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OK. So this is uh lecture se uh section for the ankle trauma. Uh in our, for an anchor course, this is where I come from. Uh he hospital in Ascot, Northeast London. And again, it's the channels where you will find all the education activities we're running uh my youtube channel and also be a official channel. So to start with, with an ankle trauma, uh the most and the, the commonest hand foot injury is the calcaneum injury and the calcaneum fracture is um a a AAA way and site of debate um since ages. So um early we were, we, we were in a stage where every calum fracture was operated. Uh skin problems and complications of wound healing and complications of posttraumatic arthritis were very, very high. So the bee will shift from that to go for conservative treatment. Try to do a conservative treatment for a leukemia fracture. Then came the hill trial at 2014 and then its follow up in 2019, which gets us again to non operative treatment saying that nonablative treatment is comparable to operative treatment until the moment there is no clear answer for the question. Shall we fix a calcaneum fracture or not. So, calcium fracture is a complex injury. It's, as you can see on the right side, it is an anatomically complex bone. It's not the thy bone has a lot of curves, has a lot of surface surfaces, has a lot of articular facets, has a different articulation in different areas, has a lot of tendons and uh ligaments running um behind and, and across it and uh approach to aid the skin in this area, taking all the blood supply from before it was coming from the bone. And to do an extended approach for the calcaneum, we divide the the skin from its own blood supply. And this where um a lot of skin and wound problems come so quick. Look on the anatomy which will dictate. Um our our discussion about the calum fracture because because of the anatomy of the calcium, posttraumatic arthritis is very high even was operative treatment. And because of the uh complex anatomy of the calcium fixation of the calia fracture isn't the easiest. So basically, the anatomy of the calcium, you have to hold the calcium in your hand to understand the treble curves of the calcaneum and the three facets. So basically, it has an anterior facet, middle face and posterial facet. And as we all know, the posterior facet, which makes the subtalar joint is the biggest facet of them, middle facet is anteromedial where the Susten tulum tli is and where part of the talar head rests on and then the anterior facet where the end of the talar head is there and where uh the articulation with a clear void happens. Uh We all hear about the sinus tarsi and you can see this is this is the sinus tarsi and it's basically between the middle and posterior facet and this is where the intraosseous sulcus there. And when with the tarsal canal from the, the, the the tail is coming on, this become, become the uh uh uh the sinus tarsi. And this is what you can see here. So, from a sinus tarsi, then the, the calm groove, then come the talar sulcus and become the sinus tarsi, the common sinus tarsi where the vessels, the lymphatics and the nerves is running through. And as we understand, the main blood supply for the talus, which is the artery of the tarsal canal, which this tarsal canal Susten empty line. The one here is actually a dense bone, dense uh uh cortical bone which where the talar head, wrists on and the flexor halis, longest ones and knees. And this is is your uh is your uh backbone. This is where you will build all the fracture, calcaneum fixation on if you don't have a proper sustentaculum ti or the sustentaculum tli goes. So a fixation of the calcium is nearly impossible because this is where you will build on when you are fixing a calia fracture. So gives attachment to a lot of structures. It's underneath it, there is a flexor hearts longest roof. It gives attachment to the superficial deltoid for to, to the, the tibial calcaneal part of the superficial deltoid, the cal ligaments in the inter osting between the and calcium and definitely the sprain ligament, the blunt of calcaneal navicular ligament and uh with a Kia fracture, you need to understand that because it's a, it's a weight bearing bone. Once you see a calm fracture, you have to put your hand on the knee to exclude any tibial plateau fracture. You have to put your hand on the hip to exclude uh neo feur fracture. You have to put your hand on the back to exclude any pelvic fracture or uh a spine fracture. So when we look at the calcaneum fracture, we uh uh basic basic investigation is to have an X ray and remember that you need for an X ray of Calcaneum at least later and exit or Harris view. So you can assist the calcaneum properly. And the most important for us from the Calcaneum is where the calcium doing its job for, for the calcium to maintain a normal subtalar joint. It has to has two angles maintained in normal in normal range, which is the angle. The only you see here where it's a line at line through the posterior cortex age and a line through uh the, the, the posterior posterior f is in, I'm sorry, and the line through uh the severe posterior face and severe prostate. And this angle is normally 225 to 40 degrees. And this gives us your uh it gives you an idea about the height of the calcaneum and the width of the calcium, if the height of the calcium is reduced, border angle will be increasing or decreasing. And when the, the, the the the vial facet is gone, border angle will be uh abnormal. So when you see a flattened or decreased angle, you know that the posterial facet has collapsed, means the height of the calcium has it reduced. And the subtle joint is not normal anymore. When you come come to angle of gisi, you have the angle of GSI. If you have a look, it's just the vuls angle uh uh as you see here between the two stops of the calcium. So the calcium spear surface and this is a critical angle because it gives you the idea about the orientation of your posterior facet. If the posterial facet collapsed, this angle will be increasing, going into more obtuse angle. And this again gives you an idea that your subtle joint isn't normal anymore. So molar angle on the left side and it's, it's tangential line across uh the posterior facet and a tangential line from posterial facet to severe to pros and it's maintained into 25 to 40 degrees. Once the ba five start to collapse high, they start to reduce border angle will be decreasing. And on the other side, Ganei angle is through the posterior facet. And it, as you see, it's an obtuse angle about 120 to 140. And when it increases, means the posterior facet is collapsing. And both of them reflect that the sub joint isn't, is in congruent anymore. And this is where the posttraumatic arthritis will happen was as such a fracture as you can see is a lot of articular surface. So definitely it needs act to understand uh how much of the height, how much is varus or valgus heel? And how much uh how is the articular surface? Our articular foci. So for us, if you decide about what you will do for the kium, you need to know if the calcium is shortened or height. Is it used or not? If the calcium is uh in virus or not? Because both it in the virus will both more will will, will will disturb the distribution of the root during weight bearing. And this will uh accelerate the the posttraumatic arthritis. Number three, if you plan to fix it, you need to understand if the lateral wall is still intact or not because of the lateral wall is gone. So you have, you have to have a fixation and lastly, you have to assist the the fos the articular foci to understand the interarticular element of it. So if we come to c to classify the calcium fracture we have a descriptive calcification which we classify the rest the calcium fracture into interarticular, extraarticular and body fracture. Then we have the Essex Laity uh classification, which is an old classification. The only importance of, of Essex laity is the tongue type fraction. And we'll come to this in a minute. Then. Uh now we have the CTC T based classification, standards, classification, which is a very important classification if you plan to fix the, the calcia, because it gives you an idea what you are fixing to what? So extra articular fracture could be the T prostate avulsion could be the anterior per fracture and could be the sustentaculum. So uh TShe avulsion is mostly with uh it happens in a trauma with forcible contraction of the avas sur anterior persis fraction is always with with foot inversion injuries, uh and later ligament rupture. So, a patient with Ankyra, you need to be very careful about the anterops of it hasn't fractured or not. Then the Susten tulum and this is this is a bit of a bit of a um like significant trauma to cause the Susten tulum to break. Then body fractures. And this is what we will classify in a minute, an intraarticular fracture. When there's a line running through the posterior facet, especially, we look after the posterior facet more than the middle and anterior facet. Because as you understand, the posterior facet is is the main component of the subtalar joint, which where the arthritis and the symptoms will come from acceler is looking into the primary fracture line which extend from booster media to an interlateral. The importance of A six is the tongue tie fracture. And as you can see here, this is the tongue tie fracture. When the line extends from the posterial fossa going through the prostate and this starts to evolve. If you, if you, if you're following me, you understand that this is attached to the achilles tendon. So it always evolves up. And the problem is this fracture will be pressing on the skin and causing the skin to recur and die. And this one from where this fracture become um uh an urgency. So you have to reduce this urgently, especially in, in in vulnerable people. All age diabetic patients, smokers, these people are prone to have a skin problems. And if you leave a tongue tie fracture, pressing on the skin, this will be determined with, with the skin loss. Um Once you do that, you have to immobilize this patient in an implant flexion because you have to relax the achilles tendon so that there is no more ball on the uh on the tongue type fracture. The other type of fracture is this one which is the joint depression and it's more commoner because you a as you understand the commonest mechanism of injury in in calcaneum fracture is far from height or axial compression. So the joint depression type is very very common if we come to Sanders classification. So Sanders has basically this classification on axial view, um Andro view of the of the uh uh city and it's looking into the posterior facet. And when you look in the posterior facet, you need to see how many fracture line running through the posterior facet. And after that, you have to look where this fracture is running and then how much displacement. So in Sanders, you both, you both you look into two views. Ronal view and exit view, you need to see, you need to answer three questions. How many fracture lines through the posterior facet if they are displaced or not? And if they are, if there's more than one fracture line, where is it? So if you have any number of fraction lines which are undisplaced, this is type one, if you have one fractured line with displacement. So two displaced fragment is type two. And if you have two fractured line with displacement means three fragment. This is type three. And definitely if you have more than this, it's comminuted type or type four and every type of them depends on where the primary fraction line is. If the primary fracture line is just in the middle of the fossa. So this is uh uh uh I'm sorry, in the lateral part of the fossa. This is a if it's in the middle of the fossa, this is a if it's medial to the posterior facet this is C and this is means it goes through and this is the worst type. So again, when you look in Sanders, you have to have act and Sanders, the main importance of Sanders is uh uh planning for operative treatment or planning of fixation. And Sanders has based his classification based on how many fracture line across the posterior facet and how many, how, how, how this place is these fractures? And number three, where is the, the primary fracture line? So if you have any number of fracture lines, but they are undisplaced, this is type one. If you have one fracture line with two fragment displaced, this is the type two and if you have two fraction line with three fragment displaced, this is type three and more than this is a comminuted type or type four based on the primary fracture line. If it's later in the posterior facet means it's away from the Susten te means I'm still having a good sustentaculum B to hold in my fixation is, is a and if it's in the middle of the facet, it is B and if it's across the Susten ecn or median is C and this is the worst type because I don't have any Susten techn anymore to reconstruct on when we treat the calcium fracture, the calcium fracture as as we agreed has a high risk of skin problems and soft tissue problems. So once you see this patient, this patient needs to have never ever brought this patient in a plaster. This patient needs to go in uh uh uh uh just swoll and creb keep this patient strictly elevated on a, on a, on a prime frame and, or bellows or whatever the, the what you use for, for elevation. And then the patient need to be continuously on ice. And this is the situation uh until the soft tissue settles. And normally this is takes up to five days to a week. There is no plasters anymore long time ago. But ii know that still some, some um institution schools is doing um uh a plaster, no plaster anymore. Warren proper elevation on, on a prime uh frame or uh bills and ice. Your soft tissue will dictate the time you will do uh the operation. So if you're planning for operative treatment, so the soft tissue is the first dictator because the main problem is uh infection and skin skin condition problem or skin or wound problems. So never ever to operate on a patient without a proper soft tissue cover. Never ever operate on a patient with soft tissue which is still Edem as injurious uh uh and um liable for problems. Would I operate or not? As we agree there is the evidence says the the main evidence court right now is the Ki Hill trial or Yoki Heel Fracture trial. And this is, has looked into 22, 200 something patients over uh two years. Firstly, 2014, they follow up or five years follow up at 2021 2019. And, and it has been published 2021 and they found that there is no symptomatic or functional advantage of operative over non operative after five years. To be honest with you, it's, it's, it's a, uh, not that strong evidence to follow. It has a lot of, of biases, biases in selection biases, randomization biases. A lot of biases. It hasn't uh included main uh cofactors in the treatment. Like if the patient is a smoker or not age of the patient, uh type of fixation, level of expertise of the surgeon who fixed the fracture. So it's so difficult to depend on it. But uh this is one of the robust evidence in our hand. But you need to understand before you take your decision that you cannot depend on the hill trial alone to take a decision to operate or not. So hill trial, as you can see, give you a clear statement that there is no symptomatic or functional advantage to operative or non operative. If I have a young patient who is non smoker and operated by a proper surgeon and another patient who is a smoker who is diabetic, who has been, have a bull fixation. I cannot both, both of them in two lines to, to compare because there is a lot of co founding uh uh and cofactors which is mixed makes a lot of buy in this, in this choice and this decision. So uh we have another evidence in two D in 2002 from Canada, it's an RCT combating operative versus non operative. And they found that the function and outcomes are equivalent but patient with work compensation do uh bo with the with the non operative treatment and the the the aim to an operation. So it's another another uh um evidence supporting non operative over operative practically from the experience I have. So Kia fraction always doesn't do well to be honest. So operative versus no operative may, may differ in the time when the arthritis will happen, but both of them will have posttraumatic arthritis at some stage. Uh In my practice, I give the Kachin fracture fixation to uh a reliable patient, young age who has virus or loss of height or uh pro lateral wall. Other than this non operative treatment will give you the same, nearly the same results with just um an an early arthritis rather than a arthritis in and and post traumatic arthritis in operative group. So practically, if you come to the practice, you will not make a huge difference for fractures outcomes with operation except in a young patient with virus heel or loss of height or blown batter wall. So you have to select your patient. You have to be sure what you are doing for the patient. You have to have an A a good conversation with the patient explaining them the best uh the the the best evidence available and the options of treatment pros and cons of each because you need to understand that the operation isn't a magic. It will not, it's a magic and it will not make a magic uh results. But the results are nearly comparable functionally because both of them both options with and by posttraumatic arthritis, the difference is when and a AAA failed fixation or a poor fixation is much worse than non operative. So because of that kin fracture management, it still doesn't have a fixed clear answer. So if you opted to operate on this patient and fix the Kia fraction, uh the one which is carries an urgency is the tongue type as we agreed because you have to decompress the posterior skin, especially if the patient uh is valable like an old age diabetic skin condition, uh smoker. And when you do that, as we agreed, you have to reduce it. You can take 22 screws across it very percutaneously or openly. Uh Your problem was the per cutaneous is that sometimes the very ostium is just uh into the fracture site. And you have to clear that before you reduce the fungal type. Other than this, you operate when a patient was a wide hi foot to avoid uh the subfibrillar impb in patient was hind foot virus. Because as I told you, this means altered mechanics al the, it, it, it, it, it altered the mechanical and both the patient at higher risk of getting a posttraumatic arthritis very early. Uh try to avoid this in smokers and diabetic because they don't do win after the operation. And as we agreed failed or poor outcome or poor uh operative results has much, much more determine outcomes than non operative. So, in a smoker or diabetic, you know that the operative results would not be good and non operative treatment will not make it any worse. So you have to speak to your patient honestly explaining what is, what, what can you do for him? What can you achieve if he is a smoker or diabetic? There is not a lot you can achieve for operative treatment. So you have to, to be honest with your patient, uh that non operative would nearly give the same results as operative in such type of patients. So, if you're planning to operate, this is two patients. Uh uh of mine, you can see uh uh you have two options of, of uh regarding the surgical approach, either you do an extended Atkins approach and Atkins approach. As you can see on the right side, you mark your uh uh lateral mad, you mark basal fifths and then you go into the demarcation line between the Healy skin and the normal skin. Make your uh this is the key is, this is the demarcation and you go as over the angle just uh over the, you feel the bone and you just go, go over the ankle as far as you can because you need to elevate a very big flap here to avoid skin nec growth and skin and wound problems. Later on. Be careful, your sugar nerve is just under my cursor here. So it will be coming in your way while you are detecting. Remember that you need, once you open the approach, you need to go across uh the whole soft tissue to the bone. So your knife needs to go up to the bone before you do anything. And when you elevate, you have to elevate a fall flap. So the elevation has to be from the periosteum. It's not allowed to be keeping any soft tissue over the bone because the more you have the thicker flap you have, the more this flap will live because more blood supply coming mainly from the periosteum. So if you keep enough soft tissue, enough soft tissue flap, this will be uh uh will give you a better results regarding the wound problems and the skin problems. Once you do that, you can hold this flap with um uh uh uh a, a suture or a wire or whatever you are doing. Then your point here is you have to go and try as much as you can to, to blend your, your, your uh fixation. You have to start uh botting botting on the sustentaculum, ti sustentaculum tonight is your cornerstone, start from sustentaculum tonight and start to up on it and reduce as much as you can in, in, in a, in a, in a STD manner. So if I have a blown lateral wall, I get the lateral wall, lateral wall open. I see the main fragments, I try to stick the main fragment to the sustain t hold it with wire and build up on it with the small fragments until I have a W shaped calcium. Then I battery it with uh a cal blade from outside. Uh the cala blade. Uh Thankfully, these times these, these days is are, are thin uh low profile. So they don't cause a lot of problem on the irritation and they have a lot of screws, va screws with multiple options which allow you to play with different fragments and get them back to the Susten tecum. I always start with a couple of cannulated screws through the main fragment to the Susten tulum separately away from the blade. Stick the blade on one side, reduce all the fragments and maintain the later wall, support it with the blade and then get my closure. Uh As you can see is if you, if you're doing from the lateral wall and you can see that the, the the if, if the fracture has, it has involved the bone uh tubercle, you can do some zloty for the Brunei and then you can repair them after the fixation So if the other option, which is getting more popularity this time these these days is a SINUS DSA approach, it is a limited approach and give you uh uh uh an access to most of it. So uh uh basically you go from the tip of the lateral manus across uh along with the fourth ray. So you hold the fourth ray in your hand, you see the fourth ray where the fourth ray is and you just open a sinus. Does that approach from the table of the lateral man across the force line with the fourth ray, it's main open as you can see a small incision. And then when you go any, you just go between the brunii uh sorry, the brunii on the uh o on the blader side and the A DL on the uh um dorsal side, once you go and you will find your EDB in the way you have to elevate the A DB uh from its origin. And then you go in and you can see uh the subtalar join here, subtalar joint here and then the calcium which you can manipulate and play with same as you do with extended lateral. The only difference is you need to be uh uh it needs some learning curve. You know how you need to know how to reduce uh the, the, the, the, the fragments. And the idea of the sinus, the side that we found at the end of the day. The maximum we can do is uh operative treatment is to reduce to, to restore the height, to restore the articular surface from the sinus D I approach. Restoration of the articular surface is very possible. And then from outside, you can draw take to restore the height before, before you do a fixation. It definitely needs a specific instrumentation and needs a specific plating when you do that. So this is a fixation from either approach, you use either low profile lateral calne plate and there is there is dozen of options of lateral uh calcaneal plate in the market in the at the moment and most of them are doing the job very well. Uh I use the synthesis plate mainly and they are doing a very good job. Then if you have the tongue time, you have the option to do a bit cutaneous two leg screws. Uh After you manipulate it with some key wires and hold it with some key wires at some point, your option may be if you opt for operative treatment is to do a primary subtalar arthrodesis when it's horrible combination under uh type three or four. And there is no option to restore uh the, the posterior facet. So what you do, you do a minimum over reduction tendon fixation to restore the height and and to, to, to, to uh to correct the flat B and then you go after restoring the height and fuse, do a primary fusion of the uh of the uh sub joint. And honestly, the results of this is are very, very consistent and good. So what the complication with uh a calum fraction as we agreed that uh the surgical outcome will depend on how many francy you have, especially intraarticular. And how is the quality of the reduction, articular reduction? Because we know that posttraumatic arthritis is the end of, of, of, of the uh um is is the end of the outcomes. But how if you reduce your fracture as well, if you restore the articular surface properly, you have a congo articular surface, you'll make this a bit late sub arthritis in the Yeah, the most common inevitable um uh complication which we need subtalar fusion at some 0.1 disease and infection. They are, they are more, more and more common complication with surgical option about 15%. And this is a huge number to have a 15% 1 complication after surgery. And the patient will under will, will, will, will, will uh reflect on the infection as a night pain virus malrotation. I'm, I'm sorry, Mun uh and this is virus mur is very, very common, to be honest with you. And the option you have for that once it happens is that to do a correct osteotomy and release or lengthening of the achilles tendon F HL damage, especially if you both long screws, which pass across as, as as we agreed, the cornerstone of your reduction and fixation is Susten and just underneath the Susten, the FHA runs. So if your screws are long uh from the, from the lateral side, they will end by pointing on the media side and injuring the F HL from your approach. If you're doing an extended later, there is a high risk to injure the shoulder nerve. And definitely if you miss the type, uh at type, you will end up by achilles tendon, shortening. And if and in inefficiency, uh we're done with the cum, then we move down to the talus and when we speak about the tail and neck fractures, uh the good thing uh Thankfully, we are not a day to day uh fracture presentation, not a day to day cases in, in the emergency department everywhere. Uh It's always happened because of forced ankle dorsiflexion. When the tar neck starts to impact on the anterior distal tibia and end by fracture of the tar neck. Why we speak about the talar neck? Because if you are, if you remember with me the anatomy and how the talar uh uh bone appears. So you understand there is a body and from the body to process it comes out and then the neck is just coming coming coming out into an angle connecting the head with the body. Uh The second thing is we understand that all blood supply of the arter is retrograde coming across the neck. So with neck fracture, the blood supply to the body is affected. And this another importance which that's why we speak about the neck fracture as a single uh or a separate entity. We classify it as, as a by Hawkins. I do all of us know. So Hawking uh uh the point of Hawking is it, it quantifies the, the risk of uh A VN. So it started from a non displaced fracture with a n of risk of about 15 to 20%. Number two is displaced fracture with subtalar dislocation and this guy is at risk of about four VN. Then uh Subtalar dislocation with tibiotalar or ankle dislocation which is has an E VN uh of 60 to 100% and end by dislocation from uh the navicular joint and this carries a risk of 80 to 100% VN. There is uh uh uh Hawkins is very good in, in, in, in detecting is in detecting the AVN. It doesn't affect a lot the way of, of management or a way of reduction, but we it, it can guide you through. So if it's undisplaced fracture or Hawkins type one, the patient will need nonweight bearing and cast for eight weeks and then start putting some weight on. So treating nearly, nearly non operative if the patient have only ter dislocation, so you can reduce that and put the patient into a cast. But nowadays, we all operate, we operate in all these cases because the risk of E VN is low with operative treatment. Uh then if the patient is a subtalar and TTE dislocation, definitely we need an upper reduction and 10 fixation. Uh The most important at that stage is the soft tissue. You need to look after the soft tissue. These injuries will come to you mostly as an IC fractures, fracture dislocation. So uh you have to look after the soft tissue and definitely if it's safe if Hawkins four, you cannot promise this patient for more. It says evn risk of 80 to 100%. So whatever you do for the patient, the patient may end by an AVN. If we uh want to look in the talar uh into a talar neck fracture, we have the canal view. As you can see you blunt to flex the foot, you moved, moved into 15 degrees internal rotation and your uh uh beam is moved uh uh cranially by about 75 degrees or 15 degrees quarterly. If you are doing a uh uh uh a bi indic beam, this is where the positioning of the vision is. You have this look. And when you do a canal view, you can easily see the whole, thus including the tar neck. Uh The most important when you look at an X ray of a tar neck fracture is to identify Hawking sign if it's there. And Hawking sign, basically, as you can see here, it's a subchondral uh radio ra rau band and this gives you an idea that this area is starting to revascularize because of revascularization. This stimulates the osteoclast and the osteoclast makes some osteopenia to start with. And when you see it's osteopenia already lose line, you need to understand that this area is starting to revascularize. So actually, Hawking sign is a good sign. When you saw see Hawking sign, it's not because of the vascularity started, but actually because of free vascularization has it started? And if you don't have Hawkins sign after a fracture or uh uh no treatment or fixation, if you like Hawkins sign and you have sclerosis, you have to know that you're going, that your patient is going into E VN. Definitely a CT is needed for talar neck fractures if especially if you cannot spread it from uh the X ray. So how will we treat a, a talar neck fracture when you deal with a talar neck fracture? You need to understand that approaching the talus isn't easy. As I told you, the talus is not just a straight bone, it's the body and, and, and, and a virus angled neck on top of it ending by a head. That's why you always need to go through two approaches. You need, firstly, as you can see on the right side, you need to be see, you need to be sure that your soft tissue will allow you to do that. And as I told you from Hawking three and Hawkins four, they are commonly to come as an open fractures. So if they become an open fracture, they need an reduction and once reduction, stabilization with some key wires or x fix or whatever you have until soft tissue, soft tissue settles and then you go and fix it. When you fix it, you will fix it from dual dual approach and to media and anti lateral approach. As you can see on this side, the intermediate approach, it just between the median manus as you can. If you draw the median males and the vigorous ts and you just go between the tibia, anterior and tibia posterior. So when you go between tip tip and and tip post, uh you would be, you will, you will be on the tailor neck straight away. You need to be careful and you need to be uh care main, mainly careful about the deltoid ligament because the deltoid ligament if you open here with a precursor. Yeah. So median man tip and and you go between the tip and, and tip post hair and once you go hair, the the deltoid ligament would be just underneath here. So you be careful about the not to injure the deltoid uh ligament especially, you know that the deltoid ligament carries uh uh uh the blood supply to, to those he and your blood supply, the main, the Tulsa artery, the artery of the Tulsa canal, which is coming here just under the was underneath the diploid ligament. If you need to go more than this, if you do need to deal with a, a talar body fracture or a very, very posterior talar neck fracture, you may need to do a, an a median uh manar osteotomy. So it gives you an approach to the uh media side of the subtalar joint coming to the approach of the an as you can see, sorry the picture on the other side, same like a sinus approach in line with the fourth ray and you go here between the BE and be uh be and Edl and once you go between be EDL and the BE be and be and Edl, you expose a sub join the navicular join and join. It's quite a very good, I'm sorry, quite a very good approach. So basically lateral mal you go from the tip tip or anterior anterior neck fracture, you go from anterior end of the lateral mal in in the fracture, you go more bluntly. So you go from the tip of the lateral m to the fourth ray in line with the fourth ray, you open your approach be will an EDR will be on this side. Benes previous will be on this side. Once you go in, you need to, if you're dealing with this area, that's fine. If not, you need to get the AD ABA DB of its origin and then you do whatever you want. So uh that once you once you, once you reduce, you reduce the fracture site from dual approach, you have a lot of options to fix this fraction. So mostly use a cannulated screws uh or you do a bilateral blading plating. This depends on how much community is a fracture. So if your fracture is just uh a transversal oblique line, you can easily uh stick two screws either from an posterior to or boo boo to anterior. Both of both of them will do the job. Nowadays, we we we're running more towards plating. So we plate mostly median plate or median lateral plates. So we can uh uh give a more support, especially if it's a comminuted fracture or a BB protic bone. We tried to use titanium to because you know, to, to, to, to follow up the A VN, you will need frequent M and follow up MRI scans. And if you know, if you use a stand still emul it will be difficult to have an MRI scan complication of the neck fracture. Again, we understand the most common complication. And this is a very common question in the exam is not the A VN. We have spoken about the E VN Hawkins or Hawkins has has built his classification based on a VN risk but it still subtalar arthritis is the most common complication. And this is a very common M CQ question was the most common complication of bother and neck fracture. It's not E VN though E VN is very high as we agreed in, in Hawkins, three or four, it goes up to 80 to 100%. But still sub arthritis are more commoner for the AVN. You have to follow the patient for two years, especially Hawkins will appear within six months to three months, six weeks to three months. Then you have to follow the patient because we don't know how the revascularization, how the bone will be half will it collapse or not? So, if a patient is at risk of VN, you have to follow this patient for two years, at least virus malunion is again, again, uh uh beating factor for subtalar arthritis because it, if you lose uh or decrease the the the the the T is a subtalar aversion, you're impinging the the talar neck. And this is when both abnormal mechanics of the subtalar ended by arthritis. Subtalar dislocation. Very common uh entity and very common association with the neck fracture. As we told, subtalar dislocation is Hawkins too. And you have subtalar dislocation either from uh lateral side or from media side. It's common to be from the media side because basically mhm the the nick is normally into is is in virus and the commonest to happen with this is inversion injuries and with inversion injuries, the subject of dislocation is commonly to happen immediately associated fracture. If it goes, if it goes immediately, will be uh uh either dorsal mediate or head fracture. Uh medial, mild posterior tus or navicular, if it goes uh laterally will be injuring the cuboid, the anterior baso the calcaneum or the fibula. Basically, as we agreed it is the medial, medial, medial um sobin nation would be in an inversion which is sobin nation in, in, in definition and the latter of dislocation was happening was poor nation which is e the mo most common question in this area is what is blocking the reduction. So he give you a case coming with uh uh media dislocated uh subtalar joint and the patient did. And the reduction is blocked under uh uh clo close reduction is blocked under sedation or under general anesthesia. Also com co communist red uh block communist structure blocking the reduction in lateral dis. It will be the posterior tibial tendon. So when you have a posterior tibial tendon, uh involve uh the posterior tibial tendon engulfed inside the dislocation, it will be difficult to reduce the lateral uh uh dislocation. And on the medial side, the commonest is the extensor digitorum previous muscle. So if you got an exam question asking you what is blocking the lateral dislocation from closed reduction? And blader dislocation is obtained from closed reduction. It is the tibia is a posterior tendon. What's blocking the medial dislocation from closed reduction? It is the e extensive digital and previous muscle to reduce the subtalar dislocation, you basically need uh to bend the knee release the achilles because this is the main, the main driving force for blunt inflection. Once you release the achilles, it will give you an option to reduce it unless either tibia posterial is blocking. If it's a lateral dislocation or extensive digital is broken if it's a media dislocation. As I told you commonly, these, these dislocations comes with an open injury or open fraction. So you need to do uh to follow the protocol post. The guidelines for open dislocation, do wound care, reduce temporarily both K wires until the soft tissue he or uh plastics do some cover for it. And then you go for a definitive fixation for what fracture you have. Yeah. The other injury which can come to the talus rather than the body and neck fractures. And the uh subtalar dislocation is the osto chondral lesion and osto chondral lesion of the talus is not uncommon. It's, it's, it's very common especially for patients with recurrent ankle sprain. So if you see in your clinic, a patient with uh hyper mobility, recurrent ankle sprains for any reason, malalignment, tarsal colation, flat foot, cavers foot and we have recurrent ankle sprains and they start to have a been uh into the joint. You have to think about osteochondral uh lesion or osteochondral injury to the T and MRI scan is a must in this stage. They may come the communist is to come into the shoulder or what he call it the do, but it, we call it the shoulder and it's either media, shoulder or lateral shoulder. So the media shoulder because as I told you, the commonest is to have uh uh uh inversion or a lateral ankle sprain. It's common to have a lateral talar dome injury. And if you have another tool, this is mostly come in in a traumatic history. It's always superficial and smaller. But the problem, they are always central or anterior and uh they, they take time to heal with microfracture. On the other side. The median do injuries is commonly to be atraumatic, commonly to happen from a vascular necrosis or OA CD or whatever. And they are more common. The problem is you cannot reach it easily by anterior scoping. You may need the posterior scope to reach it and they always large and deep in these places. So again, uh we speak about the osteochondral injuries to the theaters because they are very common, especially with ankle sprains with brains because an inversion injury is common after we have um uh uh a lateral dome injury, lateral dome is always small and superficial but it it it it behaves very poorly and takes time to heal, especially uh if you just do a microfracture or you do nothing for it. Uh medial dome is always both, it's not always traumatic, it's more common and when it happens, it's more posterior and that makes it difficult to reach uh through an anterior copy. And you need, you may, you may need to do a posterior cope. Uh bren and hardy has hard, has classified it into uh just bone compression or just a chondral fracture with bone edema. But it's still the the articular surface is maintained. Number two is if the fragment starts to be partially demanded, uh they touch it. Number three, if it's become completely touched but still in place. Number four, if it's completely touch it and start to move from place. Number five, it become cyst formation means there is no uh there is poor pad underneath the the fragments. So even if you reduce and fix it, it will be held very poorly and will not heal. So again, if we speak about bre and Hardy classification, it's number one on uh displaced such a bone edema, sub fracture or bone compression. Number two is just partially detached. Number three, fully detached but hasn't displaced. Num uh type four has detached and displaced. Type five have become assist uh formation underneath it which means more bid for healing. And that's why even if you fix it and use and fix it, it will never go back to normal. So the option you have for that if you just have a AAA small fragment which is displaced, you can do just a fragment excision and microfracture. The main and the golden line of treatment is microfracture and this patient always be halfway with the microfracture. If more than a centimeter, you may need to reduce it and fix it with a head is a screw or uh, or uh uh uh Benz or something. If uh the other option, if, if you have a defect, big defect and you cannot cover it or microfracture didn't do well, you have the option of doing a, which is osteochondral autologous uh transfer system. You get the same a fragment from the knee, from a nonweightbearing area in the knee and you just insert it into the osteochondral defect in the talus or you have to do a mozy plasty. When you go to the interchondral notch in the knee or nonweight bearing area of the the and you just uh take a chondral flap and both this chondral flap or mozy to cover the defect in the chondral uh surface of the tru we go forward. So after the te the navicular fracture and navicular fracture is very simple. Uh is, is fortunately, it's not that common. So, uh it may have traumatic or a stress fracture. You understand that uh the, the, the navicular is under a lot of stress direction of the, of the t the varus direction of the tar neck and the head and the position of the, of the navicular covering all the head under continuous tension from the tibialis, posterior and tibialis, anterior uh tendons. So it's, it's common to have a stress fracture. And the problem with if it happen, if the stress fracture happens, it's very prone to nonunion especially it is um no, doesn't have that good blood supply. Then uh the other other traumatic fractures, if you have a traumatic fracture would be either just avulsion from the head or from the body, I'm sorry, or uh avulsion of the frosty avulsion from part of the head and the attachment of the ligaments or would be a body fracture which goes into three types, type one, undisplaced, type two, displaced and type three community. So dealing with an avicular fracture, all what you need is just um high index of suspicion. So, so when you see, when you see a patient with an uh an inversion injury who is having pain on the midfoot, you have to look into uh his x-ray properly to exclude if he has a navicular undisplaced, navicular or sudden navicular fracture, especially, it's so difficult for you to see the navicular completely in one brain of X ray to see the navicular completely, you need a 3D format because if you understand the shape of the navicular, so this is the talar head, the the talar head and this is the navicular and the navicular is extending in two lanes up and down median later. So it's a big concave bone which you can easily miss a fracture on normal x-ray. Uh Number two, you need to understand how to differentiate between by uh bar or what's called uh accessory navicular and actual fracture. And definitely the accessory navicular or bipartate would be having uh um a uh a corticated end or the sclerotic end. It, it doesn't appear as like a fracture and the patient will have this from before. So it would be having some prominence in the midfoot uh uh rather than just a bit after the fracture. Then the fractures will be is avulsion. As I told you avulsion from the TS where the tibia posterior attaches and the uh the dep superficial de attaches and uh or avulsion from the body for the inter osment attaches or after that body fracture, which may be undisplaced, displaced or comminuted. So how will we treat? This is commonly to be treated non operatively. So, or what you need? It's just uh to rest the patient in a boot, uh relax the tendon doesn't have the tendon to do any stress over the fracture. And if it's, if it displays especially body fracture, because this is by definition, an intraarticular fracture. Uh So you have to fix it how we fix it. We go from the same uh intermediate approach, we went a minute ago through to the tailor neck. So from intermediate approach, you go between the tip and and TPO and just you open reduction and then fix it either by uh a leg screw or by a a dorsal plate. Uh dorsal plate. Now is is very, very nice. You can use it very easily, low profile and it has different shape which cover whatever that configuration or pattern of fracture. And a that is easily to uh the body of the, of the uh navi clear to remove it at some point. Because as you understand it, it it's was the time start the healing, have it stiff the mid foot. And this is where uh the median arch, the median within arch uh apex. So there will be a lot of stress on it. And you need, you don't need the blade to cause any stress shielding and keep this navicular weak for fracture. So you need to remove it. Uh once the fracture union happens if it's badly comminuted and there is no uh it's not amenable for any fixation though, the option is to do a navicular arteriosis. The problem from navicular fracture if you miss it is a high risk of E VN because as I told you, it's a watershed area with bull blood supply. And number two, it cause arthritis of the tail on a vehicle which is is very painful for the patient during gait, especially during uh uh uh flat foot of or of or uh loing phase. Uh The commonest uh missed injury in this um area is the Frank injury and it's very, very commonly missed because uh it's not easy to spot on the x-ray needs either uh a broad weight bearing X ray CT or even MRI scan. So this Frank is the commonest foot and an injury to be missed in the Ed So if we understand the wrist frank injury or the Fran joint to start with. So the foot has three columns. So for descriptive purposes, we we, we say that the foot has a medial column which is for formed by the first ray. Uh and this is, is considerably stiff. It still have some movement but considerably stiff. The movement in this ray is about 4 to 5 degrees. Then it have the foot has a, a middle column which is the 2nd and 3rd T MT or the 2nd and 3rd ray. And this is the most stiffer or the least mobile. And this is important for the rigidity during the two off to make the foot A R lever. Then you have the lateral column. This is the 4th and 5th ray and this is used to uh for your foot to accommodate the uneven service or uneven ground. So basically for, for, for description, the foot has three columns, medial middle and later medial column with the first tray. And this is has some degree of movement and this some degree of movement about 4 to 5 degrees. It has a stiff mid colon which give it the lever, uh make it a lever for uh two off during the gate and then a lateral column which is mobile to accommodate the uneven ground or uneven service. This is the 4th and 5th ray stability of the mid foot or the or the transverse uh uh arch is depending mainly on the middle, on the second ray or the stiff ray or the middle column. So to understand the ligament, the wrist frank ligament. So the ligament, the list frank is maintained in place by four, mainly four ligaments. The most important is the wrist frank ligament which is running from the media uniform with the base of second mid tarsal. Then you have the blunt and dorsal Tarso metatarsal ligament. The dorsal is the weaker. That's why it's common. If there is frank injury happens for the base of second metatarsal to just uh jump up. So on the later x-ray, you have to spot if this is a dorsal subluxation or not in Hawaii dorsal subluxation because the blunter interosseous ligament is much stronger. So torso metatarsal ligament is much stronger than the dorsal one because the dorsal tarsometarsal ligament is weaker. It is more commonly for uh the metatarsal base to jump up or to dorsally sublux. Then you have the intermetatarsal ligament and then you have the interosseous ligament. So it's basically to meats and this is our dorsal and blunter and the dorsal is weaker and the blunter is stronger, less frank ligament which is goes from the base of second metatarsal to the media uniform intermetatarsal between the metatarsals and enter osseous between the uniform bones. As I told you, this is uh uh uh the joints at this, this area are from minimally mobile in the first t MT to a very stiff 2nd and 1st T MT joints. And this is, is very important for your gait. So how is gait risk injury? The most common is for, uh, it crush injury or fall on a blunt flexed foot when you fall on a blunt flexed foot, all, all the trauma or all the, the, the force goes across your middle column. And this is where the next Frank happens. Then the other uh other, other, other um way of injuring it is the torsion force because when you move the, you move the foot into torsion, that mobile colons are safe, but the stiff colons are very prone to have an injury. That's why N Frank injury happened either from fall on the foot in a bladder, blunter flexed position or torsional uh forces over the foot to classify it very easily, either isolated ray. So like first ray is placed and the other four rays in place or either is homolateral means all uh the metatarsals at the Tarso metatarsal level went in one way or diversion means the first ray went in a way and the lateral rays went in another way. So either the four rays, the four later rays are in place and the the first ray only displaced, then this is called uh isolated or either both of them go in a different ways called diversion or uh uh all of them go in the same way, which is called uh homolaterally. When you examine this patient, you need, once you, once you concentrate on the mechanism of injury, you need to have a high index of suspicion and suspect a list frank injury. Once you hear that the patient um either fell on a a blunted grade foot or has has a torsion injury to the foot. You have to look into blunt ecchymosis is a very uh uh but no sign for uh laser injury. And definitely you have to check for compartment because uh this is the area where the central compartments of the foot is and very common to have this compartment syndrome. And if you have a compartment syndrome and you miss it, this will end by the patient having no intrinsic power and intrinsic weakness and contracture. And this will end by close to when you have an X ray. It has to has a uh to, it has to have a be uh a weight bearing x-ray because you need to stay the foot to see if it's a ligamentous injury with no bony injury. You will not see the ligamentous injury until you put the patient on a weight bearing foot. And the problem with weightbearing x-ray is that the patient is in a lot of pain and sometimes he uh doesn't put all of his pain. Uh I'm sorry, all his weight on the foot because it's painful for him. So you need to be sure that the patient has had the weight bearing x rays to judge on it without the proper weight bearing x-rays, you will not be able to judge uh on this frank. And that's why it's very commonly missed in the ed what you're looking in, uh uh uh what you're looking after in the X ray. So when you, when you are you after in the x-ray a flex sign which show an avulsion fracture for the uh left ran ligament from the base of second metatarsal as the one here. So because as we agree, the most strongly the inter meats, uh I'm sorry, the osseous list ligament which goes from media can form to basal second. And when this is stressed, it evolves as a base of bone from the second metatarsal base. And this is what we call the flex sign. Number two, you, you have to look into the separation or diastasis or widening between the first ray and the second ray, which this is definitely abnormal. And when you look into an an an eb, you have to, to look into the, the, the congruity between the medial border of the second and the intermediate form. And when you look into an oblique X ray, you need to see the congruity between the medial border of the fourth um of the fourth ray of the fourth metatarsal with the media border of the cuboid. And lastly, when you look into a lateral X ray, you need to ensure there is no dorsal subluxation of bazo second. So again, weight bearing X ray and you need to be sure that your patient has weight, bear on his foot when he had the x-ray. Because very commonly there is Frank missed because patient doesn't put a lot of weight on this foot because it's painful though. It is marketed as a weight bearing x-ray. It's not actually weight bearing and you need to, you need to be after a flex sign, a flex sign which will be here from avulsion of the uh uh list frank ligament from the base of second me person. You need to look into separation or diastasis between the 1st and 2nd ray. You need to look into how congruent is the second ray uh or the second and media border with the media border of intermediate skin form. And then how much congruent is the media border of the fourth ray with the media border of the cuboid on an oblique x-ray. And lastly, you need to see if there is any dorsal subluxation of base of uh second metatarsal. Uh And then once you suspect that is Frank, you have to have a CT scan, you have to have a CT scan, you have to have a CT scan and CT scan will be showing you this to this is to you more and more uh if you have the facility to have an MRI scan in the emergency ha to look into a ligamentous injury if there is no body injury and your clinical diagnosis is definitely less strength, you can go for an MRI scan to assess the li injury. So how will we treat a List Frank? So less Frank is, uh uh as I told you, it's a missed injury. It's it's a very risky injury to kill the patient with chronic foot pain forever. So you try try your best when you're doing an duty or you are seeing the patient as a first point of contact to not to miss a list Frank injury. So have a very, very high index of suspicion. Once you see the uh a foot injury with uh plantar echo mode of trauma is either to or falling on plantar fixed foot, uh suspectless rank until proven otherwise, get CT scan. And if you have the option have to get an MRI scan, that's why this Frank injury is always treated operatively. We don't treat non operatively unless there is definitely no displacement or a prop on a proper weight bearing X ray and stress fuse. And if we will operate the operation is uh number one, we have to uh respect the soft tissue, ensure that the soft tissue allows us to go and internally fix it. And your aim from fixing is to have a stable uh construct for every day. You have to get the stiffness back to the median and middle column and then you have to maintain the relation between or to restore the relation between the medial column, which is the first tray and the middle column, which is the 2nd 3rd ray. So, what you normally do? So a lot of debate about either you go and open and fix it or to fuse it or after it. Uh A lot of, a lot of schools and a lot of evidence support that you go and do a breaching plating and a lot of schools supporting that they go and do em primer arthrodesis. Every, every, every uh uh team has its own rationale and own uh valid points. So the people who are supporting that you do an over reduction fixation, they go that this is uh if it a bony injury, this is, it's very, very understandable. You for a bony injury, you never go and fuse from the start. And uh it's always this like injury in an active patient with young age. And it's unfair for a subtle joint and a and, and a good articular surface to go and fuse it primarily. On the other hand, the people with uh arthrodesis, people supporting arthrodesis. The idea of the rationale is when you do a bridging ablating. So you, you're looking for a degree uh a degree of um uh of stability. So you're basically doing an arthrodesis by some degree. And as we agreed from the start from the anatomy that these, these columns are already stiff. So the people who are supporting the arthrodesis, they look into this and saying these, these colons are already stiff and we're aiming from fixation to make, to make them stiff again. So why not to fuse it from the start? So this is the rationale behind fixation and the rationale behind arthrodesis, what you will decide in my practice, we normally arthrodes inhibition with ligamentous injury. And we know especially if it's young and we normally fix every patient with body injury, especially if it's old again. So, open reduction, internal fixation versus primary orthodes of midfoot, open reduction, internal fixation group support the idea by that this patient uh mostly in active young. So it's unfair to go in a sudden joint to go and, and fuse it as a primary operation, especially if it is a bony injury for the arthrodesis. They speak about that these joints are already stiff from the start anatomically stiff and we're trying to get them stiff again. So if the patient, especially if the patient have a ligamentous injury, better to go and fuse it as primary fusion. So, and my practical point is if you do, if you have a young patient with ligamentous injury, it's more safer to go and fuse it as a primary arthrodesis. If you have an old patient or a patient who has bony injury, it's better to bridge it or fix it uh until it heals. So if you go for over reduction and fixation, your approach should be either first or second web space according to how many uh uh race injury you have. If you have a first ray injury, you have to go from uh first, either media, dorsal media approach or first uh webb space approach. Go into the first T MT joint bridge it with a blade, either one blade from dorsal or one, a blade, dorsal and one blade median. If you have, if it's very unstable, then you go and fix the second ray and then you put a screw across the uh at the side. And the topical side of left rank um ligament to restore the relation between the anterior uh the first and the second ray. So my approach is I always go at the in the second wave space between the 2nd and 3rd mid tarsal approach from one side across the tendon. Keep the tendon in the middle approach to the second TNT joint from one side of the, from the media side of the of the tendon. Fix it in place, bridge it with a blade uh uh in a in, in a strong plate, then go for the third. Fix it with a blade. If I need to fix it, then after that, if I'm happy with the first tray, I just bus a screw uh across the list, Frank anatomic list, Frank Li and atomical side from the base of second MI TSA to the media, Kor. If I'm worried about the first ray uh since the first ray always intraoperative for every case. But if I'm worried intraoperative or I already diagnosed a a first ray injury before I go into the operation, I will start my operation in the second space bridging the, the second T MT joint, maintaining the sec, the, the second ray go immediately, dorsomedial, fix the first ray. And then once I have two stable rays, IB them together with a play with a screw either from media uniform to basal second or from basal second to media uniform if I'm opening to incision. So if I'm opening, if I'm happy with the first ray, intraoperatively is stable. And I'm just doing the 2nd and 3rd day, I go to the second day bridges the, the, the second uh T MT joint and at that time, I bought my screw from the big second metal to the media K four. If I'm worried about the first tray, I go to the first tray, fix the first tray. And I have the two options either to bus the screw from media clini to second or from base of second to media cni uh will you need to remove this screw or not a lot of debate? But to be honest, in my practice, I still removed the metalwork after uh six months. Uh a lot of screws. Now they don't remove it until the, the metal metal work cause any irritation to the patient. Uh Both options are valid. But my practice is I remove the blades and screws in six months if you come to the meara and to trauma quickly. So I'll, I'll just spot the important, uh, fractures to come in the exam. You know, definitely the mulch fracture, which is common in the military people because they do a, a strong bush of, they always have a stress fracture in the, uh, neck of second metatarsal. The problem of, of this is uh it gives them pain on gait and it always takes time to heal. Sometimes it's very prone to have uh non healing drugs fracture. When you look into the basal 50 metatarsal very injury and the basal 50 mesa, as you understand, there is an above if still young patient, if not, this is the tubercle where uh uh where the brunneous Spiriva attaches. Then this area is the articulation between 5th and 4th metatarsal base. Then after that is the shaft shaft fracture, we deal with it normally just a flat shoes, give it to heal. Uh uh This one is, is a sort of avulsion injury. It is very uh nicely healing once you relax the tendon. So we always with this type of the pros fracture, we brought the vision uh into a boot just to uh stop the veneer previous from action. So it gives a fracture a good chance to heal. The problem is in this joints, fracture where this fracture is in the metaphys, the physalia join or just above the arti just or uh through the articulation between basal force and 50 to. And because this is a watershed area is very prone to nonunion as you can see in this X ray. And this is where we think about primary fixation rather than non operative. Again, practically what we do, we just keep them on follow up. We uh explain the patient that there is a high risk for this patient for this fraction not to heal because it's a watershed area because of anatomy, because of biology, the vascular supply to this area is not the greatest. And there is a lot of stress on it while you uh weight bearing or you gait. We bought them in a boot, follow them up after two weeks. And if we feel that on, on, on uh consecutive follow up, it's not healing. We go and fix it for uh for the patient syo fracture, very commonly missed and uh uh and not everyone knows about it. Uh I've, I've seen it very uh a few times. It's not that common injury. And we understand that the sissy mo is just uh uh um a Crum inside the, the um I'm sorry. Flexor uh harass previous tendon, they give it more line of po, they give it more lever. So uh uh make it more efficient at the same time, they protect underneath them. The flexor uh in between them, the flexor uh hallucis longus. Uh they are media and lateral or tibial and fibular. The me, the media is the tibial siss, the lateral is the fibular siss. They play very important role in, in maintaining the had in place if you miss one of the dito, I'm sorry that I'm sorry, one of the sis, the other, the other thing will be bowling more strong and this gets the, the hallux either in vuls if you miss the, the, the fibular, I'm sorry, the tibial and inva if you miss the fibula, uh very common to develop csmo oitis, especially if uh a lot of stress like the military people or people are using walking all the time barefoot. Uh in rheumatoid in, in psoriatic patient in Richter's disease or syndrome. This patient commonly to have a CSIS which will be presented as uh a blunt or halos pain uh to see them, you have to do this view, which is called the simo view or axios systemoid view. And this gives you a clear picture of the simo. This is the media or tibia, simo, lateral fibra simo and this is the crest. So you can see clearly the sidal uh metatarsal joint and you can judge if there's any fracture or not, if you cannot spot a fracture or you have a bipartate and you cannot decide this fiber teeth is a fracture or a bipartate is mo this is the time you can have an MRI scan or um uh bone scan and bone scan will give you an idea. Is it a hot or, or cold if it's cold? So definitely a bipartate. If it's hot, it's mostly a fracture. Again, remember that we have and uh uh uh abductor hall is here. Abductor Hall is here and the F DB uh F HB I'm sorry, is running across the s if you lose this medium. So the, the, the, the Harris will be going into Vargas. If you lose this lateral in fibrillary, the houses will be going into Varus. So you're very keen to keep the two S to keep the, the uh F HB efficient. So it doesn't allow the two to deform in one way if you have ac small fracture. So it depends on if it's not badly commuted and intraarticular, uh uh you can just put the patient on a stiff sore foot. In very rare condition, we go and fix it with uh a head screw and uh at some stage, if we have no option, we have to do a cystoid omy. It's uh and it's now in only in, in reluctant patient because uh uh uh um a recurrent patient and recurrent problem, csmo and recurrent and, and, and, and, and uh repeated fractures because as I told you, Cystoid Deomys with both the, the two at the risk of going into virus or virus. According to what uh Cymo, you would be exciting then uh as as I, as, as I explained to you, if you excise both. So you didn't, you don't this the loss of the uh F HB function. So the A HB will be taking, taking or overow, this will end. But what, what we call a co up to then if we excise, the tibia simo, the, the toe will go into valgus. If we excite the lar siss, the toe will go into virus. Then uh if we have an injury systemoid, we, we commonly to have this what we call the tariff two. And if you know, and tariff two is basically a hyperextension, uh uh uh uh uh and actually loing injury to the hallux. And by this position, as you can see where the hero is just, is just floating up with a flexed B IB uh IB joint. Last thing to speak about is ingrowing to, it's not related to trauma. But uh um uh since we are speaking about the toes, this is the last pathology we speak about. So basically, if we have an ingrowing toe, we understand that we go. Uh uh nowadays, we have the very good option is exciting the witch and just bought a phenol to kill all the living tissues and, and the periosteum and doesn't allow the nail to grow again. Otherwise we can go for surgical, just procedure. And this is when we go excise, the whole thing, excise the whole thing and just curate up to clear it up to the ostium. So it doesn't keep any German layer, doesn't allow the nail to uh uh to go again. So this is a ZO procedure, uh uh ZO procedure. Uh but we normally use more uh excision of angle, excision angle or excision of the nail, uh wi and just funeral to stop this from growing again. If you're having the exact puncture wound in the foot or puncture wound in from the through the shoes, the communist organism to do this to, to, to cause an infection in this condition will be the pseudomonas. And remember if you have that, you have to be keen on uh uh very good debridement, excision and removal of foreign body. If it's there taking very deep uh wound samples and do a proper bone kit, if there is osteomyelitis and definitely keep this wound open to clean itself. This is, this is more part is very common question in the exam. If you have he come to you in the M CQ asking if you have a bunch of wound in the foot or bunch of wound through the shoes, the shoes, what will be the most common organism is the most common organism through the most and the most effective one. It is K nose or Cipro. So if you, if you have a AAA foreign body in the food, how you manage that. So you manage this uh with aggressive debridement, foreign body removal, uh deep uh samples and bone uh curettage and keep the wound open to clean itself. And thank you so much. So, any question guys just keep it in the uh in the chat and I'll be happy to answer it. Uh I try to make the lecture, uh the shorter I can. So it's uh 1015. So we still have 10 to 15 minutes. If you have any questions, I'll be more than happy to answer it. Uh uh Next lecture is very, very interesting with all um what you need to know about anu fracture, both for the exam and for your day to day practice. Uh So uh II promise you of a very nice lecture. Very thoughtful lecture. A lot of new information. The anu is very, very common but the information I will give you on this lecture will be uh will be new information for you. Uh As we uh always do, we will have a feedback to you once we finish this decision and once you bought the feedback, um you will be granted a certificate of attendance. Um And we are in the process of getting uh accreditation from the Royal College for that. So I'm waiting for any question if you have any question for me and hope you get something from this um position. Uh Rafa, thank you. Uh You're welcome, Rafa at any time. Uh So guys regarding uh after the foot and ankle, the, the next lecture is the last one, which will be next Friday. Uh, and I'm thinking about starting, um, to, um, give a reconstruction course. Uh, I'm not sure all of, you know, or not. I'm now, uh, the SS representative in the GC, the joint, um, committee of the Intercollegiate Examination. So I couldn't run any more courses about Fr CS because I'll be part of the exam. So I can, I don't have the, um, I'm not permitted to give any courses, Fr CS courses, but we can do any structure courses as general orthopedics. So I'm thinking about Reconstruction as the next topic. If you have any uh comment about that, send it to me. Uh All of you have my uh mobile number on my uh NHS email. So this is my number and my email and I'll be welcoming all the suggestions about the next topic to go through. I'm just suggesting uh reconstruction. If you have any other topic you feel would be more useful to go through. I'm more than happy to do that. Uh OK, guys, if there is no question so far, I hope you digested this uh session uh nicely. Uh Trauma is very interesting and this is our day to day practice. Uh I hope all of you get um everything you need from this lecture waiting for your feedback. Uh All your rhythm, bad feedback will be taken uh on board and will be valued and will be action and uh see you next Friday have a good evening and enjoy your weekend. Bye.