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So basically, this uh will be our first um lecture about uh foot and anchor review. Um This will be a course of around 8 to 10 sessions or lectures uh will go together through um what you will be asking in um Fr CS part A and part B mainly directly to part A the main questions. And definitely this will be the base you will use in part B um in practice. And in a uh my name is Mohammed Hashim. Uh And I'm a consultant with an ankle surgeon at Wickham Park Hospital from the Health and Hs Trust uh in Northwest London. Um So today, hopefully we'll speak about anatomy, biomechanics and gait anatomy here. I mean clinical anatomy. I'm not an anatomist said I'll not go into um academic part of it. I'll go to the clinic and what in the anatomy makes difference for you as a clinician. So this is my hospital, this our active h um headed hospital in Ascot and it's a state of art. It's um um new hospital with very good facilities. So this is two channels which will help you. So all our sessions here will go on both of them. Uh This is under mainly Ortho Bema official channel. I'll be sharing over my education channel because it has a bit more subscribers. So do subscribe to both of them and you will get every review. Ok. So if we speak about the ankle, basically, as you see, ankle is um form mainly of two joints. Ok. So the ankle joint and sys moles ankle joint, which is a Synovia modified hinge and um the syndesmos, which is basically a fibers joint though the most of the fibrous joint, it is still move and you will see now how it does move. So basically the tibia come and flare into the quadrilateral surface which we call the platform and articulate with the talus to form um the anchor, then the fibula come and sit inside um the notch, the frill notch in the tibia and make um what we call the incisor and make it the synthes mos and made the articulation between the tibia and fibula. The points which is in, in bold, you need to understand that the distal tip of the median malleus in uh the lateral mas is beyond the median mail. So the ankle is not at the same level. So basically the lateral mall is lower than the median mails. And this has a very important um effect on the ankle because basically the lateral buttress of the ankle is more stronger than the media. But of the anchor that's why we agree on our for fracture to be a stable fracture, treated no oly, but we cannot accept that for a medium man fracture. So if you have a a block at the joint, so the ankle compared to the knee, the ankle is a smaller joint. So all the surface of the ankle is 350. While the knee is 1100 the the articular surface in the ankle, the articular cartilage itself, the layer is more thinner than the knee. But still there is a very common question why the ankle doesn't get arthritis like the knee. So the knee arthritis is much more be valent than the ankle arthritis. A big question if, if the articular surface is thinner, if the the surface area is smaller. So getting more loading wide, ankle is not like the knee in arthritis. And still the knee is getting arthritis much, much stronger than the ankle. And the answer basically that the ankle is a very congruent joint. So if you see the shape here, the ankle, as you see is a cold box with very good uh articulation, very good configuration, um uh conformation between the surfaces. And this is what makes no point loading in the ankle, which is not the case in the knee in your knee, there is a point looting. So basically, when you put load in your knee, there is a certain point and and tibiofemoral relation with a point losing at C at a certain point which makes the ruling after that was uh threatening and pending. So basically the ankle is very conformed. So the conformation of the surfaces is very good. So the surfaces are very well co-opted. So there is no point loading. The ankle is loaded as a whole joint with the whole surface. So no point loading. So the risk of getting arthritis is much lesser than the knee cause even the knee is bigger. But at certain point of loading, the knee will be loading at one point. So you lo at one point immediately, you lo at one point laterally, you start with media because the media femur conduct is much lower than the lateral. And then with moving the knee in any direction, you still, it changes the the point of looting between the femur and the tibia according to the rolling uh mechanism, but will end by your knee in all positions having point loading. And that's why the knee is more common to get arthritis. And that's why the knee, the arthritis in the knee is mostly medial. That's why the media compartment, arthritis of the knee is the commonest area in your body to get arthritis, which doesn't have in the ankle. But on the other hand, the ankle is very prone to get arthritis, posttraumatic, why posttraumatic? Because basically you change this conformation. So the idea of the conformation that the ankle is up in this position. So it's, it's, it's, it's fully smooth service, conformed service. Once you change this conformation by any degree, you get arthritis, that's why the posttraumatic arthritis, ankle is higher than any other joint in the body. And as you see, only one millimeter talar shift in your ankle will decrease the contact area by 42%. And it changed the whole conformation lost the ankle. The most important b make it less prone to um getting arthritis. And that's why your ankle will get very commonly to get posttraumatic arthritis. And that's why reduction of the ankle fixation of the ankle has to be perfect. You can accept um tibial plateau with but not, not perfect reduction. You're definitely into anatomic reduction, perfect reduction. But if you don't get it in the knee, your vision will get arthritis on the long run. But in the ankle, if you don't get the ankle perfectly reduced was even one millimeter, he will get posttraumatic arthritis very quickly. I hope this point is very clear. Um If we go to the anatomy of the platform itself, so you need to understand that the platform is mu multiple columns, anterior column, medial column, posterior column and definitely the fibula plays the lateral column. We concentrate on the, the fond and you can you see the blood fond. You have the media me fragment. Here. You have the Vols fragment, Ly and the Chapped fragment interiorly. And compared to the Chapped fragment in the fibula is a very stuff fragment. So when you have a fracture like that, you have to identify the the fragments. This is the commonest configuration, what we call Mercedes configuration, the commonest configuration you will have in a platform fracture. And this is what gives you uh it's, it's a way to identify and the way to communicate. When you look at an X ray of the ankle, you are as we agreed, the ankle is two joints, the tibiotalar joint and the syndesmosis. And when you look at the syn mo you need to understand that the syndesmosis is in inside the fibrillar and the fibular is sitting inside it. And between them, there is a clear space and there is a bit of overlap between the tibia and the fibula. And the judgment here is based on one centimeter from the joint line and you need this space which is a clear space less than six if six more dismissing this mtic injury and you need an overlap between the TBT at least one of them or more if these numbers are disturbed on a broad mort's view. So you have symptomatic injury. Once as we agreed, the ankle is a fully conformed surface uh uh joint. So any disturbance in this relation will end by disturbance in the clear spaces. You have media clear space, you have sphere, clear space, you have lateral clear space, it should be all normal and li 4 a.m. And this relation between the syndesmosis tibia and fibula and between the ankle and the tibia and fibula should be all uniform and uniform for you. So if you compare it to the other side, it should be the same, any disturbance in one of these figures will disturb the others. And if we start to look to the ankle as um uh uh uh and and a ligament structure. So, regarding the synthes mosis, the first joint, the think this mos is maintained by three joints by I'm sorry, by three ligaments. So the anterior tio friar ligament, inferior T friary II A I TFL and and, and posterior inferior T friar ligament and the anterior osseous ligament and interosseous membrane. So you have four ligaments controlling the movement of yours in these moses, anterior inferior fibular tibiofibular anti posterior inferior fibular uh interosseous ligament and interosseous membrane and strongly, the most strong of them is the anterior inferior tibia fibular, but the most commonly injured one is the posterior wall. So why? Firstly, the anterior inferior tibial fibular is the strongest because basically you, because of the relation we said about about the, the lateral mas is lower than the median mails, your ankle tends to extend and rotate. And we, you basically, if you don't have enough movement in your ankle, you tend to extend and rotate your ankle to declare your ankle from the ground. So the the moment the main moment on the ankle is an external rotation moment. An external rotation moment ends by opening the synthes from anterior. That's why your anterior inferior tibial fibular ligament is the strongest. Your problem is anterior inferior tibial fibrillar ligament is is injured. Once the anterior inferior t fibrillary injured is a is a ring. And once the anterior inferior t fibrillar ligament is injured. Your both stress on the interosseous ligament and interosseous ligament is easy to be injured. And this is the time when the posterior inferior tibial fibrillar comes in, uh comes in on board and because it is very strong, it's commonest for you to see a syndesmotic injury or a fracture from the back from the Volkmanns fragment or poster lateral fracture. So you commonly see one of two options, either a synthes injury with no fracture. This is mostly because of injury to the anterior inferiority, bifilar and all the other side, you would have avulsion from the back, not a, not an an an and syn injury from the back. And both of them are synthy injury. By definition, basically, this is the ankle. This is the synthes most between the tibia and fibula. The anterior anterior inferior tibia fibular is strong because your ankle tend to extend and rotate. So this is should be stronger. Otherwise your ankle will be always spraining. And if you have an injury to this ligament, you have a high ankle sprain or a s this injury, then you have the interosseous, which is easily injured because it's more or less dynamic. Then you have the posterior inferior tibial fibrillar which is maintaining the dilation in the back. And this ligament because it's away from anything. If you have to do something for this, you will fracture the bone rather than injuring the ligament. Your syn this mu is normal moves. So the fibula inside the incisor is not fixed. It is a fibrous joint. Yes, because there is no s uh S sinuum. There is no articular surface. It's a fibrous joint um type, but it is still moves, it moves in external rotation and it moves backward. So it moves the fibula moves backward to the tibia and it moves in extended rotation, moves backward to the tibia. When you dorsiflex and extend, you rotate inside the incisor. If you extend and rotate your foot. And this movement is not a not, not a minimal movement. It moves about 5 to 7 degrees and extend the rotation and about 3 to 4 degrees for um uh millimeters front and back. And because of this movement, there is a lot of discussions now about the synthes fixation because when we bought a screw, we fix this joint, we, we don't allow this joint to move and without moving it, we disturb the mechanics of the ankle. Though it is still a common practice to both in this mo screw. But this is not anatomical because anatomically this fibrous joint does move, the fibrillar move 5 to 7 degrees, extend the rotation and it moves up to the back about 3 to 4 a.m. And when you fix that, you disturb this move and you don't allow it anymore. And this is disturbed the whole mechanics of your ankle. That's why the trope came in place. And now the trope use is going more and more. But the problem with the ti trope is you keep, this is very flexible and it depends in your tension when you put the trope to do the job. So it has a lot of human errors. So, and that is why it's very common for you to see after everything heals a a AAA broken screw, a broken Syme screw and the broken sys screw because you are stopping your joint from movement. And when this joint it starts to move again, it will break a screw. And that's why you have to warn your patient that the thin screw will be, will be broken at some point. And you need to um get it removed or not according to your school. But when we speak about the synthes mosis, you need to understand we have four ligaments, anterior, inferior tibiofibular posterior, inferior tibiofibular interosseous and interosseous membrane between the tibula and the fibula along the the lens strongest is the anterior because you your normal moment on the ankle is extend the rotation posterior is the leg to be injured. And when it has an injury. It always be a burning avulsion rather than the ligamentous avulsion. And what's so that's why it's common to see a posterolateral um post, post lateral me fracture or uh or posterior me fracture. The, the, the synthes mo uh joint is not a fibrous joint. It's basically as it was, we agreed, it has some movement 5 to 7 degrees, extended rotation of the fibula inside the incisor or um and posterior posterior displacement about 3 to 4 a.m. And when you fix this with a screw, you disturb the ankle mechanics. Though you give a chance for the synth ligaments to heal, you disturb the ankle mechanics. And that's why it's not an anomal way of fixation. If we come to uh the second important ligament of the ankle, which is a dicid ligament, which is the medial uh collateral ligament of the ankle. If you say so, the M cl of the ankle is a dicid, very strong, thick ligament um has a superficial part and deep part, superficial part is three bands as you can see. So one from the tibia to the talus, one from the tibia to the navicular and one from the tibia to the Kia. So tu navicular tio taylor, tibiotalar and tibia. And if you um look carefully, you understand that the part of the deltoid passed by two joints, the ankle joint and the subtalar joint. And that's why when the, the foot position gets abnormal. This deltoid is under a lot of stress. And when it's under a lot of stress and start to fail, this takes you to type four like uh this plan if we speak about this plan. And on the other hand, this deltoid ligament is less commonly to injure than the lateral ligament because basically the normal position is of your ankle is to be in virus. So the normal, you have five degrees, the normal, you have five degrees of heel virus. You have arch foot and that's why all your stress is all on the lateral side, not on the media side. So actually in the normal ankle, normal anatomically oriented ankle and foot, your ankle is in a bit, he he is in a bit virus about five degrees and you um uh you're standing on a bit of bit of arch. That's why the stress is more on the lateral, more than, than, than the media. So, and when you start to walk that the destroyed plays a very important role in coordination of the movement between the anchor and the subtalar. So basically when you walk and that the deltoid bussing by 22 joints, this makes some sort of relation between the movement of your ankle and your subtalar joint. And we'll come in details to this point. So you need to understand this is a very strong ligament. It's controlling the medial side of the ankle in the inside of the ankle. Uh it has a superficial and deep part. The superficial part is tail tibial, navicular tibial talar and tibial calcaneal. It passed by two joints, the ankle and the subtalar. While the deep part of the dis is actually thickening of the, of the um capsule. And it has two parts only as you see. So, but deep anterior and deep posterior tibial talar. So it's bus but only one joint which is the ankle joint and it's actually a thickening of the capsular, the ankle on the media side. So when we come again to this point and explain the movement between the ankle and subtalar, we will understand why all the diso is missed as a missed injury. Why we have a lot of discussion about what we call diso uh sprain ligament complex because it's not acting alone. There is another ligament which is acting in the media side of the foot, which is the sprain ligament. So um the dito ligament is very important. You need to understand this, you need to appreciate the parts of the dito ligament and to understand this configuration, especially the CIN one if you see. So this, this is a supporting event and you don't, you don't care about the numbers about where is, where is the center or where is it from the, from the center of the movement. But the most important thing you need to understand this is boss by two, the superficial boss by two joints and the deep boss by one joint, if you come to the latter side. So as you see, so as we agreed, if you stand in your ankle, so normally what's happened, you tend your ankle tend to go in. So you're standing normally with, if you stand only static, about five degrees valgus with any movement, you do your ankle invert into virus because of the tia posterior act. So always the tension while you are moving is on the lateral side, some of you will ask me a question. So we normally, if we examine the ankle and foot, we see the patient standing in a bit of vuls, yes, aesthetically. But this is not your position. When you're standing, you're standing on five degrees hill valgus. But actually with any movement, you do, the tip will hold, hold your ankle from vuls to varus. So the most of your dynamic position of the ankle is an virus. That's why the stress in your lateral ligaments of the anchor is more than the media ligament. That is why the commonly the lateral ligaments get injured. And you hear about lateral ligament reconstruction. You don't hear commonly about deltoid ligament reconstruction because the deltoid is not under connecting tension when you walk or when you dynamically move. If you can come to the lateral structures, you have the anterior fibrillar ATFL and you have the Calcaneal fibular ATFL has two bands, severe and inferior band. And you have the Calin fibular and you have the booster um the the posterior tibial, uh the posterior tib uh uh ligament. So, anterior bu ligament is two bands, posterior tibiotalar and ki fibular. I'm sorry. II II forgot to tell you one thing. The superficial band of the deltoid controls mainly the vuls movement. So exactly like the MC superficial M CL does and the deep part controls mainly the extended rotation. So if you want to stress the superficial deltoid, you both the foot or the heel into vuls. And if the ankle into vuls and if you want to stress the deep deltoid, you put the, the, the ankle into extended rotation. So this is care about the, the, the virus vuls movement and the deep part cares about the rotation movement. If we come here, we have the ATFL B TFL and the CFL. So an F TT U the fibrillar, sorry, posterior talofibular and, and a fibrillar, the strongest of them is the posterior um uh talar friar. And, but actually the one and a lot of stress is the anterior telar fibrillar. Why? Because again, ignore when you're standing, when you start to walk, the first thing your foot does is to go in blunt affliction. And once it goes in blunt affliction, this what stress while it stress on the lateral side, this is stress, the ATFL other. How did it that wave your he and I will have like a stress on the la side when I will move, he strike, I strike with blunt, blunt with virus, equal stress over AFL. And when it says the ATFL, this is the time when you get um a lot of an sprain because ATFL is a weak ligament easily to get sprained and it is under tension when you're both the heel into vuls, uh I'm sorry, into virus with blood reflection. Um the anterior t fibular as you see, it goes from the, from the, from the lateral melas of the fibula to the talus two. As you see, severe and inferior calcaneal fibrillar. And this is an an intraarticular. The uh the ATFL is, is a thickening from the capsule. The CFL is an extra articular. One CFL is very strong and it does act in, in, in neutral dorsi flection, not a dorsal or plantar in just in UTR position. And if you do an uh a virus infection, so if we go to how, how we assist the injury to the ligaments to you, assist the injury to the ATFL by both the foot into blunt reflection and you just do anterior drawer and the A CFL, you test the CFL when you both the ligand, the foot in neutral and you start doing a virus infection and you, you assess the B uh TFL when you put the foot into dorsiflexion and do an anterior drawer. So basically the ATFL and FL ATFL and B TFL, you stress in anterior drawer, one in plantar flexion, which is the anterior TFL or ATL the anterior fi and one end dose, which is the posterior fibula. But the calcaneal fibrillary, you both the protein neutral and you it in virus infection. Uh when you reconstruct these ligaments, you need to understand that the line of action of the ligament is very, very important. If you see the anterior talar fibrillar, it doesn't relate to the articular cartilage itself. So it goes underneath the articular cartilage just at the level of the lateral process of the, of the talus and ruction should be in this place. Otherwise it will impinge on the ankle. There is another very important anatomical point coming to um the muscles and the structures around the ankle. You don't need this picture, you under, you remember it from Tom has a nice uh um dog and um big and dog. So you have from the front tip and um the, the extensor hallucis um then um nice nerve which is will be the, the deep peroneal nerve. Then uh a very nice so vein nerve then um P which is no, I'm sorry uh do which is the the flexor extensor digitorum, then p which is a bit the to remember it the reverse in the back. So anterior you have tip and then flex extensive hall doses in the back, you have tip and then flexor digitorum in the front, you have tip and, and extensive halls in the back. You have tip post and flexor digital then carry on the normal as you. Um all remember, remember in the way you, you need to remember uh from this picture, I need you to recognize that the F HL is muscular to a very low level. So up to the level, up to about 1 to 2 centimeter above the a a muscular and the tendon start after that. So that's why you see it in this cross section or, and, and, and, and uh as a muscular, it's not as a tendon while the others are a tendon. So flexor digiti will be a tendon tip post at this level will be a tendon uh on the other side. On the other hand, your tip and, and extensive tip and will be attended and the extensor hallucis, it become to be attended like in the lower leg. So remember that the leg of hallucis is muscular to a very low lipid than you imagine. Um if we come to the tendons and I need you to understand, we will speak about four important tendons around and I need you to understand them. The most important is a tip post. And if you understand the tip post function, you will know how the, how the tip post to play a very important role in your life. So TPO basically allow you. So TPO basically, ii speak about the origin insertion, but it's inserted in all the, the, the tarsal and metatarsal base except the first metatarsal. And this is important because basically the tip post plays a very important role in maintaining your media, longitude and arch. Very important in keeping your normal position of the ankle, hind foot and the foot and the midfoot. So without the tip post, you would be flat and without the tip post, all the mechanics of your ankle subtalar and midfoot will change. Without the tip post, you will be having a big problem. Uh So walking for you to walk, if you compare on the right side, how much loss look at this, this graph and this graph and see with a normal T boost, how the situation in different activities. And here comparison between the normal T boost and the tip boost deficiency or a flat foot, as you say, your, your tip boost plays a very important role in moving. So at this level of he strike, then you bought a flat foot, then now you're loading, loading flat foot and then you, before you do a two off, that is very, very important for the people to put in action. So she can laze you out, she can put, she can change the blades of your midfoot or chopper joint. And this is when you make your foot as a rigid lever. Other than this, your foot will be break at this stage. That's why you see here in a normal tip post, it fires at this level to allow you to push off by this foot because it makes your foot as a rigid arm because it locks your midfoot or shoulder joint by different blanes, changing the blanes of your uh midfoot joints. Let me go to this, then I come back. But this is very important one. Yeah. So if you look in this picture, normally, this is the opal joint or midfoot joint. This is the, this is cleoid. The normal picture when you are flat is two joints are at the same lane tip post when you need to push off by your foot and just pull the na and this part of the midfoot. So it changes the blame of the T navicular to the blade of the CBO. And when they are in different blane, they lock the mid foot. So your foot become a rigid lever. So this you can brush off with without the, the, the the tip was doing this, your joints, the joints will maintain in the same lane and this will make your foot easily collapsing. And that's why you have a mid foot break. And that's why the flat foot people find the difficulty to walk and get very exhausted after very short walks. I'm sorry about this. I have to explain notes will be difficult. Ok? And FF in the same like an inter and ground uniform ashes move your foot can adapt the ground because the T and that are in the same lane. So the foot is sub F MTB joint. At the same time, 90 degrees and vascularity easy to degenerate was is very common to have a post deficiency was the flat foot is a very common condition. The common condition now has a problem and a left one la with a waters sheed area which makes the tendon weaker at this point, easy to degenerate and mm action, exercise problems. 10 is easy to degenerate. Deficiencies are common. That's why the obese people, which is a lot bought. A lot of stress on the TPO, especially with this line of action is easy for the TPO to degenerate at this and have a problem. So we have a problem. That's one I remember, but I'm gonna hit the that I made it to uh by the tip post. We have the tip and a tip and uh be mainly inverted. Uh uh The t in action now is a blunter flexor inverter and does a adu are we because we need this in a minute planter selection they gave me from behind that. That's a money virus or inversion and abduction. And this, this moment is called Sobin nation. Keep this in mind in the background. So the tip post is the strongest invertor inverts the hind foot. L flex the ankle and does a midfoot abduction. An is an, an expensive and uh 4 ft again, midfoot, um hand foot inverter and a midfoot ador. Ok. T was the best you know, it rubs like around uh a navicular opt under 70 navicular and the C four, mainly the C four, I will tell you tip. And uh uh but when you put the, the foot into, into um uh uh dorsiflexion, if you want to test to the tip and, and the tip post, basically, with the tip boost, you need to put the foot into blunt flexion. And when you put the foot into blunt flexion, what it does. Yeah, you both, you relax the tip. Um you relax the tip boost and then the tip an is into action. And the other way around, if you want to test the tip boost, put the ankle into blunt flex into a dorsal flexion. So you relax the tip and, and then the tip boost will be into action. 10 if I want to test both of them are inverted but tip and goes into action in blunt flexion, tip post goes into action into dorsiflexion. Basically, you relax the muscle. It's a large high dorsiflexion. You will relax this, you will shorten the tip and, and put the tip post under tension. Then you can test on the other way around. Uh kanak. You need to remember a tip and doesn't um doesn't degenerate. It's very, very, very rare to have a tip and degenerative rupture, but you can have a tip and laceration, uh very common lasma and in has a tip and uh degenerative uh rupture this means the tip. This patient has some sort of collagen disease, some sort of hematological disease. It's not normal for the tip and to degenerate and rupture, which is very common for a child. So, laceration. Yes, but degeneration. No. Then on the other side, we have the Brunei which is acting to counteract the tip and, and tip boost. They are mainly s we have the, the Berne Longus and the Berne Brevis and can you can easily spot that the brunneus Brevis is going in front of the, of the Berne Longus and medial to it, the Berne Tos is going outward and later to it. And you remember when you open them, if you open them before the Bernes strong is always muscular to a lower level. So to, to differentiate them, uh surgically, you will find that the longest is longer than the previous be longus, uh be goes from behind the later maus above the be in the and attached to the basal. The main job of it is as an inverter vertin. So the main job it does it just the foot and the tip, the Berenice Longus, I'm sorry, it comes from the back, it's more muscular to the end, it goes from outer side or left side and behind the tip, the bene long uh Brevis and it goes underneath the peroneal tubercle and the calcium goes in the groove in the cuboid and go to insert in the media can form and basal for me to both of them are inverters. But remember the brunneus previous, when you put the foot into, again, like the tip and, and tip post, when you put the foot into blatter flexion, you basically shorten the brunneus longus. And this is when you put the Berne previous into action. So if you want to test for the NII to test for the Berne previous, you need to put the ankle into plantar flexion and ask the patient to evert if you want to test for the longest, either you, it's so difficult for you to test the, the, the, the, the, the, the plantar flexion of phase three, the easiest is to put the foot into dorsiflexion and ask the patient to revert. This is when you put the longus into action, Bernice brevis mainly, I mean, it was that Bernice mainly with counteract a response but counteractive and or there is a relation between the tip and the disturbed en no into do them and, and, and if he but the foot into do and ask the patient to in and by the Berna previous with t encountered by the BE T and is by Berna previous and tip is by be strong to remember it. The way you examine them, both tip and and post are inverters. Both Brunei previous and longus are ted but to test them, you need to relax one muscle and both the other into action. If you dorsiflex, you relax the tip and, and the Benares and you put the be fungus into action and when you belong to flex, you both the tip post and be fungus, relax it and you put tip and, and Bernas Brevis into action. So basically dorsiflexion and inverse is testing the tip and the Berns Prius and the other way around. Remember Bernice Brevis later, Bruni's Brevis is countering the tip and, and brunnis fungus is countering the tip post with on the T you both in dose flexion, you relax the tip and and brunneus brevis. So you're testing the brune strongest and the post and you both in the blunter flexion, you relax the tip post and the brunneous strongest. So you'll be testing for tip and, and brunneus, bre what? Oh, but your ankle to be stable. We are dynamically stable in ins get in with the invertors and the two main inverters, which is the tip and, and tip post and the two main ters which is the Bernie longest and Bernice. Previous a tip ant ised by the be Brevis tip is counted by the longus D and relations in normal boost is taking is taking action over the uh uh and the tip and, and taking action over the T and ignore this in normal physiological situation. Normal physiological situation, you tip and ankle tip, the game in ankle bru previous game in four and game in uh dorsiflexion, a previous relaxant shortened from layer under tension will be under tension, relax, relax it in for the tip and, and for remember, you know, balancing and long opacum. Tell me, tell me, tell me what uh remember that it's a clear thing. Yeah. Yeah. Good. OK. And, and, and, and uh tune previous tuber kill longest uh um had a very, very, very important to, to of the first and the media, it bs the whole first tray into blunt affliction. It adds to the creation of the ash. Remember C uh uh I for long, it acts by blunt reflecting the first ray because attach it to the basic first and medial K four. And it has a very important role in this but this role we can ignore because we still have the TPO acting if the post is acting and, and, and, and, and uh and eminence per previous is above is underneath, goes through the cuboid groove and go to attach there uh be previously at this. Uh Don't care about the not remember that the be digiti is bought from the Berne um your nice achilles. So the achilles um as we understand is the strongest ligament in the body. Uh the achilles, he, he, he um gets all your weight and he counteracts for the whole body not to drop in the front. So achilles in action to make your, you make you upright. If you, if your achilles is not in action, you will not keep all right upright, achilles is three muscles, mainly the complex but three muscles and no, and Gastro has two heads, media later, gastroc. And so, so there are three muscles, three hits going into one tendon. We need to understand the relation between the heads and the tendon now. But basically, they turn against each other six centimeter for insertion. So the media head, the the median head goes to the lateral side and, and the lateral head goes to the media side and the soleus in between it has the shape and insertion, median head going to the lateral side, lateral head, going to the media side. And this makes this is a watershed area. Um And at the same time, this is, makes the, the achilles is AAA lateralizing force, is an vuls force, apply a vuls force on the hind foot. If you imagine this is the insertion of your achilles and you are standing this achilles. If you see the line of action of the media, the media is bigger and stronger and the lateral is smaller the gastros. And basically the media is going to attach laterally and the lateral is going to attach medially. And that's why your achilles and this rotational area has a watershed area with low blood supply. This is the commonest to have the rupture about 5 to 6 centimeters above the insertion. And at the same time, this is makes the lateral force for which is coming from the media head more stronger. That's why normally the achilles is doing some vuls force over your heel. That's why with most of the heel vuls problems, we tend to lengthen your 10 to achilles. Um So separately rather than the gastro has a very, very important rolling gate will gate, but keep it in your mind, what is the role of Solis? And you have to ask yourself if there is a gastro, who's two big hits? Why do we need the sole this question? Remember, I will answer in the part, but you need to remember now that you have three heads, median lateral gastro and by one tendon, this tendon has an inverted insertion, the media inert, lateral lateral insert, media, the media is more stronger. So the lateral force from the achilles on the heel or the hind foot is more, that's why the achilles is normally ul sing force over the heel. And that's why we need to lessen. The kid is when we're dealing with any vuls heel position or uh problem like the flat foot. You need to remember that this achilles has is, is, is, is a specific type of tendon and ask yourself a, a very simple question. If you have an injury to one of your fos in the hand, which is very, very small tendon, you tend to go and repair it while if you have an injury to these achilles, the huge tendon with a lot of stress you sometimes treated non operatively. Very nice question, ask it to yourself. And the answer simply is the type of the tendon. The flexor tendon in the hand is a she cover tendon but, and the cis covered tendon is a Synovia cis has synovial fluid in it. And that's the synovial fluid makes the healing of the tendon much, much uh worse. And that's, that's why the flexor tendons not heals nicely and easily. That's why we need always to go and repair them while the achilles is a Baroin CT has a full layer of barin. This full layer of barin is a very good nutritional layer and it's a very good conservative layer to the space. So when the, the, the Baroin is attached, even if the achilles is ruptured, Barin still have the option to maintain the s and even with a gap, it allows for a hematoma formation formation and healing of the tendon because it has a good nutrition, good blood supply. So the difference between them, the flexor and extensor in your hand or your foot are synovial tendons. And this synovial synovial Chis doesn't give a direct blood supply but has synovia flowed in between in inside, which is again, is the healing of the tendon. That's why these tendons doesn't tend to heal conservatively. Why in the achilles, which is much bigger and in a lot of tension and a lot of stress, it is a bar cover and this bar first maintain the tendons tendon into uh aligned and maintain the, even if there is a gap, this gap is contained inside the Baroin. At the same time, the Baroin is very well vascularized and it's very, have a good, very good nutrition. So it is the allow for a healing of the tendon even though there is a gap. But this end by some dens of the tendon, that's why we can't accept non operative treatment of the achilles, but we cannot accept non operative treatment of um a full rupture of extensor of flexor tendon in the hand or the foot. Um again has is a cliff. Yeah. Yeah. Yeah, it's clear. Yeah, exactly. If you look, if you look to the vascular supply to the achilles, as you can see. So the achilles is getting a blood supply from the peroneal artery and from posterior tibial posterior tibial is covering up and down and brunnea is covering the area of the watershed we spoke about. And as you can see, this blood supply is, is is a bit of shitty blood supply with the mechanical position of of the insertion. This makes this area very prone to be injured or to be option. If you look to the intention of the achilles, you have erythro Calcaneal bursa, which is protecting the achilles from rubbing against uh the the posterior burs of the calcium post prostate with the calcium. And this is where uh it gets inflamed with hagland deformity, which is abnormal prominence of the prostate. Then you have the subcutaneous calcaneal bursitis, which you tend to rest on it while you're sleeping. When you're sleeping. The subcutaneous calm bursa bursa is very important because it protects your hip from getting ulcerating. So you have eryr subcutaneous calm bursa and you have ryr calm bursa and remember you can easily define between uh I'm sorry, differentiate between them. This is will be at a lower level just behind the posterior tub prostate. This will be at a higher level above the posterior tib prostate. Clinically in the clinic position, I can show you how to differentiate between hagland and lateral than uh um uh a subcutaneous bursitis. So these two types of bursitis are been uh causes of the uh Benford Hi syndrome. This is uh and it is a bit high above the pros and it is very commonly to be there if it is a hagland deformity and the sub Calcaneal bursitis is uh commonly, especially with tas, especially the people who do marches and and and military services and something like that. So there are two different bursa which makes two different uh syndromes. If we come to the surface anatomy, I need you to remember nicely that the anatomy of the um subtle nerves. So basically your su nerve is just go in front of your median m be careful while you're opening your median m not to go. So anterior, because you have the su nerve and the opalus um vein. Remember that your superficial nerve, it goes mainly along along the lateral border of your four ray. So if you want to see um your um spn or superficial nerve, you need to bone, the force to and bone, the force to inverse or inversion. Then the the the superficial will be prominent and you can easily market subcutaneously and I will show it to you when we're doing your ankle, arthroscopy. Both. So remember that the softness is mo moving in front of your medial mouth and it can be injured during your incision. Remember that the superficial nerve comes from above and moves uh along the lateral intermuscular septum comes superficially um around the lower fibula and goes along the an later to the uh and then start to divide into branches, uh media the cir cutaneous and lateral do cutaneous and then the deep peroneal give the middle bursal thing which goes to the first we space ta nerve, it goes along the border of your uh tender achilles. Then it moves here just um a few centimeters above the tip of your uh lateral mall. Then it goes from here until it becomes the lateral cutaneous uh lateral, dorsal cutaneous nerve um if we come to the foot. So your foot is uh three bars, hind foot, which is P and cal midfoot, which is navicular keyboard and uniforms and 4 ft which is meats and, and pharynges very important to remember this differentiation because a lot of my uh terminology, the coming terminology would be speaking about every part, differently hand foot, midfoot and forefoot, we speak about the. So the t basically they are seven the key navicular and three uniforms. And remember that you have three columns of your foot media column, intermediate column, and later column, media column, which is uh the first tray. And remember these have a very minimal movement about 1.5 to 3.5 degrees of movement. Uh This is very important why? Because basically we needed to move in the movement. We spoke about from a minute ago about the tip post. So all the movement we needed from the first tray is to move in blunt flexion by the be fungus and the tip post or move um uh in a plant in a dorsal flexion by the tip. And and this is to create an ul and release it, create an and release it, make your foot rigid, smooth, rigid, rigid supple. So all the movement you need in the first lay is 1.5 to 3.5 degrees. If you come to the mid, it's nearly nearly stiff. And this is very important because this is main, main, the main strut of your foot. Without this, your foot will not maintain shape. And without with this, there is no media arch or la media longitude net or later longitude net. So because they are the main strut of the foot, um They are nearly has no movement in the joint. So the 2nd and 3rd T and T joints moves about 1 to 2 degree only of movement which nearly no movement. And this is why we tend to uh fuse the rest, frank injuries in adults, in young adults rather than bridging them. Because basically, we are nearly physiologically fused 0.6 to 2.6. And that's why if you come. Um uh if I say to you, if you are not a foot and anchored specialist, and I say to you, uh we prefer in young adult, especially in the Gainous injury to fuse the left Frank rather than fixing it. Oh fuse a joint which is sub which is normal. Yes, because basically it is physiologically fused. It's just 0.6 to 2.6 movement. There is nothing there and the foot gets more uh functional outcome from fixing this middle fragment because basically you don't need to go and remove hard work, you don't need to go and do anything. And you're actually doing a proper fusion by by fusing it a primary fusion rather than fixing it, which is like a delayed fusion. One on the other side, your lateral race, which is the lateral column of your foot has a lot of movement. And why? Because basically the arch on this side is low and this is the side which accommodates the gout. So you need your lateral rays to be moving freely so they can accommodate the gout. So again, you have a medial colon, which is the first ray, you have a mid colon or intermediate column or media column, which is the 2nd and 3rd grade and you have a lateral column which is the fourth or fifth ray. First ray has some movement about 34 degrees of movement. And this is, this is, is very important for your foot to have an arch and relax, having an arch to be rigid, to make a rigid lever when you push off and um lose the arch, when it needs to be sub to accommodate the ground. The mid, the mid colon, which is the 2nd and 3rd inter uh uh T MT and, and metal needs to be measured with very minimal movement, 1 to 2 degrees of movement because basically it maintains the shape of the, of the foot. And um it is the main start of the foot on the outer side, your lateral columns, it moves about 9 to 10 degrees, 11 degrees of movement because this is where you need to accommodate the ground. When you um uh walking, the media column is basically starting from behind Talus navicular media kid for a first me t the lateral column on the other side, four and 50 m tarsal KBO. And, and when I ask you, um if you have like a severe uh lateralizing um um lesser injury you say, OK, I will, if it's an adult, it's a ligamentous injury. I will definitely, I will be tending to brain if use 2nd, 3rd or even the first, but never speak about using force and fifths, if you fuse force and fifth, you will not be able to walk barefoot. So there's no option for that. Remember that you cannot, you use your 1st 4th and 5th ray and you cannot fuse your lesser to TB joints. And I'll explain you view of why now. So basically, if you fuse the lateral colon, there is no way for your foot to accommodate anything. It has a, a high media arch, a low lateral arch and you can fix it, your foot will be like that. This is moving very minimal movement on the media side laterally is not moving no way for your foot to accommodate the ground. You don't have any option except to have something soft under your foot like insoles or soft trainers, you cannot walk barefoot because it will be very difficult for your foot to accommodate the ground. And on the other side, when you fuse this um uh ray, which is the first ray on the media column, you have to be very careful about where to fuse it, where to do a lab test procedure. Because if you fuse it in the wrong position, flexing uh um uh lowering the arch, you will end by flat foot iatrogenic flat foot. So even if you have to fuse, you have to fuse it in this degree, which is 1.3 to 3.51 0.5 to 3.5 degrees of flexion. So you maintain some sort of Rh but you still confuse it because it is relatively, you just have three or four degrees of movement. 2nd and 3rd, you fuse freely because it has, it's mainly used 4th and 5th, no fusion. If you fuse them, even if you do something, you have to temporary hold it and remove it later on the way to work later on. Because if you fuse them, you will not be able to walk normally. Uh The arch is a very common uh gothic arch from before. It has a key bone which is or the keystone, which is this one. And the arch shape is maintained based on main maintenance of structure. You have media later and don't forget you have a transverse arch. Media long between an arch was maintained mainly by tip post and Bernice lus and lateral and adrenal arch is maintained mainly by Bernice previous and Bernes Longus has a role in it. And the transverse was maintained mainly by uh the ligaments, the blat fascia and the ligaments. And remember that this is very, very important which we always miss if you're going to fuse these three joints, which is 1st, 2nd and 3rd T and T joint. You remember you need to maintain this arch there. If you flex, all of them Dorsey or blunt to flex, you will lose this arch and this will make your foot less accommodated to the ground and will make put you in a problem. Remember to maintain this transverse arch, this makes your foot raise going in different direction. So the first is very bluntly flexed less the second, this is the 3rd, 4th and 5th are maybe transverse. So if I'm going to do some viral osteotomy or do some osteotomy to shorten these metatarsals, you need to understand in your mind that they are not like that. They actually like that. First to me is is the most blunt reflexed. Then the second, then the 3rd and 4th or fifth are nearly transverse. This is how the the medial arch, the transverse arch is formed and this transverse arch has to be maintained for your foot to easily accommodate the ground. If you lose this transverse arch, you're accommodating, um the ground ability of your foot will be much, much less uh uh the uh an arch that normally between an arch. How uh in, in, in, in assess a little to, to accommodate the ground out weight bear normally, normally with weight, bear and, and the first metatarsal head then moves to the fifth head. First, I'm sorry. First MTB moves to the first metatarsal head, then goes back to the or the hill to do this. You have to have a normal arch. If you have a normal arch, you have a tri boot first, MTB fifth metatarsal head and a heel. And you walk with this tri boat, this tri boat gives you the option to have a rigid lever. When you push off, this gives you allows you to move easily, allow you to, to, to translate from one step to another step in a very easy way. If you have a flat arch, you're losing the whole foot. Firstly, you put pressure on points, which is not adapting to take pressure or be telling points. D will be having a problem, pressure problems. And number two, you have a mid foot break, you load the whole foot, which is shouldn't be loaded. And rather than moving in a simple movement in a simple transition movement, you would be moving like a plaque movement and the plaque movement basically is. So the arch makes you move with a tribute first NT B5 metal head and the hip. And this gives you this picture when we do a, a bit vit gray or testing or pressure of your foot, you see that the foot doesn't loot completely. There is an arch here and there is a small arch here. Big arch, small arch here. And you do the first MTB the fifth with 1000 head and the heat. If your arch, if your foot is high arch, it's a cava foot or bal, this will end by you loading a lot on your forefoot. As you can see, so many, you may mainly load the forefoot with less movement and, and some to somewhat on the heel, but there is nothing in the midfoot and the other way around. If you have a flat foot, you'll be looting the whole foot. As you see, these two are problematic. But if we come to the walking and gait, the flat foot is more problematic than the C foot, the va foot moves more quickly and less fatigability. But the flat foot, the patient will move with sure with, with uh uh slower movement and more exhaustion and fatigability. Uh So normal is the middle one because this is because of your, of your rashes. If you lose any of the three ars, this is unfortunately a misconcept. Uh So the people always speak about only the median between the ar but this is not correct for your foot to have the troo to load the three points which is should normally load. You have to have the three arches maintained. So if you look in this picture, the first, the media long arch is maintained, the lateral long is maintained and the the transverse is maintained. If you lose any one of them, your foot brand will not be the normal. So you'll be losing abnormal sides of your foot, which is not adapting to take weight. And this end by a pressure point and this end by more fa and a slower movement. So the arches is there to give your foot a troo shape which makes you load less in the foot on a normal pressure areas, transit from one step to another step in very easy way by a rid lever arm. And we will go through this in details in the gate one. So uh what maintains your median, the most important of them is the median arch and to maintain the media long arch, um The key bone is your navicular and the media colon, as we agreed is the talus, navicular media uniform and first ray which is the first meal and uh the fungi for this media, no arch, you have a key bone which is a navicular, maintained by two muscles, the tibialis and the Brennus longus tibialis is holding the Lavi up and brunneus longus is getting the the phase two that one. So both of them are maintaining the same with this dynamic. There is a static stabilizer of your media which is the blunt, the fascia and the spring ligament. All the blunter ligament was specifically the spring ligament, which is uh the calcaneal navicular, the blunt of calcaneal navicular ligament or the spring ligament, which is very, very, very important. And we speak about when you speak about it in a minute, your plantar fascia basically is a thick fiber stent starting from uh the hermia tu pros and going in three in three. uh it's a three bands, central band, medial band and lateral band, central band goes to the middle, uh twos um media band goes to the first and um um and the, the lateral band goes to the fifth. So can GSTI where is attached attached to and then three bands, central band, media band and lateral band, central band goes to the middle toes. Media band goes to the first uh to the great to and uh la lateral band go to the er, to where they insert, they basically insert into the blunter aspect of the, the blunted blade of the first MTB and in the blunted aspect of um uh the toe and they do the very commonly uh called windless effect and uh windless, windless effect, a windless effect, windless effect. Basically. Um If you remember uh the effect in your foot happens around the MTB joint, when your toe goes up, the, the, the plantar fascia get into tension, get them in, get an ash. This is, again, is a main contributor in the git. If you're walking, how to walk, he strike, loading flat foot, then you do a bush off to do a bus off. Your first MTB has to extend and for your first MTB, because the movement in the bush off at it, it's not at the anchor in the first MTB. When the first MTB extend, this makes the plantar fascia thin and this is get the longitudinal arch formant. And this is makes your, the navicular in a different brain than your void. This makes your midfoot rigid and this is allows the whole foot to be as the live arm for the first MTB movement. Uh And it's very, very important. This affect the time. Basically frequent will be that the blunted fascia is in the blunter aspect, attach it to the blunted plates in all the toes. When you tend to push off, you push off by your mainly grade two and then start with the two, then go to the lesser twos. But if we speak about the grade two, you extend the grade two at the N TB joint. And when you extend the grade two at the N TB joint, you put the blan fascia into tension and when it is in tension, it bs in that media create it. And when it creates it, it locks the movement between the T and the ankle. Can you avoid which make your foot as a rigid lever. So you can lever by your rigid foot by your rigid foot and go and uh do a two off if this, if the blunt fascia is not working, if the blunt fascia is not um functioning well, is degenerative, ruptured any problem your midfoot, same as a material deficiency will be breaking in a midfoot break while you're doing, doing it a push off and this will make you walking less um no more. Uh more, more slower and uh more exhausting. On the other hand, remember that the plantar fascia is attached in the back to the achilles tendon. So actually it is a full complex. So the plantar fascia, three band media, lateral and uh uh uh central band and then they come to, as you see here, it doesn't go to the Calkinsia and stop. No, it goes and continue with the achilles tendon insertion and they are one complex and that's why 10 shortening in the tendo achilles or contraction in the gastrocnemius uh gastrocnemius complex deposits for uh um plantar fasciitis. And it's a very, very common missed cause you have a patient with plantar fasciitis. You treat for years and years and years, uh choke with sy giving him medication, nonsteroidal. Even some people will do uh P RP injection. Um nonsteroidal and patient is not responding, not responding because you didn't do ac test. You don't understand that the problem of the plantar fascia, it is in a lot of tension because the contracture of the gastro claus complex, all the idiotic short of the tender achilles and the R one complex plantar fascia is attached to the tender achilles and they all act as a one complex. If the contraction, if there is a contracture in your uh uh triceps, sui or in the calf muscles, this will both plantar fascia under tension and this end by the plantar fasciitis. Remember your plantar fascia is normally under tension because you normally have an ash. So the blunt fascia normally is under tension. That's why it's very common for the blatter fascia to have a plantar fasciitis, especially in obese. People give us people, people who are uh long stand for any reason. Their profession is longstanding. And the problem with the plantar fascia is mainly insertional. So your blunt fascia has always been for here on the old days, what we call his and stuff is, is the degeneration with calcification on it. It doesn't make any, any, any sense. It doesn't mean anything significantly. But there is a very common blood fasciitis. The the most common bla fasciitis is insertion blat fasciitis because basically this is the area with the maximum tension. So the three bands works together on this area and this area is commonly uh to have uh the main tension. And that's why you commonly have the insertion of blat fasciitis added to this area is the most watershed with least um uh uh lots of light. Uh So your blunter fascia is normally under tension. It's a fiber sheath, central band, medium, lateral band, they attach it to the blunter plate and the blunter aspect of your toes with the two extension and the MTB joint, the windless effect happen. And the blan fascia tightens and when it tightens it creates an arch and creating the arch, lock, the foot and lock in the foot makes it a rigid lever and this allows you to two off and continue your normal gait is commonly to have an insertion of plantar fasciitis. And this is because this is the watershed area and the area with maximum tension. Number two, remember that the plantar fascia is one complex with your achilles. So plantar fasciitis is commonly to have it was contracture of the cast or shortening within the architis. We're going ok. Or uh I think we can carry on. Yeah, there's a question but I think it's can be covered in another. That's fine. The question, which is surgical option to correct a flat foot or maintain the middle. That's fine. Now, any question away from the point is unclear, I will answer the then any anyone feeling any point unclear, please stop me. All, all the lecture depends on each other. This, this is the whole anatomy is the whole ankle and foot. So if you miss one point, you will be missing another point that, uh, while we're going forward. So please don't let me go forward unless you're following me. Ok. Yeah. Yeah, write in the chart and hers will, will pass it to me and unfortunately, I couldn't see any check, uh, because the screen is just full asleep. Ok. Come to the tips. Uh If we start to speak about the hand foot, you need to remember, uh, you have the Ts and calcium and the Ts and calcium are very unique bones and have a very unique relation. So the calcium is different than all your bones. If you have a lock on it, it has a body and a neck and a head and then a lot and osteoporosis, they are not all, they are not on the same line. So basically the head, the neck and the head are in v they are going a bit me projecting mo more median and the lateral um uh process is projecting more lateral. Remember that is covered in two cells with by cartilage head is completely covered, body is completely covered. Later process is covered. And um other than this uh because it's mainly uh uh actually it is mainly a transmission bone. So all the job that Taylor does is to change the movement of your, of your tibia onto your foot. So, and I will explain this to you in in details. So the the is basically a hinge basically in fas is in your leg or movement to that foot. There is no muscular attachment. Remember, I know Phil, Phil posterior process there is a groove where the flexor hars longest pass and the tubercle is the commonest site for austrinum. Uh And this is, that's why the Troon is al always lateral to the F HL. Remember I know ll body is not uniform. It's trapezoidal brought anteriorly. That's why when you put your ankle in dorsiflexion, you tension the ligaments around the ankle and the ankle is it's more stable and remember that um uh the neck connect the body to the uh to, to the head. And they had, it has the, the t had three foci to connect uh to um articulate with the calcium, uh posterior fossa, media fossa and Antero foss if you come to the blood supply, which is very, very important for the talus. So the main arteries which supply the talus is the artery of the tarsal canal And this is coming from the posterior tibial. So, posterior tibial give artery of the tarsal canal, anterior tibial give branches to the talar neck and then give the artery of the sinus tarsi artery of the sinus tarsi anastomosis of the artery of the tarsal canal. And this is where main blood supply to the tail scars. So as you see posterior tibial artery of the canal and anterior tibial altitude of the sinus, the anastomosis inside the sinus side. And this is where the main blood supply of the t come. You have some from the perineal artery, you have some supply to the neck from the anterior tibial but or the dorsalis be actually but the main supply is from artery kind of tibia and artery of the anterior tibia. Remember in in blood supply blood supply to the body is retrograde. How is retrograde? Posterior T is coming from the back? Anti T is coming from the back how the blood flow to be retrograde. Yes, retrograde to the body, not to the TS because as you see the artery of the tars canal, the anterior tibia, the perineal, the perineal, the artery of the sinus that are from the anterior tibial, all are in front of the body. And we go through this vascular fora in the neck and goes from the neck back to the body. That's why the body of the talus is the least supplied by blood because it's a retrograde supply And when you go up, so the the top of the t the talar body or the articular surface is the least one with blood supply. Because the highest point, basically the blood supply blood supply in water, you know, and it has to go up that, you know, against the gravity against the normal normal pressure inside the artery. Number two, it goes from down, up against gravity. Again, that's why the top, especially the shoulders of the talar body is the least supplied by blood. Very common treatment. Hawking sign. When you have a talar fracture and start to revascularize, the revascularization goes to the disc vascular area which is uh the talar body, especially median and lateral um shoulders. Uh and this creates the Hawkins sign. The second point. You need to understand that all the blood supply is mainly above the neck. And when you have a neck fracture, then this blood supply is badly affected. So, artery of the tarsal canal artery of the sinus tarsi anterior tibial branch. Uh branches to the neck, perforator of the perineal artery are all on the neck of the talus. So with talar neck fracture, the blood supply to the talus is badly affected, especially the blood supply to the talar body. Talar body, which is breakthrough grade. Um in the X ray, this is the the body, this is the neck and this is the head. It's easy to recognize this. Then you need is another unique bone you need for the and calcium. Unfortunately, um I don't have a model but I have to show it in the model if you have to hold the ki and in your hand to understand that actually me how is the direction, how it goes and vs how the calcium has a rotation and surfaces and how they articulate with each other is very unique. And this unique uh configuration of the bone and configuration of the articulation surface. What makes them transmit the movement and the rotational movement of the leg into rotational movement in the foot. It's not normal to move the rotational, they are different places, rotation of the leg in this way. And rotation of the foot is V virus vs or ee inversion. So the leg rotating in 10 and external and the foot rotating in inversion, inversion. And they are connected how they are connected by the unique configuration of the talus and and the unique relation between them at the subtalar joint. So you have to hold the, the, if you have an option for a Sobon or something of any of you who will be attending the Egyptian or Congress, I will show them uh this in the workshop. You have to hold the tru in your body, in your hand, you hold the in your hand and see the shape and how uh they are beautifully form it a lot and, and how the articulation is very uniform. And because of the informed uniform shape and uniform articulation, the talus and the calcium are able to change the movement, the rotational movement in this plane in the axial vein in the tibia to a rotational movement in the coronal plane in the foot. So from rotation in the in the axial plane to rotation in the coronal plane, this beauty happens because of this spatial which is the unique talus, unique calcium and the unique subtalar joint. So if you look at the cum, it has a posterior facet, it has a medial facet and it has an anterior facet work is by facet. So if you see the shape of the facet, you can easily recognize that the posterior facet is curved and it's covered this way. So the movement it allows is in and out. So it allows inversion, inversion while the medial facet is this way, oblique way. So it allows to move up and down and moving up and down, gives you the movement of uh plantar ends and anteriorly the calcia process is oblique in this plane. So it allows the movement of the mid foot in and out. So three facets, every facet has a different configuration which allow it allow a different blade of movement, posterior facet, which is allows larger posterior facet which is allows for movement for transition movement me which gave you the the the the movement of e inversion of high foot media facet which is in oblique position, allow the the to move up and down on the calum. Then anterior process which allow this movement of the mid foot in and out. So three blanes of movement, three different facet, every facet in a plane allowing a certain movement, inversion, inversion up and down and in and out. So basically uh inversion inversion is chro up and down is uh uh sagittal and in and out is. So posterior facet allows you to move in a chro plane media face allow you to move in a sagittal plane. And the allow you to move in a plane. And you see this unique relation there for the talus, for the calcium to move under the talus, it never ever moves in one direction. That's why the subtalar joint doesn't give you inversion, inversion. It actually gives you sobin coronation. And we will explain this in details why? Because of the orientation of the facets, it's not a one facet which allow movement. It's actually three facet in three different lanes given three different movement. As you were told, I told you, inversion, inversion in the posterior facet flexion extension or abdomen in the middle facet and in out or abduction abduction at the anterior facet. That's why your foot never move in one way, abduction, abduction of 4 ft. Yes, he has to move the foot in the, in the threes at the same time. And this is a unique for the shape of the, the shape of the and the joint. Uh We go to this in details, don't worry, but just to try it uh uh in the most important areas of the Kina, you need to understand definitely the facet. So middle facet mi uh I'm sorry, posterior facet, middle and anterior facet. It has an anterior process which has uh articulation with the cuboid and the Ravi and uh it has a very dense uh imminence of the and the media service which is uh the, the tech and I if you, it's, it's actually this one. This is uh uh is basically because as I told you, you normally, when you start to dynamically move your foot is normally he he is normally in v. So a lot of stress over the media aspect, uh compression stress if you go and remember what I told you about the de and later ligament when you start to walk your head is normally. So there is a tension over the ligaments on the later side, compression over the bone on the media side. That's why the S TT is a dense, is a dense sclerotic bone on the media aspect of the calcaneum. Why? Because your foot tend while you dynamically move to be inverse. So the compression stress is more on the media aspect. While your lateral ligament are more prone to injure because there is more tension stress on the lateral aspect just in tulum has F HL moving underneath it in a groove. And this is very commonly to be injured if you are doing um uh fixation either over or percutaneous because you do a fixation from the lateral aspect, the tip of the screws are in the media aspect. And if the tip of screws me, the like goes underneath it, they will injure the FH. So Susten is very important surgically for us because this is where we build the calcaneal uh fixation on calcaneum is a cancerous bone and when it gets injured, it crashes into pieces. And the base to build on is a Susten life which is the dense sclerotic bone, you can easily hold the all other fragments to it. But you need to be careful because underneath the Susten and the F HL is just going and easily to injure it by the tip of your screw, especially you screw is long and the Susten dec is in this position anatomically. So how a lot because you put dynamically, more virus in your ankle, more virus compression stress in your ankle and more varus tension stress on your lateral ligament. That's why you have a sustain tech, which is a dense sclerotic bone on the medial aspect and lateral ligament, which are more prone to injury because you got more compression medially and more tension laterally because you dynamically your foot is normally is he, he normally is in the virus. It's uh h hy rivaldo is very, very important. Yeah. Yeah, it's clear. Yeah. OK. Look each other good. Um If we go to the suba joint, as I told you, it's, it's, it's very unique and because it's very unique. Uh this is how, how it moved, as I told you how it translates to the movement in uh the axial plane to a movement in the coronal plane. And this is the position you see, you see it's, it's basically posterior facet which is uh convex here, concave here allow virus, virus vuls inversion. Well, I'm sorry, inversion, inversion uh of virus vuls uh media which allow the, the, the cal and the T to move up and down on each other. And then the interior Fancy Church allowed them to move in and out. They are controlled by four ligaments. So media ligament, lateral ligament, interosseous calcemia ligament uh and um and the cervical ligament and cervical is the anterior interosseous ligament. You don't even need to remember them. Remember there are medial lateral and inter inter the anterior art is a ligament. Remember that this calcium anatomy is very important. Normally, the orientation of your heel of your heel and hind foot is the calcaneum are not directly under the tibia. So tibia has the ts directly underneath. And the calcaneum actually translated a bit laterally. And this is again, but more compression stress on the media side, more tension stress on the lateral side. And that's why to maintain this relation is a very, very crucial to maintain the alignment. And don't have any problem from alignment. You need to understand this. You don't wait for your T Taylor Kinia to be one online. They are not one line normally t the is one line and Kinia is already translated a bit laterally. Remember, this is very, very important again. And this is plays a big role in the mechanics because that makes you doing dynamic movement healing in virus, a lot of stress, tension stress on the compression stress on the media. And this is how I explain you. This is, this is the leg and this is the foot and this henge, this is the unique henge which is talar subtalar calcium. The three of them are unique in configuration. And this is why they allow rotational movement in the leg in axial plane to be a rotational move to, to be translated into a rotational movement in the coronal brain in the foot. And this is what I explained to you go back, move your foot and you will find that there is no way. Once your blunt a flex, what what, what your food does ever, I'm sorry, invert and UC plantar flexion inversion and abduction on the other way around, if your dorsiflex, automatically, your foot will go into inversion and your forefoot will go into abduction. Again, blunter flex inversion, abduction, dorsiflex, E version abduction, move your foot and tell me what you find how this happens. So basically, I have to have a mother next time ankle. And when you start to walk, basically, you're, if you try to blunt the flex, what would happen? We agreed that the is wider, anterior, the talar body is wider anterior and uh um and uh now we procedurally when it blunter flicks, it allowed the the the TS to move into the ankle to translate into the ankle. Once it translates into the ankle, the posterior vessels of the subtalar will get the head into parts and this automatically will get the middle facet to move the hell to move the foot, the mid foot into more plantar flexion and the anterior facet, the t will move in the anterior facet with the whole foot into auction. So, blunt affliction inversion abduction on the other way around. If you go with the puss up your dorsiflex, the thes, when it dorsiflex, the the is fixed into the ankle, there is no movement and this time the calcium has to move. So the posterior facet allow the calcium to go into bulges and then the mid facet allow the calcaneum to uh to move the mid foot up. And the anterior facet allow the foot to abduct. And the same process happens dynamically with the ligaments and the tendons. So when you go into blunt reflection, your tibialis posterior is both into action. So what it does, it creates an arch which equal that your heel will be in varus, your forefoot will be in adu because it is attached to navicular por and mainly navicular and uniform. So basically attach it to the navicular. So it does evert and attach it to the um a uniform. It does abduct and dynamically on the other side. When you do dorsiflex, previous goes into action. So what it does it basically everts and abduct because attached to the basal ok, jointwise, bony movement, ignore the muscles and tendons, bony wise, talus and blunt flexion. Losing the ankle slides in the posterior facet. Heel goes into varus medial facet, allow the midfoot to blunt the flex. And the anterior bur allow anterior facet allow the TS and the whole foot to go into a other way around, tear us up in dorsiflexion, fight in the ankle, he starts to move into e middle facet allowed the forefoot to go up midfoot to go up and then the interior process allowed the the forefoot to go out. So blunt deflection inversion, abduction, dorsiflexion, inversion, abduction, muscle action, blunt deflection TPO in action move the navicular up, get the healing or the whole heal in virus and the whole forefoot into abduction. Other way around dole be in action, move the heal in aversion and get the whole forefoot into abduction. And this is the beauty of um a lot. This is beauty of because basically you need the both actions doing, doing by this way. Otherwise you would never walk blunt of when you go in the gate, he strike your foot, start to loot flat foot at this moment, flat foot equal what I do when you're flat foot, what do you do? What do you do? Why not? When you basically, when you, you do, you do blood, you do uh loading, loading. Basically, you dorsiflex, the ankle foot is on the ground and the is Dorsey is dorsiflex in and when it dorsiflex um and put foot in the ground or relatively with dorsiflex, basically both with out or dorsiflexion. He goes in inversion or ulcus and 4 ft goes in abduction. The va makes the and better in which the, the na your foot is sub act, the ground, one mass is reversed. When you wash off, washing off means your blunter flex deep, a deep post in action, you vert, you invert and you abduct. So your forefoot, the club is not in the middle of the PBO, your forefoot is rigid so you can wash off with it. So you need the two action in time for the gate to be efficient, flat air strike flat foot. After the flat foot, looting means your body move over the ankle. So the ankle is relatively dorsiflexed. And when it is relatively dorsiflex by the bony movement and the tendon movement, Benes bre is in action. As we told from a minute ago, your ankle goes into reversion. Your foot goes into abduction, your mid foot joint chopper joint, which is thar is in line with the calcaneum fibroid. Your foot is sub accommodates the ground. This is goes in reverse when you wash off, washing off. Basically, you blunt the flex with the action of the tip post and the and the the cal movement, your foot goes, the heel goes into inversion, your foot foot goes into abduction. Your, the navicular is not in line with the void. Your mid foot is locked, your foot is a rigid plate to push off. Any one. Didn't get this point. I can repeat it the whole night. This is the main message of this uh literature. Any comments for that? Yeah, there's no comments. Sure. No, no good. Right. Oh, no, no comments out in and out. Well, uh it's clear after that. Uh OK. It's clear out. Thanks. OK. Uh Moving forward midfoot for Yeah, on OK, I get it. Uh Cuboid like it's Cuboid. It, it's like a cuboid. It's cuboid in shape. Yeah. Has a connection ma in the back and ma fixing with in the front. Uh this for the, it has a group for the long has that had uh uh uh on the later aspect where this is to connect with um uh four and 15 uh in navicular is very important. Remember, you know, uh these, these pictures to show you that the cuboid and navicular are not the one, you know, cuboid and navicular are very big bones. When you go and fix, you will see the navicular is a really big bone and it has this, this which shape or what we call uh uh similar shape. Uh navicular has a medial plantar projection which is insertion for the hippo with the most important. Sometimes in the d already, I mean two ossification center, sometimes in two ossification centers don't um either do don't fuse or um uh they, they fuse but in, in, in the union. And that's why you see the aic in navicular and the types of the aic is either completely separated as type one or like an resembles non union like type two or actual ho as type three. In the navicular, you have um an uh attachment site for the first kidney forms and kidney and third uniform and definitely on the back, you have an attached and and uh articulation with the talus. So the back articulates with the head of the talus and the front articulates with the, the uniform. And as I told you on the la aspect, it has a facet for the cuboid and Antero of the uh um yeah, uh the relation between the navicular and the void joint, our joints, joint, navicular and the void. When your foot is flat, you have normal relation, normal, I'm sorry. Uh relation between the 10 navicular ankle, kidney cuboid. What we tell is easy to is the foot is sub bit easy to accommodate the ground. And the reverse of the foot is um if the ar is form when these two blanes are different. So um the foot is r uh ligaments of these are uh dorsal and blunter. The B for ligament come from the anterior of the to the and the uh and this relation is um actually this relation is a very fixed relation. That's why your foot, all the, the the center of radiation in your foot is the head and the navicular because navicular cuboid all the forefoot, definitely navicular cuboid and Tinian B mo as a one unit. And that's why all the deformities are from the T joint. That's why when you have a club foot or T um uh ev the actual uh the actual uh deformity is in the t that's why we use the tar head at the center of correction because basically the whole for mid foot move and high foot move around the head there. That's why you have uh the CVA, a ductus and virus and definitely the quis. So all the deformities, you will see is actually at the center of the cora will be in the navicular, the whole for and midfoot moves as one unit on this coa uh dorsal and blunted ligaments. And there is a bifurcate ligament tournament two of the two, the and the um keyboard. If we come to the uniform, uh the most important one is media intermediate and lateral uniform. You need to understand that um the second metatarsal is the longest. So it resists backward. This curve is, is a itself we 2nd, 2nd T and T joint is uh more approximate to the 1st and 3rd T MT join the and the joint between uh the uniform. And the second is the list, what we call the list or the, the list frank is um we speak mainly about this interosseous ligament, but actually, it is a ligament complex. It's a dorsal blunter and interosseous ligament and actually it has an accessory ligament to the third base. So as not as we imagine is one ligament between the uh medial kidney form and basal second. No, actually a ligament complex with dorsal plan and interosseous part um between the um uh the media uniform or the first uniform and the base of second and has an accessory ligament to the third base of third um uh meters. Um What we see here in the C the number six and number seven, these are the different joints that is fine. I'm sorry, complex are different uh ligament is, this relation is very important. Yes. And that's why your uh this injury is needs to be treated. Why? And if it's, it's commonly missed and if it's missed, the patient can always midfoot pain. Why midfoot pain? Because he lost the trans vers arch. If the this transverse arch, the key bone is the second metatarsal base. And if you lose this list frank complex, the whole transverse arch will collapse and this will end by midfoot break. And that's why the patient will get come to you with a chronic midfoot vein. The patient who has missed this Frank will come to you with a chronic mid foot pain. And uh this is because this arch has been lost uh for the metatarsal. All I need you to remember is uh the first and the sid and the ss the uh metal syo joint remember this is the normal shape. You have um a tibial and the fibular sisamo, the tibial sid, the media systemoid fibrillar sid is the, this is the normal place. If this normal place, it changes, this means the media, the head is moving into us. And this is when you diagnose helix S and this is what you need to correct when you both, when you correct the helis, you need the meth, the I'm sorry, the CID to be covered by the head of the METS. So you need to maintain this normal relation to have a normal weight bearing on the first um MTB with this, without this normal relation, without this normal relation between the C and the metatarsal, there will be abnormal loading here and this in by disturbed mechanics and this is where the helos starts. So Hex vars starts because of disturbance of this um uh mechanics. And when you need to correct helix valgus, you actually want, we want the simo to be completely covered by the head of um Methox. As you can see, this is the CYO view, you can see there is a cresta here to cresta, media and later media. Cresta has it for cymo, later cresta is later cymo. It is a very, very common uh missed cause of lateral uh of um of um uh first TB pain because of the cystoid. Uh So remember the cysto, remember the cyso view as you can see, you understand definitely that the cymo are um an accessory bone in the flexor believe tendon. And as you see this complex, the flexor has previous uh tendon has media lateral sid in them. There is inter uh sisamo ligament and there is interms uh ligaments on either side. And this is what we call the sisamo ligament complex. And this is very, very important to maintain the tube balances if you ha if you lost one of them. So you get a CSMO itis or a fracture in the lateral fibrillous syo, you go and remove the fibrillous syo this, this toe will go into virus because basically it, it lost this part of the complex. So this is not balanced anymore, the virus force from the in uh intact uh ligament complex and the media would overcome the lateral and in divide the tail into virus. And the other way around. If you lost the medial or the tibia sissy, this part of the complex will be lost and the other part is still intact. So it falls into the, the tail into values. Um If you come to the, the, the Pharyngis, I need you to remember uh uh the shape of the, of the joints. Uh this is not for anything. And remember this is an arcade. So the second is the longest and the first is shorter. And if you actually come to the second, the, the third is shorter than the second, the first is shorter than the cell, the, the third and the fourth is shorter than the first and the fifth is shorter than the fourth. So 2nd, 3rd, 1st, 4th, 5th, 2nd, 3rd, 1st, 4th, 5th. And this is the normal arcade. And if you're doing a, a transmitter tonal osteotomy, I'm sorry, amputation, you need to maintain this normal arcade. You need the, the second, it does have to be longer you need after the second, the third, after the third, the first, after the first, the fourth and the four after four, the fifth because this shape gives your foot the unique shape which make it chewable, makes it goes into shoes. If you look into your shoes, you will see that the, that the shoes is permanent from the center, not from the side and shorter on the media side and more shorter on the other side because it needs to recreate the shape of the arcade which is longer, second and then an arcade is coming 2nd, 3rd, 1/4 5th, um uh very, very important for the uh uh MTB joint is to understand the blunter plate. B blade is not um an uh a simple structure. It is a very complex structure. It's a fibrous blade. It's the main stabilizer of the of the MTB joints. We speak here about the first MTB. As an example, the blunter plate is it's very strong fiber sheath. It is connected to the metatarsal by two bands as you can see and connected to the pharynx by one band. So two band to the metatarsal and one band to um the pharynx. Um um it received the attachment of the transverse metatarsal ligament, it received the attachment of the plantar fascia and um it is the main stabilizer of the to not to float up. So basically, to understand this, you need to understand that the long tendons are working on the IB joint, not on the MTB, the long tendons, long extensor or long flexor, they work on the, on the uh IB joint B IB or D IB they don't work on. The MTB MTB is mainly uh controlled by intrinsics and the intrinsics tend to, to flex it. So I'm sorry to extend it. And the blood tablet is the one which maintain it into um stabilized. That's why when you lose the blader plate, your toe will go up. And this is the mechanism how the hammer to happen when you have a hallux valgus, you, you to the lo from the first when with Ha because it's pronated like that. The hallux, the hallux is short and the first metatarsal is elevated than normal. That's why the er metals you have to the other two with the feralia, the the blunter blunter structure starts to attenuate when the blunter blade attenuate. This is how the MTB goes into extension with the ball of the flexors, the toe, the toe go into hammering or even into clawing, which is like that. Again, the blunt blade is a very strong fiber. It's the same in the hand. It's here. That is very strong fiber has two limb attached to the metatarsal, one limb attached to the pharynx, it received the attachment of the intermit ligament, transverse intermittent ligament and the attachment of the blat fascia in the foot. Um If this attenuated for any reason, the communist is when you have an hallux fs, the metatarsal head is elevated, it's not getting the load, the load, this goes to the lesser toes, they are not adapting to get to uh uh uh load. That's why the blood tablet start to attenuate. When it starts to attenuate. It allowed the TV to uh uh extend. And the flexor tendon bullet, the tool into flexion to give you the, the characteristic hammer too. And this is the main pathological way of getting the hammer to with Harris uh blunter blade. If there is no disease in the vision is not having, it doesn't have a rheumatological problem. It's easy. It, it should be repaired. The problem with the blunter blade that it sometimes miss only one of the limb, either media or lateral. This if you miss the media, it the, the toe will go into valgus and if you miss the lateral, the toe will go into virus. If mi or mi mi post or both or the blat bies, I think we did, the toe will float up and then when it's flow up, that float up, um It goes at uh remember that the tonal basement to the ligament has the LMS underneath and the O ci above and remember that the is goes underneath the tunnel to the ligament and this is where the uh mortals in your arm happen. So this is the shape of your um TB joint. So you have the flexor tendons underneath the extensor tendons or the extensor hood, uh up metatarsal head. And remember that transversal mi a transverse metatarsal intermetatarsal ligament has um uh the inter above the lumbar and the digital nerve underneath because the digital nerve is underneath. With any cause of overloading of your forefoot. You do. We put more load on the transverse intermittent cell ligament. And this is when the, the the nerve get um degenerated and form the synovial I'm sorry, form the uh bursal complex what we call the morals neuroma. So, mortals neuroma happened because the nerve is bing underneath the intermittent cell uh ligament and with any cause of looting, overloading the forefoot, you push more on the um uh forefoot, the intermetatarsal ligament, uh the nerve gets uh uh injured between not injured, this get, get overloaded between the inter metals ligament and the ground. And that's why um it's common to have the Mortons ino. Um as you see, if we speak about the, the tendons, you have uh long extensors, A HLA dla ba dla A DB and the flexor on the other side, FF H LFD B. Um F uh if I'm sorry, F HLF H BFD LFD B, uh the long extensors as you know, goes up to here, then it, it uh goes into an extensor hood, the extensor hood as you see is getting the long extensor, the short extensors and make the hood which is attached by single band to uh the base of me. And then this tube by band and these two bands come into to, to I'm sorry, two bands. Um They come together in one which attached to the distal. Uh this is very, very important. It has um um two oblique bands here and it has two transverse oblique bands here. These transverse oblique bands which lead um the these extensor bands to be in place. If you miss this one, this extensive band will move up. And when they move up, they allow you to, they don't do the action anymore because they are not in the line of the action. Uh So extensive hood, longest and longest and make the hood, the hood has a transverse bands holding in the hair, then the oblique bands holding from the side, they go as I told you as two bands to the um base of me PX and they continue as one band to the base of distal PX. Uh you have four layers in your foot. Uh Every layer has um uh um a certain muscle and tendons to remember them easily. Remember that two and four has the long tendons, one and three has the short muscles. So layer number one has an abductor ha and abductor D and flexor D2. And previous, remember that the axis of the foot is just and beside the second toe. So everything which you b this way is abductor and which everything which you bow this way is an abductor. So abductor doesn't mean to the axis of the body but to mean to the axis of the foot. So your midfoot axis is there. So this one is abductor, her and this one is abductor, uh digitally, meaning though they are moving in two different directions because the move the headaches and the mini away from the mid axis of the foot, we are not calculating with the mid axis of the body as we normally do. So mid axis of the foot is just um beside the second, mid to I mean second uh toe, anything which moves away from the mid axis of the foot is abductor. Anything moves to the second to the midfoot and I'm sorry to the mid axis of the foot is abductor. So 1st and 3rd layer, you have the uh short muscles, 2nd and 4th layer, you have the long extensors. So first layer, you have abductor, abductor, digiti flexor digital brevis. And on the third layer, you have the flexor houses Brevis, you have the flexor digitorum brevis, I'm sorry, digital mime. And you have the ad doctor houses first layer abductor, helicis, abductor, digiti flexor digitorum brevis, third layer a uh flexor digitorum digiti Mimi flexor hars Brevis and uh abductor house long tendons on the second, which is uh long flexor Harris, uh Longus and flexor digitorum Longus was added to them, the lumbrical because they are attached already to the flexor digitorum Longus and uh the, the quadratus. Plenty. Um Don't worry about it. But remember that the second layer has long flexors, flexor has longest flexor digitorum Longus and the Flexor digitorum Longus has that um at attention to it. Layer number four has the tibialis posterior again, long long tendons, tibialis posterior and the longus. And the so four layers of the foot. First layer 1st and 3rd layer has short muscles. 2nd and 4th layer have long tendons. The number one abductor Harris, abductor, digiti minimi flexor digitorum and remember abductor to the central axis of the foot not to the central axis of the body. Number three has a flexor hallucis previous flexor digiti minimi previous and a doctor hallucis layer number two has long flexor Harris, longest fixer, digital and longus and with the fixed digital longus, the lumber and the quad plenty. And on the other side, um the uh layer number four, sorry tibialis, posterior, um tibialis booster and um Ben Longus and the entero uh remember the accessory bone. So accessory navicular as we agreed is is actually a center um uh of ossification which either uh has a united or united with five Brazilian oy go and A and O is in the uh long and O as I told you just later to the F hr uh ossification. Just remember that calcium come in the six months, calcium tabo media, kidney form later uniform intermediate kidney form. Remember it like that, I'll not go into the numbers. Remember that the nerve supply of the uh of the foot. So media is supplied by suina. Then uh lateral amount is supplied by shoulder and all the dorsum of the foot is supplied by spn, superficial pern nerve except the first to a deep pern. And remember it is a reverse in the hand. So in the hand, the ferrous wave space is supplied by and the others are supplied by um median. Here is a reverse. Here is superficial radial. Here is deep rene. So in the hand, the first wave is space is supplied by superficial radial in the foot, the first wave is supplied by deep rene. Um then the blunter aspect of the foot you have um here the media CIA which is coming from the posterior tibial, the posterior tibial is divided or tibial nerve is divided into two parts, lateral perineal and lot and media blan remember and it's again the from the hand for the hand, the median is supplying the 3.5 fingers and the other supplying 1.5 here. The median uh the median is supplying 3.5 and the latter is supplying 1.5. So to remember it easily, median is nerve. Lateral mas is uh sure nerve calcaneum has three branches later and media and uh mid calcium, medial calcaneum is coming from posterior tibial or tibial nerve. Remember in the whole dose of the foot supplied by superficial perineal except the first will be spaced by deep perineal. Reverse is in the hand, first will be spaced, supplied by superficial Raia superficial in the hand, deep in the foot and in the hand, 3.5, the the lateral 3.5 supplied by the media and the media 3.5 and 1.5 supplied by the reverse in the foot. So the media 3.5 supplied by the media planter are going to as I mean and the lateral 1.5 supplied by lateral uh lateral planter nerve, uh you have nine compartment in the foot. So central compartment, which has four interosseous compartment, as you can see and then superficial, middle and deep, central, then you have media compartment and lateral compartment, media compartment, lateral compartment, central compartment into four layers. O ci so uh deep media and superficial. So all are nine and if you want to open them, you have to open them from three incision, longer, median incision and incision over 2nd and 3rd 2nd and 4th meters and second enforcement ta allow you to go to the interosseous compartment, super deep and immediate compartment, media and lateral and the media. One allows you to go to the media to go to the deep intermediate and superficial center uh complication. Uh The problem with the fasciotomy of the foot, it always complicated by chronic pain and hypersensitivity. So you haven't had anything, you may have fixed deformity of the digits. That's what a lot of the people speaks about have. We should we do an acute decompression of um a compartment syndrome of the foot or not, if the patient will end by the same problem with fury or without. So that's why the BO guidelines say there is no consensus over how to manage foot compartment syndrome. Most common cause of foot compartment syndrome is fracture. And remember if you have a patient who is um athlete which is doing a lot of sports, which uh you have to ask him if he has any gia fracture before or not. Because sometimes it's a, a subacute like uh Comparative syndrome which was very unnoticed and the patient in by contracture and deflection of his um short muscles. And if you need to do an F HL transfer in this man, you need to understand that his intrinsic are short and he cannot use them. So it's not optional for him to, to lose the F HL. It's a bit clinical dilemma. But remember if you're going to do an F HL transfer for a like a chronic ales rupture, you have to ask the patient if he has a leukemia fracture before, not, especially if he's athlete cause if he has a fracture there, there, there will be some subacute compartment which ended by some contraction in the intrinsics. So without intrinsics, you cannot move as we agreed that the long tendons, flexor and extensor move the IB joints, but the MTB is moves with uh intrinsics. And if you lose your intrinsics because of had chronic compartment syndrome from a aia fracture before um you cannot lose your lung as well. That's why you cannot do an F HL transfer for a chronic ait in this patient, if we're doing an ankle arthroscopy. So this is our portals, we have anterior and posterior ankle arthroscopy. Remember that you need to, to, to uh mark them. This is one of my patients. So this is the tip end and this is where um the extensor digitorum and the B is, and this is my S BN. As you see, if you b on the fourth toe, you will see the S BN very clear here. So your, your borders will be entered just media to the tip uh and between the tip and then the media me your uh lateral border report that will be between the be uh and the PN and definitely for post portal view just inside the skin. And after incision of the skin, you go with a um with a, a clip just to be sure that you are not uh attacking any of the tendons or the nerves. And then you're going, remember when you're scoping the ankle anteriorly, you are not going into the ankle, you're actually going into the anterior compartment. So the direction of your scope and instrument is not like that is like that uh posteriorly very simple. The patient is already lateral. Then you basically bought some instrument here to have the axis of the foot from the axis of the foot, you bought this axis of the instrument at the same blane over the tip of the lateral. And then this will be the level of your borders on both sides of the achilles media. And later, so an instrument here over the hill to know, to know the ax of the head, move it uh approximately over at the tip of the the mark on both sides of the head. This will be your media and not reported. I don't think we have a time for uh I, no problem, right. Uh I uh comments I for next time uh of of um defeat it reasonable, defeat it, strong it short, it be completely in Arabic should be completely in English A com. Uh Anyway, you will receive a feedback of the decision. We already should have received the feedback from uh from it all. But all what you want in the feedback is how I get um the insight of it. Tell me what's wrong, what's good, what's bad? What do you feel? OK. Or do you feel uh wrong? Um uh a lot of talking a lot of uh of brain storming. So, uh if there is any mistake sent to me and II II can correct it. Um If you bought yourself in, in, in my, in my shoes, you will have a lot, a lot of benefit just to confirm with the MG and T. Yeah, definitely, definitely. If they don't move, you will not open. So the move is basically how, how your arch, how your arch form is arch form is because the head of the, the, the, the dic goes into blunt protection over the head of the T uh So, and the other way in the people. So, you know, that's why they are drug. Uh, and, um, this is how they are oriented, uh, exam oriented. Ahmed. This lecture couldn't be anything except that because this is the base. If you don't have the base, um, there is no way to answer any question, uh distal to each other, uh level distal and approximal doesn't make a big difference. So a navicular is more distal to the void. That is not more to the, but the point is, um, point is the plane if, if the foot, if the foot is flat, we are in the same blade. If the foot is out, the T on Nabi is in, in a, a bla is a severe blame than the boy. So the unlock. So the point is not if they, they are distal to each other, yes, they are distal to each other. And, um, uh, as I told you, uh, they don't. But the, the point is, um, how, um, how the blame if they are in the same Blane, the foot is sub. If they are on different Blane, the foot is rigid and you need the sub to accommodate the ground and you need it to be rigid, to wash off and have um uh a lever uh uh about the exam orientation, this lecture without this lecture. And the gate um is so difficult for you to understand how we're going. Uh exam orientation will be from, from the uh not next picture the ture after because it's about the pathology. But you will have this question in the exam. And if you uh both part A and part B, but if you um you don't have this understanding of the uh basic knowledge, anatomy, biomechanics and gate, you will not be able to answer that. And if you, if you digest this lecture nicely, you understand every point it, you go and see the video do whatever you want, video will be in the middle if you want to go back to it uh and understand it very well. All the lectures, the coming lectures would be very easy. Oh This is what I will speak about in foot in us in this rank as as you see, all the literature is clinically directed. But without this lecture, no way I cannot, you cannot be exam oriented in a in, in a sense that they will ask you about no, if you understand the clinical anatomy, this will make you easy to make you efficient to answer any anatomical question, any biomechanical question. And it makes you understanding of the posology very easy without understanding that the physiology is so an anatomy is so difficult to understand the posology. That's why the ankle posology is a dark side. It's dark side because most of the people are not on top of the basics. If you get these basics nicely digested nicely, it's so difficult to come with everything in the literature. Go back to it. Anything unclear, anything you feel wrong. Some, some of the information I give you because it's all, all, all just uh interchanging between as well as invention, invention. If I miss miss say some words, just be back to me and I will uh I will um explain it to you. Uh feedback will come to you uh very good evening for every one of you and a good night and see you in the next session next Friday. Yeah. Thank you, Mr Hash.