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So uh we'll go now through the ankle fractures. I didnt out what's wrong with that. Um And we aim to make this easy for every one of you. So um I understand that every one of you is dealing with ankle fracture every day. There's no single orthopedic surgeon who uh doesn't or don't deal with uh ankle fractures. Uh This is where I come from. My name is Mohammed Hashim mama, an ankle consultant in Northeast London, uh Wickson Park and Hew Hospital and this is um elective h where I come from hew hospital at aut. Uh This is the youtube channel where you find all um the videos and all the education activities we share. It's between my based on the channel has education and channel and or be my official challenge. Ok. So to start with, we are not here to speak about simple uh principles of ankle fracture. Every one of you is an expert in dealing with ankle fracture from a very senior level to a very senior level ankle fracture is second or third communist. Uh injury comes to the trauma uh unit or the trauma emergency. The point I'm coming to um to give you in this literature is just how not to miss an injury and how to deal properly and promptly with it. So not to miss an ankle fracture, you have to have a weight bearing X ray. So some normal x-rays, uh so buying x-rays are not acceptable because easily you can miss number one, a very solid fracture. Number two, a very stable fracture. So weight bearing x-ray will give you a physiological status. When the patient bought all the weight on the foot. And the tricky point here, you need to be sure that the patient has both his weight on the foot while taking the x rays. Some of the patient because that you, you have to remember that this ankle or this foot is painful. Sometimes the patient doesn't put actual weight on it. Yeah, he's standing, it's a standing x-ray and the huge difference between a standing x-ray and weight bearing x-ray, weight bearing X ray when the patient intentionally put weight on the injured limb. So this is the actual physiological situation and you can easily spot a sudden fracture and you can easily spot an unstable fracture. The problem you need to be sure from the patient himself that he did put weight while they taking the x-ray, not just assembly standing x-ray, we don't aim for a standing x-ray. We aim for a weight bearing x-ray. Remember that if you worried about syndesmotic injury, that it is the commonest extended rotation, radiograph patient, basically, the patient will be on the couch, keeping the foot hanging from the end of the couch in an extended rotation position. And this is by definition is this is a syndesmosis. So you can, you can easily spot uh any sort of syndesmotic injury. You have to remember that deltoid is two parts, superficial and deep and the superficial deltoid ligament is the main restraint against valve gas deformity. And the deep deltoid is mainly against the rotational anterolateral the displacement. So when you don't, you never miss that, it may be no bony injury in a rotational injury because basically the failure wasn't in the bone on the medial side but was in the deep deltoid. So, deltoid is superficial and deep, superficial is mainly about the movement in the coronal brain, which will be the valgus movement of the ankle. Uh It's a, a rest against the vuls, but the deep deltoid is mainly against the rotational deformity. So it's it's a primary strain against anterolateral talar displacement. So when you see a patient with a an rotational ankle fracture, like symptomatic injury, like uh uh high high fibular injury, we perceive uh mi fracture very proximate in the neck of the fibula. Remember that if you even if you couldn't see another b injury in the anchor ring, it could be the deltoid, not the, not the bone, especially the deep deltoid. And you can easily spot that by stressing the ankle, putting the ankle in a valgus position or putting the ankle in an extended rotation position and take an X ray or you can spot that if a weight bearing X ray was, was enlarged or in uh widened media clear space more than five. So normally you have the media clear space equal to the severe uh clear space. And when you see that the media create space widened more than five with an element of flotation injury. On the latter side, you have to spot that there is a median injury and this median injury will be in the deep even if there is no median mallear fracture. Remember that we diagnose the in this mos in a proper uh uh uh modes view by measuring the tfi tibiofibular overlap and the and the three space. And I will show you this in a minute. In on the end, x-ray, we have to look into the shin line, we have to look into the dim sign and we have to look into the telo cool angle and all of them is here. So when you have a robber uh MS view, you can easily spot the media clear space. So this media clear space, it should be equal to the severe clear space and it should be less than five if it's more than five, especially if there is a rotational injury. Either as I think this Moses high fibular or very proximal femoral fibular, like the missing of a fracture. You can spot easily that there is a deep deltoid injury here. This is a gentle line of the ankle, equal to the gentle line in the in the in the hip. So basically, this gentle line shows you that the ankle most is this conformation, ankle most is congruent. This is the dim sign and this is is the arranged which gives you an idea about the fibular lens and was disturbed as you can see with disturbed with dim sign. This means the fibular lens, the fibular is short or me rotated the intercrural angle. If you get, if you come to the proximal uh uh talar talar articular surface, your your both and pericar line and measure the angle between the tips of the uh the lines through the tips of the me uh medial and lateral mali compared in relation to this if it's increased like that. So I OK, like this. Now, it can if, if you, if you imagine that we bought um over over the talar talar body of the dome, we bought a line. We we draw a pericar line over this line, then we draw a line between the tip of the man line, measuring the angle angle between this line, the telo crural line and the pericar if this angle is below 80 or above 90. So we speak about a disturbed telo crural angle. And this is means a fibular lens is not right if it is increased, this means the fibula is short, if it's decreased, it means the fibula is long. So again, when we have a look, firstly, we're looking into medial clear space, looking into the intact s line, looking into the dim sign to diagnose. If these fibular shorting, then we measure the telo crural angle. So line along with the tar dome pericar line on it and then a line across from, from the tip of the medial to tip of the later Meli. And we measure the angle between this line and the pericar line on the shin line. If this, this angle should be about 80 if it's below 79 or more than 87. So we know that the fibular means is not right. So if it's less than 79 this means the fibula is long if it's beyond 7887 this means the fibula is short. Then if you look here in a broad modes view, you can see a clear space between the tibula tibia and the fibula and you can see an overlap between the fibula and the tibia. And this is, gives you an idea how is your synthes mosis. So if the, if the clearest space is more than 10, this means this tibia and this, this uh synthes diastasis or synthes injury. And if this clear space less than six, this means again, there is a synthes injury or diastasis So again, because this is this is the most important bit of this lecture is how to diagnose a subtle ankle fracture or a subtle syndesmotic injury. It's not about how to diagnose a an marlar fracture or bim marial fracture because you are all expert in this. The point is how to diagnose a very subtle fracture, very subtle synthy injury, which can be easily missed. So again, weight bearing views and a proper mortis views what we are looking to uh looking into. We're looking into the media clear space and the the line to diagnose if there is any media injury or not, we're looking into the tia tibiofibular clear space and tibiofibular overlap to diagnose in this injury. We're looking into the sign to diagnose any fibular shortening. And we're looking in the telo angle to diagnose the fibrillar lens either short, prolonged again, a line across the interchange to line perpendicular line on top of it. And then you li draw a line from the tip of mid to tip of la mid me to tip of later me. The angle between it and the perpendicular should be around 80. If it is less than 70 line or more than 87 means your frill either long or short. I hope this is clear if you want to check the position if you have a very proper lateral x-ray like this one on the right. And you want to, to see if your fibula is inside the incisor, the tibial incisor or not means the fibula is inside the synthes mosis or not. You can easily, you can easily draw this line from front to back of the tibia. And if you make it into two cells and one third, the fibula should be in the back two cells. And this is in a proper lateral view. This is where your fibula should sit because this is where the incisor of the tibia is uh classification of an fracture. All of us know about Weber or Weber classification. And this is depend on the level of fracture and in relation to the synthes mo and basically this is is more of a descriptive classification and give us uh a, a guide for the treatment. So we know that type one is very stable when it's mainly a clonal brain deformity or a clonal brain injury. And at that time, there will be an avulsion fracture at the distal distal fibula below the synthes moses B is across the syndesmosis and C is above the synthes mosis. This is both of them are croon brain injuries. This is is an axial brain or additional injury. And that's why this is the most risky one and this is the one where she needs a fixation. Definitely this one though it is an arti intra articular fracture but that this is not a weight bearing articular surface. So all what we aim for is to be sure that the ankle is stable through a weight bearing X ray. And if your ankle is stable, all what you need is to keep the vision in a cast for a week, then allow the vision to weight bear in a and that's it. Same for the Syndesmotic injury. Because while your uh your injury at uh or fibrillar fracture is at the syndesmotic level, the syndesmosis is still intact, the the ring is still intact. And so there is no risk of displacement or uh um uh instability. So you just get an X ray and weight bearing x-ray and another weight bearing x-ray in a week. And if there is no displacement on weight bearing, you keep your vision in a boot, weight bearing and you are not worried about instability or displacement. This one is by definition, a rotational injury. So there is no point to wait because for this to happen, the ankle should be injured at two sides of the ring and this by definition needs a fixation. So Weber classification though it is a very simple one, but it is very important one to guide us what this patient will need if it is as in is a Weber A or Weber B. This means it's more of an an an uh coronal blade injury. And this is by definition, stable fractures you need just to ensure that it is stable by weight bearing x-ray on, on diagnosis and a weight bearing x-ray in a week. And if there is no displacement equal, these fractures are stable and all what you need is just to keep the patient in a boot and allow him to weight bear and they will heal by e even it takes time, it will heal because you are, you are sure that the anti ring isn't injured in more than one place and it is a stable fracture. By definition, this one is by definition, a rotational injury. And uh basically, it has a higher fibular fracture because the fibula has been fixed on a long beaver arm. And this means that, that, that a the anchoring is injured in two places. And this by definition will need a fixation uh to stabilize the ankle log Hansen. And there's a lot uh uh of debates about the lung, Hansen and I will give you Log Hansen in a very, very simple terms. It makes you never ever miss uh a type of injury over Log Hansen Log Hansen B based on three points. Boy, number one is the patient had a direct or indirect trauma. Number two, what was the position of the foot at time of the injury? Was it so or pro and we agree before about what is Sobin Nation, what's pronation and basically what is, what is uh uh Sobin Nation is a blunt deflection at the ankle, inversion at the hind foot and abduction at the forefoot and pronation is dorsiflexion at the ankle abduction at the forefoot and inversion in the hind foot. So the second thing log Hansen depend on in the classification. What was the position of the foot at time of the injury? Was it blunter flexed, inverted and abducted, which is subin nation or was it dorsiflexed e and abducted in the ation? Then the third uh uh element or the third point where uh the classification depends on what was the direction of the force applied to the foot. Has this foot has a translational movement or a rotational movement. So if it's a translational force, this gives either abduction, if the foot is subin or ab abduction, if the foot is pronated and if it is uh uh a rotational movement will be an extended rotation, either in subin or in pronation. So again, to understand Luch Hansen, you need to understand what is about. And Luke Log Hansen basically is about, is the the injury direct or indirect. How was the position of the foot at the time of the injury? Is it, was it subin or pronated? And then what was the direction of the force applied to the foot? Was it a rotational injury or a translational or uh force or injury? And there is few rules for you to understand Log Han and you don't need to remember anything. You need to understand. It's not about remembering what's subb abduction, what's abduction, what's subb external rotation? What is external? No, once you stick to these rules. You can easily classify any fraction according to Luke Hansen without remembering any names, you need to understand that tension site fails first and this failure either will be a ligamentous injury or avulsion fracture. You need to understand that compression site fails lost and it will be either an oblique fracture because it's a compression force or will be a combination at the fracture site. So the tension site will fail first. So the first injury would be tension failure at the tension site. And this failure will be either because it's a failure in tension will be either avulsion of bone or ligament, rupture, compression side will be a compression force and it happens lost. So the compression site will be injured, lost and will be either in the form of oblique fracture or a combination. You need to remember that sobin nation equal lateral tension and media compression and pronation equal lateral 10 media tension and lateral compression. So with any foot, you see that the injury on the media side is tension injury and on the lateral side is compression injury. This was a coronated foot at the time of trauma at any fracture, at any x-ray, any fracture you see on an X ray and the tension was on the lateral side and the compression was on the media side. You remember that this foot was subin at the time of the injury. So again, tension size fails first and it fails in tension. So it either avulsion of the bone or rupture of the ligament compression site feels lost and it fails in compression. That's why it either an oblique fracture or a combination. Remember that Sobin Nation equal that the tension is on the lateral side and the compression on uh is on the media side and proration equal the the the reverse which means media on the tension side and compression on the lateral side. Remember that rotational force equals synthes injury. So when you see a synthes injury, you understand that this injury is rotational, it's not translational. You remember that posterior man is part of the syndesmosis. So the Volkmanns uh fragment is part of the syndesmosis because the most important for us is the posterior inferior tero friar ligament which is attach it to the Volkmanns, volkmanns uh fragment in the tibia. And when you see a posterior mal fracture, this fracture is a rotational injury fracture by definition, except if this patient has an axial and a blunt that flex his foot, which is very, very rare. And that's why in an isolated posterior medical fracture, you need to speak to your patient and get a detailed history about mechanism of injury. How was his foot? How was the mechanism of trauma to be sure it was an axial load, not a rotational lo and this is only if your posterior is isolated fracture, any association of injury with by posterior m you do need to ask if this is a rotational injury. By definition. When you see an isolated posterior me, you need to go back to your patient, speak to him or her. Get a detailed history, ensure that the injury was an a loading, not a rotational injury. And this is very rare any abduction injury equal a pin fracture. And I will explain this in a minute. Remember the ring ankle is not a a simple joint, it is a ring and ring injuries are not always bony. Some ligamentous injury explain the tension size failure, not a bony injury. I hope this is very clear, very important. We'll we'll we'll relay on this in the next slide. So Log Hansen has classified the the injuries in the ankle into four types two sobin nation, two pronation sobin nation abduction, sobin Nation extender, rotation and pronation, abduction and pronation extender rotation. By this. Again, we will not remember any word sobin Nation. We know that form sobin nation. This means tension is on the lateral side. Compression is in the media side. So the first thing to fail will be the fibula and it will fail either in an avulsion which is growth, transverse fracture or rupture to the lateral ligaments. Then the next stage after fibrillar, a fibular failure will be failure. This is the first detention site which fails 1st, 2nd side which will fail. Last will be the combin site which is the median man which will have a vertical fracture. And the problem with subin abduction if the uh amount of forces is enough to cause uh uh uh uh uh subb abduction injury, it may cause an anteromedial mar margin and infection which is bone fracture. So subin nation abduction is being on fracture or fracture of the tibial platform by definition. So once you see a fracture that you suspect it is a subin nation abduction injury, Greece get act because it's not uncommon to fight an anterior medial margin and infection or anterior medial comminution in the tibial platform. So by nation external rotation, again, tension size will be still lateral. So the first going to fail will be the fibula either with a short oblique or a spiral fracture from uh an to post severe, then extend the rotation starts to happen after. So tension site for lateral first fails, extend, rotation starts to happen and extended rotation goes from front to back. So first thing to to fail in the synthes most because we externally rotating. The first thing to fail will be either the anterior inferior terial fibular or the t low fracture. And I'll show you this in a minute. Then secondly, if the force is enough, we'll get the interosseous ligament rupture. The if the force is more and more will get the posterior inferior arterial fibrillar ligament to rupture and or the posterior m to fracture, then end by compression site which will be on the medial aspect. And you will find either this the transverse fracture or disruption of the deltoid ligament again. So by nation equal tension on the lateral compression of the media. If so by nation abduction start with failure in tension on the bilateral side, failure on in in in comb on the medial side with an anterior medial marginal infection or period of fracture. So by nation extended rotation again, tension will be on the lateral side. Fibula will fail into tension. Then the media side will fail into compression between them. The extended rotation element where the syndesmosis will fail in sequence starting with anterior because it's an extended rotation. Anterior fails first in the form of anterior inferior ti friar ligament rupture or T or fracture. Then in o ligament rupture, then posterior inferior tero friar ligament or um uh posterior mrac, if we come to the coronation side, reverse. So in the ation, the tension will be on the medial side and the the the compression will be on the lateral side. So again, when you see an X ray with tension on the medial side, you know this is a coronation and if there is no rotational element, it's coronation abduction which means tension on the medial side in the form of avulsion fracture from the medial man or rupture of the deltoid ligament. And then after that combination of the fibula which will equal highly comminuted fracture and a high level like we proceed ation extended rotation, same story. So the tension will be on the media side, compression, on the lateral side and rotational failure will be in the in these moles. So the media side failed in again, either uh avulsion of the of the median man or rupture of the deltoid rotational element because it external rotation. So it will fail sequentially between anterior inferior tero FBU or TDO fracture, intraosseous rupture, then posterior inferior tero or posterior mal and end by a compression over the fibula which is causing again, we see or very high fibular neck fracture, missing oval. Remember that with any pronation, external rotation, you need to examine the whole fibula because it's not uncommon to have the injury at the proximal fibular or fibular neck. Then uh there is a special name uh fragments you need to know about. So you can see from here up, ignore the, the, the writing and remember the images. So the anterolateral aspect of the ti of the tibia is called t low. And as we said, if anterior inferior t the frill fails, it either failed by rupture of the ligament or by avulsion of the t low fragment for the anterior from the antila tibia. Then on the other side, it's the anteromedial aspect of the fibula, which is called the stuff fragment. And again, it in in rare condition, you may see that the anterior injury of the synthes mosis is either at of fracture from the anterolateral tibia, a rupture of anterior inferior frill ligament or an avulsion from the anteromedial fibula, which is the stuff fragment in the back. The injury will be either uh uh booster poster lateral aspect of the tibia, which is called the Volkmanns fracture or Volkmanns fragment or tear of the posterior inferior tero friar ligament. Or still, we didn't have the name for the posterior uh uh medial fibrillar fractures. But yeah, we're waiting for one of you to uh to name it or we we we certainly would name it with um with some evidence. So we stuff is avulsion of the anterior fibula by the anterior inferior tele fibular ti low is avulsion from the anterior tibia. But again, the anterior inferior Tito friar Volkmanns fracture is avulsion from the posterior tibia about the posterior inferior t fibular. And Bosworth uh fracture dislocation is basically as, as we mentioned from a minute ago. This is means the fibular is posteriorly dislocated out of the tibia incisor then uh di between fracture, which is another name for Weber C or high super syndesmotic uh fibrillar fracture classification is classified the posterior man in the last uh like 20 years. All the direction, all the interest goes to the posterior man. The posterior m was early uh very underestimated. We just deal with it like uh uh if it's less than 25% of the of the articular surface means it affects the stability of the anchor posteriorly. If it's less than 25 ignore it. But then we came to know that this is not the truth. The actual uh the actual situation is the posterior malf fracture is an exhibition of a synthes injury unless proven otherwise. And as I told you, uh 95% of posterior mal fracture are a form of synthes injury. And 5% will be just uh an axial loing fracture of the posterior man. That's why we start to look very carefully uh into the synthesis. The last uh uh 10 or 20 years by Harrisi classification and by uh uh uh uh Mr Malloy, we we go in in a minute. Both of them looked into the posterior man. Harras and Mr Malloy looked into the posterior man and give it more consideration and start to speak about types of fracture. Hars has made his, he made his classification based on act study and classified into three types. As you see. Type number one is just the posterior lateral fragment. And this is you see more often and this is mostly because uh of uh um uh rotational injury and failure posteriorly rather than the posterior inferior tele fri fails. It just evolves the Volkmanns fragment. Then type two which say that there is a posterior poster lateral fragment with immediate extension. So you actually have two fragment, one booster media and one boster lateral. Then type three when there is only small she uh uh uh shelf of bone and this is just a very minimal avulsion which you don't need to care about. So type one, booster lateral, type two, booster lateral and booster median extension and type three, just wide and thin fragment. Then uh Mr Malloy from Liverpool looked very specifically into this and classified into three types. So type number one when is is is uh uh uh just an avulsion from uh I also from the back, sorry, I also from the back. And this is with the syndesmotic injury. Then type two which is a rotation, they call it rotational pillow. When there is a booster media or booster media and booster lateral fragment because of a rotational injury, then uh type three which they call uh axial loing pillow. So avulsion injury, rotational balloon and axial loing pillow. So I'm sorry, avulsion injury when just the booster lateral fragment has avulsed, sometimes it's very small, doesn't need anything to be done for it. And if this, if this significantly avulsed and displaced, uh you need to do a booster lateral fixation for a steral uh uh approach uh come to B I'm I'm sorry, two. So two A and two B and two we call both of them as uh uh rotational pen on fraction two A when it's only lateral. And this is we need fixation from poster lateral fragment. For this rotational paon, you have to fix it. There is no option because it's not about the the, the, the posterior m fragment itself. But about the rotational injury of the ankle and the instability. If you have a booster lateral, which is two A, you will go to fix this with from booster lateral approach with a booster lateral plate. And if you have two A two B, which will be a booster media and a booster lateral, you need to fix it from either a booster media or media boostered approach. And we will uh I will mention this to you in a minute. And when you're fixing this type two B, which is a additional P loan with a booster media and booster lateral. The recommendation according to the anatomical study is to fix the media first and this by definition will get the lateral reduced, then you can fix the lateral, you cannot do the reverse. So you need to fix the media then the lateral. So you, that's why you go from booster media approach because it gives you an easy access to both poster media and booster lateral. Then the last one which is an axial uh uh axial load B and this is bon by definition is a fracture of the tibial platform. And this will need fixation from the back and uh mainly from poster media uh uh approach. So the good thing about meso MAOI is an anatomical study. It looks into uh median manual fracture as an anatomical injury. So look, look into the mechanism of injury and easily uh guide you. What approach could should you use? So either an avulsion injury or a rotational pen on fracture or an axial no pen on fracture, avulsion injury would need a fixation from the V to lateral side. Rotational bone will be either two A or 2 B2 A. If it's only posterolateral two B, if it's poster lateral boostered two A will need fixation from poster lateral approach. Two B will need fixation from both poster media and uh booster media or media booster media. And you have to start with fixation of the median poster media fragment. First, then the booster lateral fragment and type three is pong by definition, Xlu Pong by definition. And you need to do a fixation from booster for booster media approach to this uh fragment. So when, when you fix your ankle and uh you find a lot of debates in the trauma meetings and handovers about uh shall we be fixing uh uh this ankle or not? So, if you're looking into uh uh uh open reduction antenna fixation uh uh indication, let me just to check if you have any question before I go. OK, that's good. So if you're looking into the indication for over reduction and tender fixation of ankle, um number one, any displacement is not acceptable. We agreed from the last uh lecture that the ankle is a very congruent joint and this is why the osteoarthritis, the primary osteoarthritis is very low incident in ankle. But this is goes to the opposite side if you have any talar shift or talar displacement, because only one of talar shift will reduce the the contact pressure between the tibiotalar joint and make the tibiotalar pressure. Uh I'm sorry, the contact pressure at the tibiotalar joint to increase by about 42%. So imagine only one of talar shift would increase the pressure, uh contact pressures at the tibiotalar by about 42%. Remember that a at any time you have two injuries to the anchoring, you have to fix this ankle because it is unstable. By definition, definitely any open fracture and posterior mal fragment, we have two options if it is an isolated posterior mal because of an axial loading injury. This is the one when the rule of 25% or less come into uh uh consideration. This is by definition type three mesomelic classification which is axial loading pong. And this when you look into the stability of the posterior ankle and if it's like less than 25 you can ignore if more than 25 you can do. But you need to be sure that this is an isolated posterior m. There is no other injuries in the anchoring any function of bima fracture, which means it's not only bi male bony injury, it could be one side, bony, one side ligamentous. This is again, is two sides injury of the ring and needs an open reduction tender fixation. So what the guidelines say? So both in 2016 came to say that you have to look into the soft tissue. The ankle fracture is a soft tissue injury with bone fracture or both bone broken inside. So you have to assess the skin integrity and neurovascular status. You have to look into the patient and medical comorbidities because it will affect the way of fixation. You, it will affect the most operative care. It will affect the prognosis and outcomes. So, patient is di if, if patient is diabetic. If patient, if have a pro per neuropathy, peripheral vascular disease, osteoporosis or patient is a smoker, you need to war. WW Yeah. To uh warn this patient that I will need to do a double fixation. I need to fix as stronger as I can because the ankle, your ankle won't be healing nicely. And the prognosis is not that good. Risks of infection and complication are higher by even the double in something like diabetes or smoking. You have to do an urgent reduction and splinting. It's a, it's a joint, it has to be back in place as early as possible to maintain uh the the viability of the articular surface and articular cartilage. You have to recheck x rays and neurovascular status. Once you reduce the ankle, which is done everywhere, what's the aim from open reduction in what we aim by open reduction and 10 fixing? So firstly, you need to, to make a bi backbone to build on. So your, your, your strut or back bone will be the lateral column, which is the fibular. So the first thing to do is any ankle over reduction and tenon fixation is to restore the fibrillar lens and rotation to build on. You have, you cannot build on uh a ma reduced fibula or a shortened or a Lenin fibula. You have to get your fibular lens perfectly back. You have to get your fibular rotation perfectly back. You have to get your fibula inside the tibia, tibial incisor. So you can build up on this lateral Corum. Once it is stabilized in a, in an anatomic reduction. Once your fibula is anatomically reduced, all fractures should reduce normally if your ankle uh ring is intact because basically the ankle more is one piece. It just have three colons. But in one in harmony. Once you get one colon reduced, the other two colons should go back to normal. Unless there is something is blocking or stopping the reduction, you have to restore the medial column because the medial column is not an AAA weight bearing area, but it's a very important restraint without the media column in your T will be tilted. So you have to re restore the medial column. You have to fix the man if there's any other injury in the R because this is we fix your in this MOSES and there is a large debate between, shall we fix the posterior ma only without synthes fixation or shall we support the posterior malfixation with some sort of synthes uh uh fixation either with the screws or troops. And this is a big debate, but once you stabilize your posterior ma get it reduced, anatomically, we'll fix it or batteries in place. Your synthesis should be uh stable. Remember that synthes moses is not a bone, it's a joint, even it is a fibrotic joint or a fibrous joint, you have to restore it to the anatomy. That's why the old uh uh practice with the tic screws though it is, it is still doing your job. And the evidence says that the, the results from the synthes screws versus the title are comparable. You need to understand that the syndesmotic fixation using a screw is not anatomical because it is a joint and you were just taking a screw across the joint. So stopping the movement there. Anatomical studies has changed from, from, from, from MAOI as well. From Liverpool has shown that the fibula has a range of motion inside the tibia tibia incisor. So there is some movement inside the, it's in these mo in all direction, internally, externally, it moves about 10 degrees and through posterial, it moves about 3 to 4 subir inferior, it moves about three M ma lateral, widening out and in about two. So again, synthes mosis, it not, it is not a bone. It is a fibrous joint with minimal movement inside and anatomically to have a normal an function, you have to regain the synthes mos anatomy. The anatomical study showing that the synthes most the fibula moves inside the synthes modes into all directions. So, rotating in internally, externally about 10 degrees, moving an through posterior, about 3 to 5 degrees, moving subir infer about 2 to 3 degree mmm and later lateral widening or coming out and in is about two. And logic, logically, if you go and fix the synthes moles a screw you, you, you just stop all this movement. So this is non anatomic though the evidence is still support that this is where regain the synthes mosis and will regain the the anchor function and the results and outcome coming from that is not, is not bad. So it's still comparable to a tightrope. The good thing about the tibe, if it is done properly and both 100 lines under properly, they can maintain this movement going on. So it is a it is a form of anatomical fixation of the synthes mosis. Your ankle X ray has to be assessed very, very carefully while you're doing your operation intraoperative. You need to be sure that you, you restored your fibrillar lens, your fibrillar irritation, you need to be sure that the den sign is back and it's not is there is no dis dis disturbance or disruption of the ring. You need to be sure that the shin to line is restored again. You need to be sure that the tibial clear space is uh uh is reason five and the overlap is more than 10. You need to be sure that the uh uh your clear spaces are normal. So come to the fixation, if we look about the fixation, remember that as we said, fibula is the reference point. So uh uh you have to get your fibula back and the fibula, once the fibula is back anatomically, you can build everything in the ankle up based upon that. If you have a spiral oblique fracture, remember that it is a long sign fracture and the best to fix this is with a leg screw just to, to, to uh uh uh eliminate all the movement, all the stresses, all the deforming forces. And then you can neutralize this with a plate. If it's a short segment, a small, a small blade can do the job if it's a large segment, spiral fracture. Remember that you need a leg and neutralization. If you use a trans, if it's a transverse fra you remember you need a stronger plate and II advise all of you to use the LCB DCB from synthesis. This is the strongest blade. I use different, different different systems. And I can, I can say to you there is nothing like the LCB DCB in the distal fibri or the, or the anatomic and fibrillar plate. Um Either from synthesis or from Acom. All the other systems are nice are good but not in the fibrillar plate, like uh lavender like paragon, all this stuff, they are slim, they are uh low profile, they are va looking, but at the end of the day, they are very flimsy. And if it's a long segment, they cannot do the job for you. So if you have a long segment or if you are not sure about the quality of the bone and fixation, go for LCB DCB, either from Acom made or remember if the fracture is we c and a bit proximal. Remember that the SPN is in your way. So be be very careful in this sick thing there and getting the S BN away from the way of your uh reduction and fixation. If you're fixing the median matter. Remember that uh the most important problem with the median man is that because of the anatomical structure of the median man, the periosteum over the median man is under tension. And once the median man fractures this, this uh periosteum rules into the fracture site. And that's why you have to get all the periosteum out of the fracture site. You have to clean your fracture site to be sure that the union will happen. So again, because median man is like that, it bi osteum normally is under tension. Once the median ma fractures, the bi osteum goes inside the fracture site and make the make it stop the reduction, the anatomic reduction and lead to uh nonunion or delayed union. So, the most important when you're fixing a, a medial mal is to get all the soft tissue out of the fracture site, clean all of your ostium and remove it and ensure that your anatomic reduction doesn't have any soft tissue interposition. You can put two screws and remember, you have to uh preoperatively analyze nicely. Where is the fracture? Is a fracture in this whole medial mal or it's an anterior corus or posterior colliculus. So where where is the line of your fracture? Because the screws shouldn't be like a very brilliant uh uh bar and nicely on the X ray. The most important is to get your screws pericar on the fracture site. So it's, it's not always the position of the screws which is going better to each other in the lateral and very in, in like one screw in the anteromedial and anteroposterior uh plane. No, the point is ignore the X ray to get the fracture reduced and nicely fix it. You need to get the screws, the two small con screws. Pericar on your fracture line where the fracture line is. If you both in your screws, there is a debate again. Shall I use a 35 or 40 lens? Uh can screws. My, my advice to you is to aim to the Pfizer scar. This is the Pfizer scar you see on the right side because this is a dense sibil bone and the, the, the hold of the, of the screws will be very good. So if I both two screws, I bought the screws up to here, one here and one here. And my aim would be this fi blade because it's a dense a sclerotic bone which will have a good hole for the screws rather than getting a very long screw, which is just uh float into the middle. Now, without any hole, if you have an oblique uh fracture of the median ma, you definitely need an anti gliding grade to stop it. And remember that the anti gliding rate, you need your fixation to be just proximal to the the apex of the fracture to do the anti gliding function for the posterior man. The main uh uh the main idea is to buttress it because it is it's hold by by, by ligaments from all around all what you need. It doesn't allow it to slip up or to go to displace posteriorly. So you're aiming to Batres the posterior man and to have this done properly, you have to aim to have a blade fixing the apx of the fracture and the screw or whatever you're holding with to be is just at the top of the avix. Remember that for the median man and for the posterior man battering means it's holding proximal. You don't need to put any screws distance to the fracture site because the idea of the battery is to stop any anti gliding of the fracture. Nothing more. If we go to the synthes mode and we spend a bit of AAA few minutes around the synthes mosis, you have screws or tightropes you need when you're fixing the synthes mosis to keep the foot in and uteral dorsiflexion. Unless you are not, you don't have the sensitivity of tightening the tibe, you can both your ankle. So if you are aggressive and you tighten the tightrope and you don't have the sensitivity to know that this is where your fibula needs to stop. And you're worried about over tightening, put your ankle in a uh uh in a dorsiflexion in a forced dorsiflexion. This will not allow you to overtighten if you have a sensitivity. So the idea is to keep the foot in neutral dorsiflexion. But if you worried about over tightening, you don't have the sense, you can easily uh both both the ankle and force the dorsiflexion and this is will stop you from over tightening. If you don't have these things, you have to have a reasonable tension. So not over tighten, not over loose, and you have to avoid over tension. Definitely because basically the over tension will move your fibula a bit posteriorly and this will make your fibula appear short and will add to a the tilt. So what the literature says about the fixation. So 2011, they found that regarding the Syndesmotic screws versus the tightrope. They found that uh I'm sorry about the Syn screws. They found that keeping the synth screws or removing the them at and by a similar outcomes, there is no problem of keeping the broken screws and you can remove them at four months if they are still intact or remove it, be below eight weeks if they start to have a, if there is a uh a Tia fibriller, no, you, if you remove it at eight weeks, this will it end by a tibia fibrillar diastasis. So finish literature review from our chief of orthopedic and trauma 2011. And this was speaking about keeping us screws or removing them all days until the recent few years, we we always remove the screws, even they are broken and even uh some companies like Baron has made a screw with a BT in the middle which allow you to remove it from media. And later because it was a common practice to remove the broken screws. This literature review says that the outcomes is similar, either you remove or not. And if you remove it before eight weeks, the, the, the the most ligaments isn't healed yet. And this will end by tibial tibial fbal diastasis. And if you remove at four months, they may reduce this, do your dorsiflexion because you lift it for a long time, how to watch your mo screws. So you always bought it from posterior to anterior was about, it was 25 or 30 degrees posterior. Your hand is dropped down and you go from posterior to anterior because this is where the anatomic side of the fibula, the fibula is posterior to the tibia. And you have to d definitely tibia to the tibial but not to, to build the fibula up or down. So if imagine this is the tibial platform and I go with these motor screws up, I would be bowling the fibula up. If I pull it down, I would be pulling the fibula down. And this is with the, the short, the fi or L but just to, to build the fibula to the tibia, you need to be better to the tibia platform. Shall you use tricortical or four cortical? Uh Again, another debate, tricortical is the ideal but four cortical, you use it either if the bone quality is not good in diabetic or if you, if you're planning to remove them. So the four cortices give you the option to remove from medial and lateral. So either you both tricortical or uh or quadricortical, this depend on what you're aiming for. Either your bone quality is not good or the patient is diabetic and you need a more robust fixation, you can go to quadricortical. So four cortices or if you're planning to remove it at some point. So you, you will need to remove it from median and lateral. Remember, this is a position of the screw, it's not a compression screw. So you have to be a fully threaded cortical screw. You can use either 3.5 or 4.5. But remember it's not a like screw, it's not a compression screw. Otherwise you will over tighten the synthes mosis and this will end into uh uh uh uh above results. Remember that the screw will lose in 15% and will break in another 15%. So, don't worry if you have to wa to warn your patient or to educate your patient, that don't worry if the screw starts to be loose at some point or to to break at some point because once you regain your normal movement, there is no status over the screw. The screw will get easily broken and get easily loosened. The two small fragment screws if this high fibular fracture, such a missing a vote for injury because it is a missing a injury, as you told as we, as we told this a rotation and injury by definition. So all what you need is to maintain the synthesis. So either use a two small fragment screws or use a two hole plate to fix the synthes mos. So both speaking, speaks about the management of ankle fracture and they say that what we emphasized earlier that stable Weber bee ankle fracture should be treated with analgesia splinting and patient allow it to be full weightbearing where the fracture stability is uncertain or the but position is acceptable. You can mobilize non weight bearing review in two weeks and then weight bear x-rays to inform that to be sure that stability is still maintained, always check that there is more stability during doing an over duction and tender fixation. And the way to do that is Boh B test, which is we call cotton test. So you bought the screw diver against the tibia, you bought the bone ho against the fibula, you both the fibula away from the tibia and take an X ray. And if your synthy moses is opening or diastasis, uh di di and or the, the, the talar space is, is widening. This means that the sys is not intact. The other way is to stress the foot in extended rotation and take an X ray. And if your syndesmosis is opening, this means it means a fixation. The surgical patient should be forward bearing as to and this is, has been uh supported now by the wax trial, which has been uh published 2002, 2024 in the lancet. And you II advise all of you to go and read the wax trial because it was uh to uh early weight bear these patients. And it, it show a pragmatic noninferiority trial, randomized controlled trial between weight bearing and nonweightbearing most anchor fixation. And they found that early weight bearing is not inferior to late weight bearing, no consensus or removal of smas screw as we discussed before. No, no, no consensus on the vta prophylaxis, advise your patient on function and recovery and rehab and return to work and sports and driving as early as possible. Nasal in, in, in, in journal of uh of trauma. In 24,011 found that ankle fracture treated operatively has an increased postoperative complication if the patient is a smoker. And as you can see, the smoking can get uh deep infection higher six times the normal uh individual diabetes mellitus. If the reduction is unsatisfactory of, if the fracture complicate a fracture pattern is more complicated. So it's very, very important to mention to your patient that without stopping the smoking, the results of an fixation, whatever you do for him will be very poor. The prognosis will be very poor complication will be very high. And we there is no question that diabetic and neuropathic patient will have um a poor outcome and poor results so quickly we'll go through the approaches. So the booster approach, she, so your skin incision would be midway between uh um the thing that the posterial aspect of the fibula and the indo achilles or between the posterior aspect of, of man and the achilles. Be careful that 8 to 9 centimeter from the, the the tip of the pros will be your shoulder nerve running there. You be careful about the shoulder nerve and the peroneal artery here and then you go between the Peri, as you can see on this side, Peri and F HL remember that F HL at this area would be a fleshy uh fibrous motor tendon. You just get it away and then you go across the very ostium to the back of the tibia. Remember that you have the posterior inferior fibrillar here and remember that there is a lot of perforators from the perineal artery running there, which they are inevitably injured. And that's why boulla approach is not that good anatomical approach because it injured the the the perforators of the perineal artery or even the perineal artery itself. And there's another anatomical studies from, from uh L mesen about this, you can go and read it media booster media. So you go a over over the key post. So just uh uh behind the border of the media man. So once you go, you open, you be careful that this will be your uh uh uh tip post. You open the sheets of the tip post, you bow the tip post to the me to the media side. You've been, you open the bit of the tip post and you go from there on the, on the, on, on your uh lateral side would be the neurovascular bundle and the flexor flexor digitorum and on the media side will be the tip post and then you can expose all the media booster media tibia. The risks here is in the tip post, complication of um problems of the tip post, postoperative and definitely the neurovascular injury booster media or traditional. This is one was this was the media booster media. So you go very media. So just over the tip post and through the tip post, P the the traditional booster media is the booster lateral. So your skin incision will be midway between the media border of the achilles and the medial mal you go here in between them. This is a very, very nice, very, very extensile approach, very easy approach to see the whole posterior tibia. And then you go, you dissect to official dissection, you cut the fascia and then you would be, you go between the F DL and uh F DL and the uh uh uh uh the tibial nerve and the neurovascular abundant on one side. F HL on one side. And then you go and you can see the whole posterior tibia very easily and a very safe approach on what you need to be careful about the neurovascular abundant under your retractors. You have to have a good assessment to hold this in hand. So deep dissection on the mid lateral side will be F HL on the medial side will be F DL with a neurovascular bundle easily, easily. You see the tibial nerve running under, under, under your hand, release ti tibial nerve all the way down until you reach to the ankle. Keep the tibial nerve secure under the F uh F DL. And go detect subperiosteum, remove all the periosteum and you can uh or dissect subperiosteum and get all the periosteum away from the, from the uh bone. And you can see beautifully all the posterior tibia and you can fix booster media booster. Very easy. It's a very common, very common approach I'm using in my practice and um I advise all of you to try it and thank you so much. So, any questions I'm more than happy to answer it. I hope um, it is clear and it gives you something different. Um, ankle fracture is, is not not, it's not nothing in you to you. I know every one of you is practicing ankle fracture, fixation and management and fixation every day. Uh All what II tried to shed light on is what's what, what's easily missed. What can you do differently to um, probably manage your ankle fracture? Uh I hope the whole course was uh useful for all of you. You got something new from it. I hope um I was able to deliver the message nicely. Um Both in the question and the chat in the chat, any question you want and even not about this uh this lecture about all the lectures. I'm more than happy to answer it. Speak loudly. Guys, don't worry. There is no silly question, ask whatever you want to ask. Well, I would be very happy if you all of you understand every, every and each point and there is no, there is nothing unclear. Thanks a at this. Yeah, it's my pleasure. OK, good guys. So again, same story. You will get um uh a feedback link was once we finish this lecture, uh please bo the feedback, everything you feel good, everything you feel bad, your feedback is very, very important to me. I'll take everything on board and this will be reflect uh reflect on the uh next course. Uh We planning primarily to start the next course by um mid Feb or uh late Feb. Uh because the guys are going to the Fr CS part A examination in the first uh week or two of FB. So we aim to, to start by NFIB or early March for uh and we'll speak about reconstruction. So we've done the basic science, we've done the foot and ankle. And I think the third one will be uh uh reconstruction to hip, knee and shoulder, arthroplasty, ankle, arthroplasty as well. And I promise you of a very useful one, very, very uh fruitful one which you'll find something different that when you, what, what, what you read in the box. Um But the feedback, you will receive a certification once the feedback is there. Um Thank you so much for attending all the lectures. Seven lectures is not short, but I try my best to make it concise to what you need to know and to give you something new. Uh all the best in your exams for the, for, uh, who it would appear for the exam in February. Uh, and for part A or part B, uh, all the best in your practical life. I'm more than happy to receive any of your question at any time again. I bought my email and phone number. I'm happy to receive all your um, questions formally or informally. Don't worry. And, yeah, I will see you by in Feb or um, early March with uh reconstruction. Good luck guys and have a very good evening and see you soon.