Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

This is a typical presentation, isn't it? And so again, we could pick on someone to talk about it, but we've done that. You guys have done a lot of talking. So, um this is the kind of thing that you can have to make a decision on. This is the kind of one if I was going to show one in the test in the, in the past. Yes, this is the kind of one I would give you. Um So what would we expect from you? You might be able to describe what the injury was. Again, it's very easy to say what the initial management was, but then you need to be able to sort of think about the classification and we start to get a bit hazy in our memories and then the aims of surgery when we would, why we wouldn't, is there any evidence? Maybe then they push you to say, how actually would you fix it? And then obviously we can always talk about post. Uh huh. To me, uh this is one of the reasons I like foot and ankle. But to you, some of you might think, oh my God, this is dull. Uh And the idea of looking at different facets of one joint might be a bit boring. Um But the subtitle jumps got three facets and we mainly talk about the post your facet. That's the one that would be a sort of 45 degrees on our last election. Um get the middle facet and the anterior facet and they function differently these two middle and the anterior facet. Um they communicate with the navicular and the tele navicular joint. And that could be called the acetabular Peters, which to me is just making foot and ankle surgery more appealing to hip surgeons. Um These facets have the intraosseous ligaments between these ones that sit within the sinus tarsus and the sinus tarsus that funnel shaped tunnel running from laterally to medially, which sits above the middle facet. Next, the middle facet, you have the FHL, which is an important structure which sits behind the system tackling tail. I on the medial side, you have the, but then you have strong ligaments, which is the bifurcate ligament, which is the one here which sits between the anti oh process and the cuboid with the perineal tuberosity, which is a novel on the lateral side around which the peroneal tendons. Remember they come around the back of the fibula, they run underneath the perennial tuberosity and they then they get curved towards the fifth metatarsal or underneath it. You have the thing that we all call the constant fragment. It's called a constant friend because it's always in the same spot. And that's the assistant tackle and Taylor and it's called the constant fragment because it's attached to your deltoid. We all know your deltoid is pretty thick. When you, when you injure your ankle, remember you're not looking at superficial deltoid injury to give Taylor shift, we're looking at deep deltoid. So again, it's all those kind of mcqfrcs type questions. Is it the superficial, the deep but maybe a deep deltoid goes to your Taylor's a superficial deltoid goes to assist in tackling to them. So the constant fragment, the thing that doesn't move is constant because it's attached to your deltoid and that's at this part of the Calcaneal fracture, a system tackle and that you can feel it's that novel just below your medium malleolus attached to it at the deltoid, but also elements of the spring ligament. Remember the spring ligament is what we talked about in terms of the talonavicular joint and flat foot correction, but it's not just one small ligament between the two. It's a band of plantar ligaments which runs really throughout the mid and hindfoot is attached to assistant act. Um So not only is the deltoid making the constant fragment constant, it's also the system that the spring ligament part of the spring ligament? So that's why this thing does not move because it's held their bike ligament. So what happens when someone jumps off a garage being chased by the police or when they try and commit suicide or that we had one at the West Africa. The last two weeks, he was a drunk Irishmen at a wedding and jumped off a bridge onto the floor, no water involved. And so managed to fracture both Calcaneus. Um So initially they have an actual load. So you land on the back of your heel. Uh when you jump, your legs are out straight or slightly bent, and then you drive up your post, your tuberosity into your poster, your facet, it smashes into a couple of pieces. The anterior facet, I either uh the Bettany, calcaneocuboid joint on the anti A process that stays put, it stays put because it's attached to the bifurcate ligament and it's got the spring ligament around it as well. So under the idea that the anti A facet, the anterior portion of your calcaneus really doesn't go anywhere. Your post, your facet gets split and we'll talk about the classification of that split, get split into a couple of fragments, the more fragments, the harder it is different. But one of those, hopefully. So the more mediaone's stay where it is, the one is closer to that constant plugging, but the others they end up anywhere. So when you look at that original, actually, that's officially a pass it here. You can see it's been punched in uh this is the middle hospital for that. There's other fragments depress that depression of those postaer fragments into the body of your calcaneum, blows the lateral wall off the lateral walls, got the perennial tuberosity in it. So you can then injure or dis look at your parents' or tenderness. If the more energy involved and the more extra loading, more the tuberosity, the point of your heel back of your heel then ends up in various or displaced away from the body. So then you think that that's the mechanism. So then uh then we get these fragments that will produce on it. So this is just off the a a website, we get this constant fragment number for JU brasi T number. To remember this has been driven up into this smashed apart three and four, which is the posterior fossa because these smashed apart and this gets depressed, the lateral wall comes up. But number five is the anti oh process held by the bifurcate ligament that stays in place. So it doesn't move. So this is held by ligament and this is held by ligament. Remember this is the medial side FHL is under you and this has got the deltoid and the spin ligament. So there's a fragment of the calcaneal fracture. And when you try and fix one, these are the fragments that you addressed, we can all guess what the initial management's like. But really when your time to think about managing these opportunity or whether you should or you shouldn't. Yes, of course, you want to think about high energy and other injuries. The history is kind of an actual load, but essentially we want to know. Is the patient? Yes or no. What kind of patient are they? So my 32 year old Irishman who is fit and well, who just happened to be a bit drunk at a wedding is entirely different to the one we had yesterday, which was a 75 year old man with lots of co morbidities who had a low energy. If we think that the plain x rays show a significant fracture, then you should get a CT scan in that will help the foot and ankle surgeon decide whether they want to fix it on it. You can normally pretty safely send them home and get them back to a fracture click. Um But if you're concerned and think it's more likely that they're gonna fix it, get patient admitted. So then you classify these things. I used to hate all these uh people could remember the random names of different classifications and when it's type 1234. So just keep it simple. So is it undisplaced? If it's under space, they can go home, if it's displaced, then they might need to fix it. And then we this idea, you can then classify to intraarticular or extra articular. So the extra articular ones again are most likely to try and treat conservatively whether it's an anti a process that's and that's conservative, an avulsion. Again, the posterior tissues that are involved, then you might need to operate on them and assist in tackling tale I fracture. That's again a bit of an unusual one on the legal side, but most of them were talking about is talking about the articular a post your facet. And as we know, they're divided either by the Essex leprosy or the Sanders classification. So this used to confuse me massively. Um But essentially what when you jump, drive your post rio process into your poster, your facet, what happens is you get this fracture line here, that sort of primary fracture line, you get this one and then you get a secondary spit either across the body towards the generosity or across more horizontally, my EKG or tongue type fracture in this type, this fragments going to come down, this type, this bit comes up. So that's the main thing with Essex Lopressor, but mostly reduce the Sanders. And that's a ct, an actual ct of the widest part of this is the middle facet and this gives you your constant fragment and then you can count the fragments. This will be a 123 or Sundays three. And there's choose more flexible because it's only two jumps and there's four less fixed because it's important. So that's your classification. So there are some, there's always indications to operate. There's some absolute ones that it's open or it's a tongue type two in those tongue type ones, postrema tissues are affected. You should try and get those two theater the same day or first thing the next morning. Not like the other are chemical factor, which you can sort of wait a week or 10 days or even choose. Um So I recently had a 92 year old with a tongue type fracture who took 36 hours to come to the hospital. So we excised it. Um, and then I stuck her into a Qantas and then in the Qantas cast breakthrough and then gradually brought her up. But these are the ones that maybe you try and fix in the younger group with screws or a tension wire. If they're open. Obviously, I guess these days they could probably go to relative indication. So why would I fix the calcaneal fracture? You know what, when you show that CT scan and the X rays to a foot and ankle surgeon, what are they looking? We're looking to see whether the heels of virus, but that's not very well tolerated, whether there's a joint depression. I combination of the post your facet, which is correctable is the heel very wide. And the idea that you're going to try and give them a foot, which is a bit now, er, maybe something that you can use these fitting issue, another perry attendance dislocated. So this is quite subtle sign of a flex sign which is a little avulsion on the lateral side of the figure, the more you look, the more you'll see this. But if you have a, someone who's uh fracture connect looks a bit like a ankle fracture, but you can't see a fracture, but they're sore and swollen. Look for a little abortion fracture. So this happens when the lateral wall pings off tuberus, she comes with it and it pulls off the peroneal tendons out of their groove and the peroneal retinaculum pulls off a little tiny piece of fibula. And the more you look for this, the more you'll see it. So the people we don't like operating on those who those are gonna go out for a fag afterwards. Uh Those are going to just walk around it, noncompliant, the alcoholics, but they're old and frail because the bones just hard to fix whether there's any idea that the flaps gonna die. Um Because the more you do the flaps in these patient's, but eventually you'll get one um doesn't heal. And that's a big problem. If you got a plate and a natural flap, we all know that you can find, uh you can find evidence to do whatever you want. Um If you want to fix it, you'll find evidence to help you fix it. If you don't want to fix it, there's lots of evidence to say you don't have to fix it. Um It's all about being selected with the post, more bias, you are more better resulted. So I was that touched on that, the aim of surgeries to correct the virus, try and give them a suitable foot. So stop it being wide, reduce the peroneal tendons, make sure the post re of facets as reconstructed as you can possibly get it and restore the height of the clock in and then the limp. This is sort of a standard answer to what you have to set up, isn't it? But I think the biggest thing you have to try and decide is what's the surgical approach. So this bottom picture here is that the typical surgical approach with the extended lateral approach, but there's not really any fracture that you can't throw it through the sinus tarsus I approach, which is uh sort of just off horizontal vision centimeter or two below the fibula. Uh This allows good access to the posterior facet and the anterior process. So that helps you, you can still correct the virus, you can still correct the whip, you can reduce the panel tends more easily and you can definitely get a good view of the posterior facet. When you fix the fracture through this approach versus this approach, the main difference is the metal work that you would use. So for this one, you'd use that typical sort of calcaneal shape plate, which has got lots of holes in it. But this one, you're more likely to use a straight plate or a specialist Sinus Tarzi minimally invasive plate. This isn't particularly minimally invasive, but it is avoids this kind of L shaped, flat route, l shaped flap. We're worried about part of it dying off. This is apparently what most jobbing, foot and ankle trauma surgeons do these days. And then Mike Barrett does this almost exclusively. He doesn't really ever do this. I used to do this. This is the way I was taught. I've started doing this, this, we're less likely to get complications when you use these small plates for this one versus the big plate of this one. You have to think about using extra screws, a 6.5 screws, either to support the joint or just restore the length and or the height. So again, to achieve these things correct the bearers, you know, with the height and the length, these need to be held with big squeeze the posterior facet that's held with they're not completed. But this is how to fix the Calcaneal factory. So this is what goes through my mind when I'm trying to see when I go in through the sinus tar site or indeed the natural approach. The first thing I'm going to hit you with this fragment, the lateral war. So if you're on a big L approach, what you would do is you would almost dissect this off and put it in a bowl and use it later be using a sinus tart. I approach, you'll see the top of this and you kind of just have to shove it down out of the way. And then what you're trying to do is reduce the tuberosity onto the constant flagging to do that. You put a pin in it and you reverse the mechanism of action. So you're trying to distracted and you're going to try and correct the valgus there. So when you land it goes into various, so you're going to pull it into valgus, you're gonna disimpact it and what you're looking for on that actual view on this. Um When you got the patient in the lateral position, the idea is to try and get an actual view. So that acts, your view is going to show you the medial wall. You're trying to reduce that media wall to correct the shape. You, once you pulled the tuberosity onto the constant fragment, then you re constituent did the height of your campaign, then you can build on the poster of us. It's so flagrant three, then gives you your width and also restores your postrema facet. If you're lucky, you get a big fragment like this. If you're unlucky, this will be in two or three pieces. Yeah. So this will be if that is a Sanders dream. But if you've got another piece here and maybe another piece here, smaller, this constant fragment is the harder is to reconstruct. So you want this to be as big as possible. Otherwise, it's quite hard to get screwed. And for once you've reduced the post re of facet. We've got the height, we've got the height here. We've got the shape, we've got the post your facet. So you've got the joint and then really, we're talking about the lead. That's the relationship between number two and number five. If you're gonna use a lateral, extended, lateral approach, then you would restore this by using the long take. If you've done a sinus tarsus, I approach and the plate really only goes between three fragment. Number three, um maybe not fragment. Number five, that will keep your length a little bit, but you restore that length a bit more with a longitudinal screw backwards. Then so these wires, this goes through the point of the heel. So from here into the posterior Frederick, what that does is maintain this reduction and then with two or three wires and then you maintain the posterior aspect under the wire, all you then need to do is once you put your plate either on here or on here is to recreate this with a screw. So this will replace the screw. The why? So why with the screw just to maintain that height in that shape, another screw it on from even tooting the five to keep that shape. And then the locking plate along here is to restore the joint. Sounds easy, right? He's pissed. That would uh give me that. Uh So again, that's me talking. Um That's the way. So any questions about