taylors, which four of you have very correctly pointed out there. Well done. So next question, drop a pin on the posterior talofibular ligaments. Remember orthopods like to keep it simple. So the say what you see. So it's the post area tail oh fibula ligament. Okay. Yeah. So if you, you might want to review this anatomy, um Yeah. Can you come off the little square block thing? And I'll just point out what the anatomy is. Um So the, the bone, the heel bone that's sticking out the back there, that's the calcaneus. The bit that you can't really see because it's covered because it's underneath the ankle is the taylors. So the tailor fibula ligament is running from the tailors to the fibula but easily confused with the calcaneus also sitting beneath the ankle mortise. But you can't really see the taylors there because it's, it's an integral part of the ankle mortise that's sitting beneath there. So what three ligaments make up the ankle syndesmosis? No takers something that, what was this day? It's multiple choice. So you've got, I don't know what the odds are. There's three right answers here. Yeah, fine. So, okay. So majority of got it right there. So you got anterior taylor tibiofibular ligament, you know that. Yeah, that's a tibia fibular ligament can't really see. Yeah, anterior tibia fibular ligament, posterior tibial ligament. And remember that's the ligament that's joining the tibia to the fibula and then the strong interosseous ligament between grand. Okay. So, okay. So yeah, it was your food. So alas it is a Weber a fracture. Um So the I can sort of see why people might think it's a B but this is this S A D type injury where you have a web, a avulsion fracture and then you're driving up the Taylors into the medium Calaio's call it causing this vertical shear type medial malleolus fracture. Um So that it's below the level of the same osmosis there, you can see it's sort of at the level of the, the talus. So that's definitely below the level of the syndesmosis on that fibula fracture. Okay, true or false. 75% of bone fractures have an associated fibula fracture. Yeah. Great game is a good game. Any final? Yes. Ground. Yeah. So you're correct. That's true. A lot of them do have that associated fibula fractures. Why people confuse them was just diagnosed him as simple ankle fractures, which should be avoided. Drop a pin on the navicular bones. So we recapture anatomy. Then you also remember that you palpate this when you're doing the Ottawa ankle rules. So just think back to that diagram. Okay. Okay. Good job. Correct. So that is the navicular bone. Good pink. Yeah. What type of injury is this? 10 points? If you remember what's written on his James time. That's cute. I should have added that. And it's a bonus question. Just come up with a word cloud this one. Um Oh yeah. No, I think I'm going to have to show the answers so people can answer and then we'll show everyone's the group said we'll wait until we get to, you can get four or five. Okay. Go with this. See. Okay, perfect. Well done. You're listening. I think we're coming last couple of questions now. So what is this test called to value? Uh achilles tendon rupture? Mhm. Okay. So the answer is Tinel's test. Sorry. It's Simmons test um to diagnose achilles tendon rupture. Tinel's test is the one that you do when you're tapping on a nerve in order to exacerbate any symptoms you do in uh carpal tunnel, cubital tunnel tapping on the nerve and seeing if it makes this until worse. Uh okay. But you haven't done so far. And the maid said to a compartment syndrome as well as originally the five piece. But I've now learned differently. That is a ski area. I think this will just get bigger because of help it. Mom. Well, there's nine answer for this one. Where have you all come from? Great. Yeah, pain is the main symptom. So not all the others which are in a scheme Iqlim. Okay. I think this is the last question. And then which picture demonstrates accurately the location of the lower limb fasciotomy, incisions. So that's for that two incision for compartment fasciotomy. Okay. Great. So yeah, the answer is A B is too proximal. You're going up into the knee there. See no one thought it was that's good. And D is two distal. So you want it somewhere in the middle so that you can decompress adequately those uh, four compartments. Okay. Okay, great. So that is the end of the foot and ankle teaching. I hope you guys all enjoyed it. I hope you learned a lot. I'm available just now if anyone has any further burning questions. Um, otherwise you probably have your evenings to get on with. Okay. I'll just, I'll pop the feedback form in the chat here. It will also get emailed out to. Um, but thank you very much guys for joining us um for the series, all the recordings will be available on Medal um as of tonight once this last one goes up. Um So if you want to review new materials, that's absolutely fine. Um Yeah, feel free to contact us on Instagram or Facebook if you have any ideas, further events or things like to see from us. Yeah. Thank you, Caitlin for your excellent organization who's been running this behind the scenes, working with all those divas. So, thank you. No worries. Ok, we'll end the session there. Okay. Have a nice evening everyone. We'll hopefully see you again.