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Secondary signs, a tendinous injury and where we tend to, I find MS secondary signs is in injuries of the lateral ankle, the neglected midtarsal injury, uh and uh the secondary signs that suggest lisfranc injury that get overlooked. And so here we see an example of an osteochondral fracture of the talus tome. Uh these usually are recognized but they can be quite subtle. Uh and we can see here along the lateral dome of the taylors, a small non displaced osteo chondral defect and which is very important to be picked up on the initial plain film film radiograph patient. These injuries can go on to have MRI for further characterization. And we can see here a similar injury and osteochondral defect along the lateral shoulder of the tailor stone with some minimal displacement and localized edema. Now, just a quick review, the staging of osteochondral defects. Basically, you're stage one is where you just have a inflammatory or a de missus change. But without any structural change, then you've got your subcategories in stage two A two B which are just various degrees of subchondral uh fracturing assess essentially, but without it being complete. Stage three is where the defect is complete, but it's non displaced and stage four is where it's complete and displaced. Now, often I find that with a plain film radio graphs in the context, acute injury, often the abnormality is recognized, but the context or what the abnormality represents is mist and you often see this in reports on plain films as well where often the osseous flec uh Affleck of ossification will be mentioned. But the context of where it is and what that represents misses the crux of what the diagnosis is. This is another example of uh missed injuries on plain film radiograph. Here, we can see an aussie is fragment in the area of the distal aspect of the mid achilles tendon. Uh the patient's already in a in, in a plaster of paris. But we can see here that because of where this fragment is, it's consistent with an avulsion fracture of the achilles tendon. So it's very important to review these uh these fragments and identify where they are in relation to the anatomy that they're in to help you reach your diagnosis. Here's a more obvious uh fragment which we can see is completely displaced from the posterior calcaneus. And this is a standard fracture revulsion of the medicalese and quite significant displacement of the posterior superior calcaneus patient's like this can go on to get sound to further characterize the degree of avulsion and patient's with this type of injury. Here, you can see an ultrasound where we can see the evolves fragment defect, the actual defect between the vaults fragment and the native calcaneus and the achilles tendon which is attached to the uh volts fragment. Just a quick review of the anatomy. Sorry, the classification of such injuries. Here, we've got a type one which is the type of injury we've seen in the previous sides. Your standards, avulsion fracture with your which are osseous fragments attached. Type two is basically where you've got this be eking fracture which extends to the posterior superior calcaneus margin. But without it being fully displaced. And with the achilles tendon attached type three is where you get a superficial, a vote of the posterior achilles tendon with Aussies fragment attached and type four where you can get this kind of beak fracture along the posterior superior calcaneus with some displacement and avulsion of the the deep achilles tendon fibers. And not for example of uh the important reviewing that kind of injury on plane is in this radiograph here where we can see that there's a significant amount of soft tissue swelling adjacent to the lateral malleolus in the context of conversion injury. Until we see a strip of ossification adjacent to the distal fibula. This is very important again to recognize within the context of where it is this fragment is adjacent to the distal fibula. And as a secondary feature of a superior perennial retinacular injury, a superior perennial wreck, the superior peroneal retinaculum is a very important structure which we can't see on radiograph. It's responsible for anchoring both the Pyrenees Brevis and long behind the um there are categories of uh of perennial, regular injuries. And type one is where you basically get periosteal stripping along the outer margin of the fibula, which creates a pouch which then the Pyrenees Brevis, how long as can displace into and they tend to get intermittent displacement. Type two is where you have a full tear of the peroneal retinaculum at the level of the distal fibula. But without any osseous avulsion. Type three is where you get a full thickness tear of the peroneal retinaculum. But with displacement, uh an avulsion, a fragment from the distal fibula and type four is where you get a tear of the superior peroneal retinaculum just proximately the peroni as long as some Brevis. Another very important secondary sign in the context of uh ankle injury is that of secondary features of syndesmosis injury, widening of the tibia. Listen, since you're in the context of an inversion injury is very, very frequently overlooked. And uh I've uh it's an overlooked injury which have encountered in our department widening of the tibia. Listen, cicero greater than and five millimeters should prompt further assessment of the patient for an anterior lateral ligamentous injury. Patient's that have the secondary signs where it may go to have a further imaging in our department. Ultrasound is most successful modality and here is a patient who had widening of the tibia, listen, Sanctura, who now has a significant diffusion as we can see along the anterior lateral recess and the interior talofibular ligaments, which is meant to extend across in a band like structure like this is completely gone. So this is consistent with a rupture, grade three sprain of the ATFL. They may also go on to have an MRI scan. Uh And here we see a patient again with a similar injury, secondary evidence identified on plain film radiograph and Hiroko were meant to see the line of the ATFL. We can see there is no line. So there is a full thickness, tear rupture of the ATFL. A grade three sprain. Another example of a very subtle secondary sign of a ligamentous injury in the ankle is this little fleck of ossification inferior to the fibula, again, maybe commented on, maybe noticed. But without recognizing the context of where it is in relation to the anatomy, the meaning of what it represents could be overlooked. This uh fleck of calcification is in the region of the CFL, the calcaneofibular ligament and this should prompt a suspicion for um an avulsion injury secondary to CFL uh terror revulsion. Here, we can see an example of a patient with similar sign on the radiograph. And here we can see uh what is the CFL and a gap between the CFL and it's attachment onto the Calcaneus. So there's a rupture with small a volts fragment there and a bit of a Dema at the attachment site. Again, very important to pick these up secondary signs up in plain film to instigate further imaging and management. Moving on to the mid tarsal zone. Again, a very over often overlooked area because the injuries tend to be quite subtle. Um Here, we can see a very a fracture, a minimally displaced fracture fragment of the anterior superior calcaneus um which is quite large in this case and displaced, but they can be very small and it should be always part of your review area. When you're looking at playing films here, we can see in a bleak radiograph again with a slightly more subtle injury along the anterior superior calcaneus, which is minimally displaced, but again, very important to review for these injuries as they're very overlooked, especially in the acute setting. Here, we can see another area that can be overlooked here, we can see well, in this case, quite a significant osseous fragment with minimal displacement along the lateral margin of the calcaneus. And here we we can see a representation of an avulsion fracture at the origin of the extensor digitorum brevis. Again, these can be very small and quite subtle but again, very important to pick up on the plain film so that you can so it instigate further imaging assessment and management. This patient had a radiograph and centered on the Calcaneocuboid articulation. We can see a small little fleck of calcification coming off the margin of the calcaneus. Again, this may be noted but in the context of where it's located, the meaning of what it represents might be overlooked. And this is in the region of the CC ligament and it's representing a CC ligamentous avulsion injury. And it's important that this is recognised and flagged up in the initial radiograph. This is a patient with a very similar injury who's gone on to have a CT scan. And you can see here again, the CT scan demonstrates this small fragment. A volts from the calcaneus representing the ligamentous uh of ocean. And finally, at the level of the mid tarsal. Uh another area that you commonly see an A and A in the context of trauma and tenderness along the mid tarsal components. This tiny little fleck of ossification dorsal to the navicularis again, very easy to see it and comment on it but its location. So should prompt further questioning. This is in the region of the talonavicular ligament and this is a secondary sign of a tale. Oh ligament is a talonavicular ligaments devotion injury. This patient went on to have a CT scan that shows a small, minimally displaced fracture of the talonavicular leg at the talonavicular ligament distal aspect and further assessment with MRI shows that the talonavicular ligament morphology is completely abnormal, consistent with a high grade sprain and the small fragment now has displaced itself more proximately at the level of the taylors head moving on to the base of the fifth. Again, an area where we commonly see injury, we can see subtle injury that can be overlooked. And we can see mimics an overview here off the base of the fifth metatarsal. We can see at the very proximal aspect of the base of the fifth is where we get avulsion fractures where the Pyrenees brevis tendon inserts onto the base of the fifth more distantly at the metaphyseal region. We see the zone where the Jones fracture happens and more distantly as we go along, the diagnosis is the location where we get stress fractures. Approximately, we have to be aware of uh peroneus breakfast of ocean mimic, which is the ost perineum, which will be identified because it's usually very well corticated and it has a very smooth morphology around here. We can see a patient who on the slightly oblique view has a transverse lucency at the base of the fifth. This is at the insertion of the Pyrenees Brevis tendon and it's not current, it's not displaced but very important review area. Here, we can see a mimic. Uh Here we can see a, a small well corticated osseous fragment adjacent to the cuboid approximate to the base of the fifth. However, this is an aspirin e um and not to be mistaken or confused with a Peroneus brevis avulsion fraction of the base of the fifth. Finally, we're going to go on to a very important topic which is that of the Liz Frank ligament and identifying secondary features, which can suggest it in that there is an injury of this ligament complex. The Liz Frank ligaments very important complex and it's basically, it's anatomy is quite strange. So basically, um the most, in most cases, the Liz Frank ligament complex is divided into three segments, the doors of the intermediate and the volar. Uh the dorsal element usually extends from the media Conair from to the base of the second metatarsal. And it's the weakest element of the list of the ligament complex. The interosseous component which again is between the medial uh in a a form and the base of the second metatarsal is the strongest element of the ligament complex. And then at the volar aspect, we've got these bands which connect the 2nd and 3rd metatarsal usually to uh to the, the medial cuneiform. And we can see here on MRI that MRI can delineate the anatomy of the Liz Frank uh ligament complex very nicely. Here, we can see the dorsal component here, we can see the intermediate component. And at the bottom here, we can actually see some of the volar component emanating from the volar aspect of the second and the third and uh and connecting them to the medial cuneiform in the context of Liz fried injury. There's three main distributions of our categories of injury. You've got your home lateral injury where you get either complete lateral displacement of the first to the fifth metatarsals or lateral displacement of the second to the fifth metatarsals with the first metatarsal intact. Here, we can see an example of a home, a lateral injury. Here, we can see that both one that uh the metatarsals from 1 to 5 are completely displaced laterally. Divergent is basically where you get lateral displacement of the second to the fifth metatarsals with medial displacement of the first metatarsal. This is a rather um gross example of this where the second to the 50 concealer displaced laterally with medial displacement of the first metatarsal and isolated lisfranc injuries where you get isolated metatarsal and displacement. 123. Now, secondary injury, secondary signs of Liz Frank ligament injury are very important to recognize is most of these patient's will again get plain film radiographs, ask the initial and imaging investigation. And here we can see that the space between the 1st and 2nd and base, the 1st and 2nd metatarsal and medial and intermediate cuneiform is widened and any widening greater than two millimeters should flag a suspicion for Liz Frank ligament injury. Here we've got the the step off sign on the lateral view again, a very good secondary sign of Liz Frank ligament injury where the the base of the second metatarsal is malaligned with dorsal aspect of the Canadian forms and this can be exaggerated on weight bearing and an actual loading. And again, this should prop high clinical suspicion for significant Liz Frank ligamentous injury. Another more subtle sign again, that can often can be either overlooked or recognized but not recognized in the context of where it is is the flex sign. And here we can see a small little fleck of ossification medial to the base of the second metatarsal, which again should raise a strong suspicion for significantly is frankly demented injury. Here we have a CT scan on a patient with the flex sign. And here we can see that there's a tiny little fleck falsification at the base of the second metatarsal. And incidentally, you can see some widening between the base of the second and medium and intermediate Conair form. Again, strong secondary signs of Liz frank ligament injury, where is frank ligament injury is suspected and MRI is your gold standard for characterization of the ligament complex. And here we can see an MRI of the forefoot. We can see that the dorsal component, an intermediate component and volar components of the ligament complex are completely gone. They've completely lost their normal morphology. There's diastasis and that area is completely in, filled with fluid. So this is consistent with a full is frank ligament rupture grade three sprain. So in summary, um it's very important to recognize subtle bone injuries and secondary signs on plain film. As these, these can often hide significant bone ligamentous or tenderness injuries. Plain film is by far the initial screening investigation for pain shoot ankle and foot injury, which will instigate further treatment and management. So it's very important to remember your review areas to review for osteochondral dif. To remember your review areas for a not neglect the mid tarsal area to pick up or subtle midtarsal injuries. And also to receive ossification can represent significant divulge in fractures. It just depends and it's all dependent on where they are anatomically located. Always review a plain film for evidence of soft tissue injury. As this will train your eye to look towards areas of potential injury. And remember the secondary signs and and such as diastasis of the tibia, listen, Sanctura. Um if lateral ligamentous injury is suspected, don't forget your review areas for Liz frank ligament injury and if in doubt, ask for further um imaging for assessment idea, be it CT or or MRI. Um So if you have a very, very low threshold for further assess and um suspected is frankly garment injury and these are my references and I'm happy to take questions.