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yet. I think we are live now. Okay. Good evening, everyone. I hope you can all hear me nice and clear. If any problems, please write in the chat box for me. Welcome to this evening of orthopedic teaching. This session today is about radiology of the foot and ankle. It's part of our orthopedic X ray interpretation course that we delivered on the 20th of August. And this is just a continuation of of the course with an add on lecture. We try to stay focused on the topic. We will try to finish early, So hopefully less than an hour by seven o'clock, you'll be finished. Um, very important. Always in all our sessions to be interactive. So, please, if you have any questions, any doubts, please write them the chat box, and we will not leave today until all your questions are answered. We'll ask you to fill a feedback form, and you will automatically get a certificate. And for we will try obviously to make this recording available for you. Um, obviously free of charge as part of your registration. My name for us? A note. I'll be hosting this event. Um and we're very proud to be hosting this for the first time ever on middle. Um, we've been introduced the middle, and we've been training how to use it. It's fantastic platform. Um, And we This is our first live event. We had a lot of training on middle, but this is our first live event. So please excuse us if there are any hiccups today. And I'm very honored that Speaker for our first middle event is Nicky Evans, who is our colleague. Orthopedic surgeon. Um, and she is one of the founders of orthopedic Academy, and she's been educated with us for a long time. And she's taking on today the topic of the ideology of the foot and ankle just to warn you guys, there are polls questions, so please stay focused. Yeah, the polls are anonymous, so please give it your best shot. But stay focused with us to our representation over to you, Nicky. Okay. Thanks very much for us. And welcome everyone. Um, So what I'm going to do is just go through the radiology of the foot and ankle and maybe some common conditions. So you know what to look for when you're looking at X rays. of this part of the body. So if I start with some normal anatomy, So if we start with the ankle, this is a typical a p x ray of an ankle so we can see we've got the fibula down on the lateral side. We've got the distal tibia here, and there's a few things that you need to look at. So if you look at a true AP, you will have some overlap of the fibula on the tibia and a little bit of overlap of the fibula on the edge of the Taylors. So this saddle shaped here is the Taylors, also known as the Taylor Dome. Um, and what we look at is we're going to look at here is the ankle joint space along here and down here. Now, on this AP view, we're not going to comment on that space. We're going to look at a mortar, if you for that. But what we can see on this view is we've got the lateral process of the Taylors down here. We've got the distal end of the tibia. Uh, the fibula. Sorry. Also known as the lateral malleolus on the medial side. Um, we have the medial malleolus, which is the distal end of the tibia. Um, and then we've got this part of the tibia here, which is the distal end of the tibia. But it's also given some other names, particularly when we talk about fractures so it can be known as the tibial plateau font because it's flat or tibial Pillon, um, again, just describing the way that it sits in the mortise of the ankle joint. Um, so if we then move on to a lateral view, there's a couple of things to look at on this. So if you have a true lateral view, what you should be able to see is some joint space through here Now, as as in this X ray, we've got a double shadow for the Taylors here and here. Um, so the media on the lateral margin of the Taylor Doma overlapped. We've got the fibula, which is here, and it's projected over the tibia. But if you can just see the margin come down there and then this bit at the back. So this which says 12 is actually the back of the tibia, it should be extended a little bit to here, which is the overlap of the fibula on the distal tibia. We're going to look at the Taylors, in particular, the Taylor Dome, which comes around here. We've got this indentation here, which is the Taylor neck. And then we're gonna come on to the anterior process. This kind of rectangular bone here is the navicular. Um, this one here is the Calcaneus, um, and the joint below the Taylors between above the calcaneus. This is the subtalar joint. The joint that we're seeing here is the talonavicular joint, and we go further down. This is going to be one of the intermetatarsal joints at the back here of the Taylor. Sometimes you can see a little projection, which is the posterior Taylor's personally a process of the Taylors and that can sometimes be fractured. And really, it's just symptomatic treatment for that. So let's have a look. This is a mortise view, and the way that this is taken is with 15 to 20 degrees of internal rotation. So what you're going to see on here, as opposed to the AP view is you won't have any overlap of the fibula on the Taylors and the reason that we do this view is so that we can look at the space that constitutes the ankle joint. So you've got the medial malleolus. This part here is known as the medial clear space. You've got the area between the tibial platforms and the Taylor Dome across the middle there. And then because we've got this particular view, we can also see the lateral clear space down the side. Now, in the absence of any ligamentous injury, then this clear space should be symmetrical on all sides. Um, there is always a little bit of overlap between the tibia and fibula here. And this is the tibia Taylor, um, ligaments, which constitutes an anterior posterior and the middle component, um, also known as the ankles and osmosis. Okay, we've got lateral ligaments from the distal end of the fibula to the Taylors and also to the calcaneal Calcaneum. Um, so it's a lateral ligament complex. And on the medial side, we have a deep and superficial deltoid ligament. Okay, You might see somewhere that you know, if this space is greater than five millimeters, it indicates an injury. Well, yeah, it's possible, but what you're looking at is the symmetry of this, plus some other features that we'll have a look at when we come to look at the ankle fractures. Now the foot. The foot can be quite complicated because it's got lots and lots of bones, but there's a few things that you need to look at here. We're looking at an oblique and, um, an AP. So you're going to look for this rounded bit here, which is gonna be the anterior process of the Taylors and that is going to articulate with this kind of rectangle here, which is the navicular. And he was here on this side, on the lateral side. At this level you got the cuboid, which is like a cube. That's why it's called the Cuboid. So that's on the lateral side, and then just this, sort of that you've got the uniforms, which you can really only see the first cuneiform on this view. But if you look at the slightly oblique view, you can see the medial, the middle and the lateral uniforms. And the importance of these is when we come to look at Lisfranc injuries is that if you see how the medial one projects up like this And then there's kind of a little a little, um, slot for the base of the second metatarsal to slot into. And then you go along the lateral down to the cuboid, all right, and there's an important ligament. It goes from the medial cuneiform to the base of the second metatarsal, which holds this all in place, and it holds it in place in three planes. So if you think about a Roman arch, that's how it all slots in. And it maintains the arches of the foot as well as the overall alignment of the bones, and we'll have a look at that when we come to it later. So then we come to the metatarsals. Here we go. The first one is easy to recognize because it's the biggest we've got 2nd, 3rd, 4th, 5th, um, and they're going to go on to the phalanges of the toes. So the toe like the thumb. You've got a proximal and the distal phalanx, and then you've got proximal middle and distal for all of your lesser toes. And there we go. There they all are. Okay, um, sometimes it can be very difficult to see a fracture in the foot, which is why we use CT scan's a lot of the time to give us a clear anatomy. Because if we look at the lateral, the lateral foot is quite good for looking at the ankle joint like we see here is one with the posterior process of the Taylors. Here, we've got our Taylor Dome anterior approach the Taylors. We've got our calcanei years here, and then we're going to look at the navicular, which is here. Um and then we're going to move on to the middle cuneiform, and then we're gonna go on. And if you look at this, it's quite difficult to see which metatarsal is which and the same with the phalanges. But what you can sometimes see on a lateral view is if you've got a fractured metatarsal where there's a spike of bone projecting posteriorly or anteriorly, you can see that, um, if there's any disruption of the talonavicular joint or the subtalar joint, if there is a Lisfranc fracture dislocation, which is involves the Tarso tarsometatarsal joint to the foot. What you might see and we've got an extra bit soon is this will be sitting, um, asymmetrical. The calcaneus which is this bone. We sometimes get this axial view of the calcaneus, particularly when we're looking for fractures. Um, and it's done as a kind of axial view. Um, in order to see this this kind of outline of the actual heel bone itself, and you can sometimes see fractures through this area if we want to look closer at the important parts, which would be the subtalar joint and the calcaneocuboid joint. Often we use a CT to give us a better idea of what's happening there. Okay, so we've had a look at some normal X rays. Let's have a look at some fractures, so ankle fractures are really common and there's a few components to them. And there's a spectrum of disorder, and it goes from, you know, a mild ankle sprain, which would be usually a tearing of the calcaneofibular ligament or the anterior talofibular ligament to something really nasty. Also known as a tibial pill on fracture. Okay, so as well as the bones, we need to think about the ligaments around the ankle joint. The big one is the inferior tibiofibular ligament. All right, so, as I said earlier, there's an anterior middle and a posterior part to this. The posterior part of it is the strongest. And, um, often you can pull off the posterior part of the tibia. Um, if that ligament is very strong, so we're going to look at the ankle. This is also known as the singers, Moses. Okay. And this is important when we start to look at classification of fibula fractures. So we're gonna keep an eye out for this area here. The interosseous ligament runs from above the syndrome ASUs between the tibia and fibula, almost all the way up to the neck of the fibula. Okay, now, if you have something called amazing nerve injury, this ligament is torn. And so although the X rays themselves don't look very exciting, the fact that you've got the whole of this ligament torn makes the ankle joint quite unstable. Um, and it's a fairly big injury that needs to be addressed, Which is why clinical examination of these patients goes in conjunction with interpreting the X rays. Um, here we have the medial malleolus. We've got a superficial and a deep deltoid ligament they attached to the Taylors. Um, and they're gonna maintain our Taylor's within our ankle mortise, if you like. Okay, so there's some ligaments. Let's have a look. So this is the weather classification of ankle fractures. It's a pretty simple classification system, and it directs your treatment. So this is the one that we tend to use, and if we look at it, it's quite simple. It's all based on the fibula. Here's the singers Moses, and the rule is below the singers. Moses isn't a at the level of the sin. Diagnosis is a B and above the level of sin, diagnosis is a see. Now when we say the level of the fracture, what we mean is the most distal part of the fracture. So if you've got a fracture line, that's starting up here, but it comes down to here. That would be a be all right. So normally we look at the diagrams we've got our sin diagnosis are lateral ligaments and, uh, deltoid ligament. Here it's normal. It all looks nice as a good space in a Weber a fracture. We except that the ligaments are probably intact because your fracture goes through here. So it's below your syndrome. ASUs. It's gone through the bone rather than tearing your lateral ligaments, and there's no reason the medial side should be injured if we go with a B. These are the borderline ones because sometimes they disrupt the singers Moses, and sometimes they don't. So we have to make a judgement call based on clinical findings and other radiological findings, and we will have a look at some of those. The question is whether there is the, um, integrity of the syndesmosis is intact there by stabilizing the tibia and fibula and whether the deltoid ligament is intact as well. So these are the ones that you need to look at closely the Web see relatively straightforward because they're above the syndesmosis. The syndesmosis is gone. They can be quite dramatic. The ankle might be dislocated. Um, um, on this view, you've got a fracture of the medial malleolus here, but alternatively, you could have no fracture and disrupt your superficial and deep deltoid ligaments. These are nearly always unstable, and you and nearly always need an operation. So a we don't need to operate on. See, we do need to operate on and the ones in the middle. We have to make a clinical judgment. So let's have a look. So this is a website. A fracture? Okay, They're usually transverse. So here's one here. Sometimes there's a medial malleolus fracture, usually a transverse at the same level. Um, and the ligaments are usually intact. The if you look at the mortars view here is our clear space is fine. Um, and they're usually stable so we can treat them depending on how much pain the patients and we can treat them in a walking boot. Or we might put them in the backside for a couple of weeks to let the pain settle down and then let them go into a boot and start walking. Um, and as we can see, our syndesmosis is going to be in this area here. So we're below with transverse are joint space looks fine. Are ligaments look intact? We don't need to operate on this patient. Let's have a look at it. Be okay. So these are the typical kind of configuration that you see with a B fracture. If you look at the fracture line goes into this area, which is the syndrome ASUs. And if we look at the joint space around here so we know this is a mortise because there's no overlap between the distal tibia and the Taylors. Um, what we can see is that there's probably a little bit of this place in the fracture site itself. But what's a little bit more worrying is we look at the gap on this side compared to the gap here seems to be wider. There's also this little flake of bone here, which could indicate a rupture of the deltoid ligament with an avulsion of a small piece of bone. So this is one that we are going to examine carefully. We may do some more X rays or we may decide on clinical examination. This is one that should have fixation. Um, here is another one. Now, this one is slightly different, so it looks like the same kind of configuration here. But if we look at the distance between the tibia and the fibula on this, that relationship appears to be preserved. Whereas on this one it appears to be a bit wider. So this one also has no, uh, increased opening on the medial side. This one is very likely to be stable, but again, we're going to assess it. Clinically looking for medial tenderness, medial bruising. And we'll probably do some stress views. Um, on the lateral. This doesn't really He doesn't give you a lot of information, but you can see that the ankle joint is located. And if you look at the overlapping fibula, you can just see the tip of the fracture there, um, existing poster village, which is what they normally do. So we move onto Web. See? So this is a Web see fracture above the level of the singers Moses. And if we look at the distance between the tibia and fibula, it's wide okay. It's that Cindy's Moses all three bundles of it has gone. These bones should not be that far apart. There's probably a little fragment of bone there, which is probably off the back of the tibia, um, which often happens. So your fibula fracture is above the level of singers. Moses. Here it is. It's a Web C type fracture. You've got widening of the ankle syndesmosis, also known as Diastasis, which means the two bones have come apart. And then this one, you've also got a fracture of the medial malleolus. And then, if it couldn't get any worse, the ankle is dislocated. So here is the distal end of the tibia with it's nice dome. And here is the Taylor Dome, which should be sitting underneath here. So this is a fracture. Dislocation of the ankle joint, and this needs to be reduced. I mean, we wouldn't expect you to be able to do a close reduction to reduce the whole fracture, but what we want to do is get the ankle located and take the pressure off the skin on the medial side. This ankle will look very deformed, and it will be very painful. So we're going to look at another view now, which is something called a mason of Fracture. So these are the ones when I talked about that interosseous membrane that goes between the tibia and fibula for the whole length, how a simple X ray could lead you down a false path. So if we would just just x ray the ankle here, you might say, Oh, well, it's overlapping a bit there. It looks a little bit wide, but I'm not sure. And yes, there's a massive clear space on here, so there's definitely something going on, but I can't see the fibula fracture. Well, the answer is you need to look further up. So this is an X ray of the knee, A lateral view, and you can see a fracture here through the proximal fibula. The force of this injury, which is usually a fairly significant twisting injury. For example, somebody falling down a flight of stairs and the fracture has gone through the proximal fibula all the way down the interosseous ligament through the syndrome ASUs and out through the medial ligaments, namely, the superficial and deep deltoid ligaments. So this is something that we need to fix. We don't need to fix the fibula fracture, but what we do need to do is reduce this, um, get some kind of fixation across the syndesmosis to reconstruct this, um, normal relationship. And when we do that, this will often reduce, and we don't need to do anything else. Sometimes if the belt deltoid ligament has been torn and stuck inside this gap, when we try to reduce it from this side, we can't do it. So we have to open the medial side and actually pull out the deltoid ligament. Um, often the deep is gone and the superficial can remain intact. If you've got a superficial and you reconstitute the syndrome ASUs, then you usually don't have to do anything else to the deep, but you're going to screen it and make sure it's stable. You may have heard of the A O classification of the leg. Handsome classification. I mean, I don't think it's particularly useful because the weather classification is simple and it guides treatment. And if you talk about everybody, knows what you're talking about, the leg. Hanson. It's nice because it explains how you get the different patterns of injury. Basically, as you Super Night and I ducked you go lateral ligament or or lateral malleolus, and then you go around until you get to the medial side. Um, and again it's It's as you increase force through the ankle so a ligament or a bone will be injured, and it's nice for understanding your mechanism, but it doesn't really tell you how to fix it. Um, and again the A a classification. It's good for writing papers, but it doesn't really help us with a lot of these ankle fractures, because if you look at the classification, it's either extra articular partial articular or intra articular. Um, you know, and most of them are going to be in the type A, so that doesn't really help either. So what do we do? So we've got the Web, Web A. That's usually going to be a boot. And whether it's tolerated, we've got the C, which is usually going to be surgery and non weight bearing. And then we've got the web of bees, and we need to determine whether they're stable or unstable. And you can do a stress view, um, or a weight bearing view. And what you're looking for is widening of the medial side of the joint, which would indicate a more unstable fracture pattern and probably surgical intervention. So this is a typical stress view. Now, this is a website because you can see the fracture up here, so I'm not sure why they've done a stress for you on this, But there you go. And what this one. This is what we would do in the operating theater with the patient asleep. I think this will probably be too painful to do in the X ray department, but you can see the examiner's hand here and what you're doing is you're putting a stress of external rotation on that ankle joint to see whether the medial side opens up, and in this case, it does. If you compare that distance to this distance, I can see it's a lot wider. This would be unstable. Here's the Web be This is a different type of stress for you. So in this one, you put the patient on their side, and you let gravity hold to see whether the Taylors drops with the distal end of the fibula. And if it does, you'll have increased opening on this side, and I'd say this one's not too bad. I don't think there's a lot of opening on that side. It hasn't moved a lot, so I'd say this one is probably stable, and the last one you can do is you can ask the patient to wait there and when they wait there, Um, if the tibia and fibula have got an injury to the pharmacist and what you find is on weight bearing, there will be. It's an increase in the gap between the tibia and fibula. Um, and you may see increased, uh, medial joint space, but you're looking at the gap between the two of them. And in fact, um, I had a patient in clinic last Tuesday that I was pretty sure it was like this. It was it looked relatively unstable. But I got some weightbearing views after a week, and it actually opened up a little bit. So we are going to go ahead and fix that, even though clinically it was difficult because she didn't have any particular medial tenderness or medial bruising. But the stress of you was quite remarkable. Just the weight bearing. And it showed that the ankle mortis, the ankle joint, opened up quite a lot. So they are useful. How do we fix them? So here we go. We have here. We've got a web. See? Fracture. Uh, sorry, Weatherby. Fracture down here. We've also got medial malleolus fracture. Now, if we think about this, if this is where it's supposed to be, then we've definitely got increased medial space there and you haven't disrupted the deltoid ligament. But you fractured the medial malleolus. So this is going to be unstable and we are going to fix it. So how do we fix it? The first thing we do is we reduce the fibula and put a plate on it. Here's our plate, all right. The reason I put this in is because patients often look at this x ray and say, Oh, my screws fallen out, which is this one here, But that's not what we do. So if you have tried to imagine this in a three D, But if you reduce the fracture and the fracture line is going this way, what we do is we put a lag screw to hold the fracture in place, which goes at a different angle. Then we put a plate down the outside and we fix it. We fixed the medial malleolus on this side, usually with two screws through there, and then we test the stability of the singers Moses, Um, and if there's any concern, then we put what's called Diastasis screwing, which is one that goes from the fibula into the tibia. Some people used to. Some people go through to the other side of the tibia. Some people don't. There's no real evidence to suggest what you need to do either way, provided you get this joint reduced, we keep them nonweightbearing for at least six weeks until the fracture is healed. We used to take out the syndesmosis screws routinely. Again. We don't do that anymore. Sometimes they break, but they don't tend to cause any problems. But we do take them out if, um, if they're causing any symptoms. So you know, I've got a patient that is about six months after having fixation for a fracture Very similar to this. Uh, he does a lot of hiking, and what you can feel is clicking and grinding. And that's probably because the screws not broken yet. But, um, it may be that holding these two bones together and then allowing your foot to do dorsiflexion and plantarflexion if you're climbing up and down hills might give you some restriction and some discomfort. So here's someone that we are going to remove the screw for, um, but it's usually on a case by case basis. So the other end of the spectrum are these tibial platform fractures, tibial pill on fractures, distal tibia, fractures. Um, they're usually quite bad. Um, the classification doesn't really help you because we almost invariably end up getting a CT scan to see the extent of the articular surface involvement. And if you look at this, you can have just simple fragments. Or you can have ones that look a lot worse than this in multiple multiple fragments. And the principles of management for these are to manage the soft tissue because they're usually very, very swollen. Manage the soft tissues. You might need to put an extra Lasix later on, and then you want to try and reconstruct the joint surface as much as you can, um, and then deal with it later. But that's kind of beyond the scope of this lecture. It's just there to show you what a really bad ankle fracture looks like. Okay, so here's the first question. Um, I've got this X ray here. We've got a 23 year old female who falls down the stairs and complains for painful ankle. So your X ray shows and you've got some options. The fibula fractured tibia fracture, Lisfranc injury, Taylor shift. Prompting further investigation. Or is it a normal x ray? Um Ferrous. I can't see any poll. Yeah, so I'm going to share the polls now. Here you go, guys. Uh, this is the first question again answers all anonymous So, please, uh, give it your best shot, and there will be further few pole polling questions coming later. We'll give you a minute. Um, and I'm going to try as well. I test myself. I can't actually see the polls. So because you're on the presenter, you just see your presentation. Yeah. Um, so what, you fall downstairs? I think one of the maybe a bit of an issue here is that the question might be obstructing the X ray. Um, and you cannot move the box out of the way. But if that happens to you, then, um just close the polling question. You will find the question in the chat area. You could then again look at the options and the X ray and then answer there. Um, that's wonderful. Um uh, people have answered, um, so we'll stop the pole now. Okay? Did everybody get it right? So 63% went for option D. Beautiful. And otherwise, it's nine and 18% for other options, and no one picked less Frank fracture, which is great. Okay, uh, normal. 9%. Okay, so, uh, we don't have a large audience today. Okay? 9% means one in 10, and actually, 11 people attempted so that 9% means 1%. Okay. All right. So what we're looking at is an X ray of the ankle. Um, we can see. Here's the distal fibula. There's no fracture here. We're looking at the distal tibia. I can't see a fracture there. Lisfranc Injuries in the foot that will come to We're looking at the medial clear space here and comparing it to this one, and it's massively abnormal. So if you remember, if we look at the distance between the tibia and fibula here, there should be some overlap. So this is one of those things that we need to look further investigation. And what do we need to look for? The proximal fibula fracture? This is the major nerve injury. And this is the trap that you fall into if you don't examine the patient an X ray, the whole of the tibia and fibula. Um, so the correct answer is taylor shift, prompting further investigation. Okay, we'll move on. So I'm just going to talk briefly about these because, um, it was the fracture was the main one I wanted to talk about, but ankle arthritis. Here's some ankle arthritis. It's got the typical features of arthritis. You've got joint space, narrowing sclerosis, uh, subchondral, cysts and osteophytes. So we've got some osteophytes happening around here and around here that would be ankle osteoarthritis. Charcot ankle. So Charcot disease is usually the end result of diabetes. Um, in the Western world and the classic features of Charcot are that you get fragmentation, bone destruction dislocations, um, and a very abnormal looking x ray. So if we look here, you know our distal tibia joints more or less gone, it's collapsed. There's no end of the fibula. Um, and there's all these kind of areas of where the bones fragmented. Could this be infection? Yes. Um, could it be an end stage of rheumatoid? Possibly. But when you see this volume of joint destruction, it's usually Charcot or infection. All right, let's have a quick look at pediatric ankle fractures. Um, so I haven't gone through the Salt Harris classification because it was covered in one of the other lectures. Um, so that's why I haven't gone through it. But if we look at this one, we've got a distal fibula growth plate. We've got a distal tibia. Growth plate are fibula. Fracture is up here, so we've got a distal fibula fracture. And if we look at the tibia, we've got the EpiPen ASUs here with the medial malleolus. We've got this metaphysical fragment here, and our fracture line has gone through here and through here. And here's the other fragment. So the ankle has gone into valgus. You have, um, Metamucil triangle of bone attached to epiphysis, which makes it a salt, uh, Harris to. And the worrying thing about this injury is the amount of deformity and whether this is going to cause pressure on the skin on the medial side. So this needs to be reduced. Um, yeah. So a couple of fractures that are particular to the pediatric population and the first one is the try plain fracture, which is usually happens around about 12 13 year olds. Um, and it's because of the way that the growth plates fuse is so you don't get this this kind of appearance. Um, in the younger Children or in the older Children, it's only really this particular age group. Um, and it's called a try plain because the fracture is in three planes So you have on the lateral. You have the fracture, which is Metamucil, which is similar to assault Harris to, um So you got a triangle of bone. You have a fracture below the growth plate in this plane, which is here, which is similar to assault Harris three. And then you have the other fracture that goes through the growth plate. So you're going through the tibia through the growth plate and out through the epiphany CIS. And the best way to visualize this is on a CT scan. So if you look at the CT scan here, you can see this part. The epithelial part of the fracture is there. So you've got a gap about 3.3 millimeters there. You've got this component of the fracture, which again, too salty Harris to You've got your little fragment of bone there, and it's gone through in this plane. And then you've got this other fracture that goes actually through the growth plate. So these usually depending on what they're like, you usually need to reduce them. Um, usually, because if you have a step or a gap in the joint surface, you want to try and correct that so it's only one or 1 to 2 millimeters. You may be able to get away with the operating, but otherwise we need to reduce that to preserve the articular surface. So as the growth plate continues to fuse, you get this fracture, which is known as a pillow fracture. And it's this component here. So because of the growth plate, So we're looking at the growth plate here. The growth plates fuse is from medial, which is here. And then it goes around the back posterior around here. And the last part to fuse is the anterior lateral part of the distal tibia. So what happens in a Tillaux fracture is you've got more fusion of the growth plate than you do in the 13 year olds, so you don't get the try plain. But what you get is this fragment of bone being pulled off by the ankle syndesmotic ligaments there. So you get this chunk of bone. So in an adult you get a syndesmosis injury. In a younger child, you get probably salt has to type fracture. But in this age group, which is usually a little bit older than the try planes, you get this till a fracture. When do we need to operate on them? When there's a step or a gap in the joint surface of two millimeters or more and again, the CT scan will give you more information. So here's the next question. We've got a seven year old boy with an injury to his ankle during football. What does this X ray show? Does it show? A Tillaux fracture. A try. Plain fracture, assault, whole household Harris, One fracture of the distal fibula. Assault Harris three fracture of the distal tibia or assault Harris to fracture of the distal tibia and a fracture of the fibula. Okay, guys. So I shared the poll. Uh, please try all to answer. We'll give you a minute or so. Okay. And if if anyone finding any part of this talk require any further explanation, please don't hesitate to ask you questions. Yeah, What an anchor. Ideology can sometimes be a difficult topic, So please, guys don't hesitate to ask you questions. We don't hear us how? Yeah, we've done. We have. Yeah, we have responses now, so I'll stop the pole. Uh, so we have 42% went for option E mhm and 28 for B 14, 4 A and 14. 4 D and 04 c. Okay. Excellent. So is the correct answer. So why is it not a pillow or a try? Plain Well, the kids seven. So we remember the try Plain is around about 12. 13 until I was around about 13. 14. And because of the nature of the way that the growth plates fuse is this kid seven. So his growth plates are wide open, so that rules out a and be nobody picked C, which is great because it isn't, uh, salt has three fracture of the distal tibia. So salt has three is one that is through the epic ASUs rather than the actual metastasis. It's through the Pegasys through this part. So it's not that one. So it's a soldier Harris, too, because we have this Metamucil fragment of the distal tibia. So it's a soldier Harris to fracture of the distal tibia. We also have a fracture of the fibula up here, So well done, everybody that got it right. Okay. So the next ones can be quite complicated. I'm gonna try and make it simple. Um, and don't overthink them too much because the Taylors and the Calcaneus and a lot of the foot things we will do a CT scan, um, to get the, you know to be 100% sure of what's going on, and that's beyond the scope of this lecture. We're just going to talk about X rays. So that's what you might come across in the emergency department. Um, so let's have a quick look right now. The Taylors is a complicated bone, all right, it's difficult to see clearly in plain X rays. Um, CT is good for fractures. An MRI scan is good if you're looking for something else, like a vascular necrosis or osteochondral lesions. So it sits in here and it sits in there and it's got three joints. It's got the TB oh Taylor joint, which is one. It's got the Subtalar joint, which is the joint between the Taylors and the Coq. 10 years, and it's got the talonavicular joint, which is the joint between the Taylors and the navicular. You remember the navicular is the rectangle, and the cuboid is on the lateral side, and that's the Cube one, and we'll look at that in a sec. All right. Why are we bothered about the Taylors? Okay, so the problem with the Taylors is its blood supply, and it's got this. Uh, it's a bit like the skateboard. It's one of those bones that's got a blood supply that if you knock off part of it, then you get a vascular necrosis. And so if you have a fracture through the tail and neck and you take out this arterial supply, you're losing the blood supply to the anterior part of the Taylor Dome and further down here, because the supply from your posterior tibial is only going to go so far. So the tailor neck fractures are the ones that we get a little bit excited about, and here it is. Okay. Taylor's tibia and fibula Calacanis Subtalar joint talonavicular joint here. There we go. All right, let's have a look at some of these. So this is the classification system. I don't expect you to know the classification system, but it helps to understand why these can be, um, concerning. Let's say so. We're talking about the tail and neck here, So that little indentation So we've got one. That's undisplaced. Chances are the blood supplies. All right, so the risk of getting a vascular necrosis is between zero and 13%. The type two is where we have a fracture through the neck, and the subtalar joint is dislocated. Slightly higher risk of a vascular necrosis. Now we get onto the more exciting ones. So the type three has got a sub Taylor and the tibia Taylor dislocation. And often with these, the Taylors is part of the Taylors ends up either open on the road or at least out the back on the X rays. That's that's a type three, Um, and then the type four, which is sub Taylor tibia, Taylor and Talonavicular dislocation. And again, this fragment can be excluded out the back. This fragment can be excluded at the front, and these have got a much higher, um, risk of avascular necrosis. That says type two there. I'm sorry about that. I should say type three. Um, so 1234. So one is not too bad. Four is terrible and the other two are in between. Let's have a look at some X rays, right? So here we go. Here's a type four. Here's this lender. The tibia. Here's the calcaneus. Here's here's the navicular and we've got the Taylors fractured and popping out the front. And if you look at the skin line here, this is going to be open. All right? It's a type four. This is going to have a bad outcome. Here is a type three. So we've got a fracture through the Taylor neck. There it is. We've got subtalar joint disruption, and we've got to be a tailor. Um, disruption as well. And you can see the Taylor Dome is actually kind of spun around where it is. Um, here's a type one. So we look at this one, we've got a fracture through the neck, but, uh, tibia Taylor joints. Okay. Our subtalar joint is probably okay. And are talonavicular joint is okay. Here's another one. This is a type two. So we've got a fracture through the taylor neck, and we've got a disruption of the subtalar joint Taylor navicular joint is okay. Um, and this one you can't You can't always trust this view because it looks like the tibia Taylor joint is in joint. But it can't be because we're the anterior process of the Taylors. Is out here. It's actually come out spun around. So the tibia Taylor joint must have gone. Subtalar joint must have gone on. The talonavicular joint must have gone. And the thing is, with these, we're going to do a CT scan. If you've got this, you're going to treat it as an open fracture. Um, and you're probably going to try and reduce it, but we're going to get a CT scan to identify where all the fragments are and what we've got to work with. So something simple. This is another type of tailor fractures, and it's just the lateral process of the Taylors. I don't know about this country in Australia. Used to call it the snowboarders fracture because snowboarders used to get it. You don't need to do anything for it. Treated nonoperatively symptomatic. Maybe a boot. If they've got a lot of pain and swelling over their ankle Taylor dome lesions again. It's only here because you might hear people talk about it. You can have medial and lateral the lateral ones of the Sorry. The lateral ones are more likely to be traumatic. So somebody that's had an ankle sprain that just hasn't got any better, I might have a tailored, um, lesion. The medial side ones tend to be related to more chronic conditions. And although you can see them on this x ray, sometimes you can't. So the method of choice is an MRI scan. And what you can see is a loose fragment of cartilage with a piece of bone uh, missing there, because what happened is with avascular necrosis, you get collapse of the underlying bone, cartilage is over the top. And then, with time and wear and tear, the college will collapse as well. Tosel coalition, um, happens in kids. Usually the kids present in adolescents with recurrent ankle sprains. Just so you can see it on an X ray, there's two types. Um, there is the, um sorry, this one which is the Taylor Calacanis. And it's a C shape here. So what you've got is an abnormal connection between the Taylors and the Calacanis. Um, and then you've got this other type which is supposed to look like an ant eater. Um, and it's a connection between the calcaneus and the navicular, and it can either be purely bone purely cartilaginous, or it can have, like a little uh, synchondrosis between it again, treatment is symptomatic. MRI scan will give you a better idea of what's actually happening. But in case in case you come along something and someone's always a coalition, it's got a C shape or it's got an anteater. That's what it is. Okay, so here's another question. We've got a 38 year old male involved in a road traffic accident. Here's his X ray. So what should we do? Should we put him in a back slab and send him to fracture clinic in seven days? Shall we assess his neurovascular status and advise trauma Orthopedics? Does this have an avian rate of 10%? Is the subtalar joint reduced requires an urgent CT scan. So think about what you would do when this patient rocks up and you're the first doctor to see him. What's going to be your first thought is no. Right. It looks like people listening carefully to you, Nicky. Are they getting it right? Yeah, almost. But clearly everyone is listening. So that's good. All right. Should I talk through it? Times? Yeah. So Option B has 83% beautiful. Okay, so let's have a look. So backslash and fracture clinic followed with seven days. Oh, God, no. Please don't do that. It has been done. Um, but I'd probably say not in this case. Um, so if we look at the X rays, here's the distal tibia. Where's the Taylors? Oh, my God. It's over here. So, tibia Taylor's gone. Subtalar joint is gone because it's over here and here is the navicular. So the tibia Taylor, the talonavicular joint is also disrupted. So that puts us into a Hawkins type four, which is the worst type, which has an avian rate of 70 to 100%. And so the subtalar joint is reduced. Absolutely not. It's gone. Urgency t scan. It probably does. But your first thing that you're going to do is assess the neurovascular status and advised trauma Orthopedic, because this is something that needs urgent reduction. Um, in the operating theaters and even if you know this looks open, we get this to theater, we reduce it, we can assess it. Even if we do temporary fixation, wash it out, then we can get a CT scan later and fix it later. Stage. But it needs to be reduced. You've got three joints dislocated in the ankle. You guys 38. You don't want to get on to this as soon as you can. And you want to know if there is any nerve or vessel compromise, so well done. Here we go. Here's another question for you. You got a 12 year old male history of recurrent ankle sprains. Here's his X ray. I've even got some nice helpful arrows in there. What's this? Is it a tailor? Neck fracture, a tarsal coalition calcaneus fracture, Lisfranc injury or Alex Valgus? Actually, I think I must apologize here for some reason on the polling instead of Tartar Coalition is coming up as fractured navicular. But I think the options are, as Nick is saying, you know, ignore reporting. I think that must be a mistake. Okay, well, if the if the correct option is not there, I better just talk through it then, um, people have been picking, I think because I left your question on the screen so that people have been able to to choose the options from your question. Okay, so they're 57% choose option B. Okay, that's the coalition. All right, So this is a coalition. We're looking at the C shape Taylor neck fracture. No, not really. Total coalition? Yep. And we've got this nice C shape. We've got all the arrows pointing to it. Calcaneal fracture? Probably not. Calculus looks okay. Um Lisfranc Injury. We haven't covered that yet, so it's not going to be that. And Alex Valgus, we haven't gone into the big toe. And also he's got a history of recurrent ankle sprains. He's not a motorcycle accident or a fall from a height. So the age, the history of ankle sprains, the X ray findings would be consistent with a tassel coalition. Calacanis fractures again. One of those things that we usually get a CT scan to better identify. A huge range of them usually fall from a height, sometimes bilateral, sometimes associated with vertebral fractures. Um, typical ones are quite fragmented to go into the subtalar joint. Here is the actual view that we talked about earlier. You can see it's gone through here, and it's gone through here, and a CT scan will give you a better idea of what you're dealing with. Um, the old Essex LoPresti type classification classified them as 21 was in two particular joint depression. And the second one was a tongue type where the Achilles tendon had pulled off a beak of the calcaneus back. And you do sometimes see them and they're relatively easy to fix. But we usually see to them anyway to make sure that Taylor joints intact. He's small. Yeah, so here's one going through here. So this is probably, you know, the kind that that it's difficult to see. This is why we CT scan them. But the subtalar joint might be all right there. It may just be this part that's lifted up, and it's possible we'll be able to treat that nonoperatively or just with a couple of cannulated screws. The main thing about Calcaneus fracture is is to get them elevated and get the swelling down and make sure they don't have any other injuries. And then we can address the calcaneus fracture itself. Tassel fractures okay. Again. You wouldn't be expected to know a lot of this. It's it's kind of just for interest. So let's have a look at some things. Some pitfalls. So this is the first one. This is the accessory navicular. Okay, why? Well, here's the navicular this nice rectangle. And here's this. Why is this not a fracture? Well, it's It's in the tendon. Um, it's got smooth edges. There's no soft tissue swelling. Um, and that's the place where you can get an accessory navicular, and it doesn't normally need anything. Often you see patients with ankle sprains, and they have some accessory navicular or little bits all over the place, and you think it's a fracture. But it isn't always, and the clue here is the smooth, rounded edges, and it's in the line of the two post tendon, so that is an accessory navicular. Let's look at a fractured navicular. Here's one is it? Right now it's rectangle bone. Here's the Taylors, and we've got a fracture through the middle of it there. Um, sometimes these can be undisplaced. Sometimes they can be open, Um, and usually we can treat them operatively or nonoperatively. Often it's operatively, and we just get some fixation across here. Cuboid fractures. Remember the cuboid on the lateral side, articulate with the calcaneus? Here's a fracture through the the cuboid here, and here's another type of cuboid fracture, which is a small avulsion fracture at the base here. so Pyrenees brevis attaches here. So we get a forced in inversion injury to your ankle. You could, um, pull off that little fragment there and again. You don't need to operate on this, but you do need to protect them and treat them symptomatically. Okay. Next question. 12 year old inversion injury to the ankle. Here it is. What are we looking at? We're looking at an accessory navicular. A fractured navicular, a fractured taylor's, um, fracture cuboid or a lisfranc injury. Okay, Nicky, I think, for some reason to polling questions, um, got mixed up this one, the previous one. So, um, that's all right. We'll just talk through it. I'm hoping my computer doesn't shut down. You know, you can see this thing flashing on the screen. Um, it's an accessory. Navicular. It's the X ray that I showed before. It's got smooth. Round edges is the navicular. It looks okay. It's in the line of the tube. Post tendon. Um, you know, it's not the best X ray of the Taylors. You can't see the Qvar because it's on the opposite side. And it's not a lisfranc injury. So here's a list, Frank. These are right and left feet compared if we look at this line here, so we're looking between the medial cuneiform and where the base of the second metatarsal slots in next to that. And if we look here, there's a straight line. We look on this side, there's an increase in the gap. Okay? And if we look between the medial cuneiform and the base of the second metatarsal, there's an increase in this gap here. That is the basics of a Lisfranc injury and his diagrammatic representation of it. Now there's lots of different configurations of this, but that is the mainstay, um, of the Lisfranc. So let's look at some X rays of it. So sometimes on the lateral. If that ligament is gone, you can see here is here is your navicular and you can see that your metatarsals have subluxed off the top. And here's another version of it. So here's your medial uniform and look where your first metatarsal is. It should be over here, but it's shifted all the way into the whole of the tarsometatarsal. Points and ligaments all move to the side. This is a very nasty injury. Um, and not only will you need to reconstruct that ligament, but you probably need to put some kind of fixation in to hold the rest of the tarsal bones back to the mid foot. Uh, metatarsal stress fracture. So typically somebody that's been on the feet runners, soldiers you might not see anything on the first X rays. You'll only start to see it when the fracture starts to heal and you'll see this kind of callous formation and there is a little bit more. So three weeks later, you might start to see callous treatment. Again. The treatment is just symptomatically. You just need to think about it. If somebody presents with that history, Rheumatoid foot were coming to the end now Rheumatoid foot, the rheumatoid disease destroys the joints. Sign of itis destroys the tendons and the ligaments, and you get progressive subluxation and dislocation. And that's what's happened here. Your MTP joints are all dislocating through there, and that's what happens in the hands as well in rheumatoid diabetic foot. So we talked about the Charcot ankle earlier on. Here's another one. You get fragmentation dislocation subluxation in the mid foot, so you get these abnormal appearances. You get this kind of rock bottom appearance, you get ulcers. And if you look at the diabetic foot X ray, you can see these patients had amputation of his big toe amputation of the little toe. He hasn't got very many mid foot changes on there, to be honest, um, but you'd be looking for that kind of appearance. Okay. And the last question, if we can we've got a foot X ray. There you go. Does it show fragmentation dislocations, ostial, isis fractures or all of the above? Uh, Nicky. Yeah. I'm not sure if we can fully see your x ray is related to this question. Okay, We're still seeing the X ray, which has the amputation of the big toe and the little toe. Uh, and there is this message. That's, uh yeah. Can you see it now? Yeah. Sorry. I think it's because my computer's decided it needs more space. Yeah. Yeah. Sorry. I'll just keep taking that off for now. Okay, guys, this is the last MCQ for this, uh, lecture. So please all try to answer it. You do your best. Show us that you're still with us. It's also the last slide, I think. Hey, I think That was really very useful. So I think. Okay, guys. So, um, your best. It's very difficult. MCQ. Very difficult question. Very tricky. But that's something you might encounter in your practice. It's more common than you think. Um, wherever you are. So what do you think you can see on this X ray? So I think you would. You is your main focus on the lateral view. And the key is it? Uh, no, I've just got an A P. Um, I'm not sure we're still seeing the one with the amputated toes. No, it's not. Come through then. Now it's come through. Now it's coming through. Yeah, that's fine. Now it comes through. I was, you know, the lateral view you on that previous slide was also related bit, but yeah, so Okay, guys. So this one, what do you see here? Um, in this foot X ray. So we have some answers. Sorry about the technical problem. I think the key is computer, as has been challenging it. Um Great. Okay. So, um, will take over from Nikki now. I hope you can all hear me, guys. So this X ray is 42%. Got the correct answer. It's showing all of the above. There is fragmentation. As you can see, the bone is fragmented. Uh, metatarsals and metatarsal bones. There are dislocations and loss of normal alignment of the bones and loss of the joint normal joints nostril is is as well as the bone has clearly been dissolved in multiple places, but particularly, um, around the basis of the metatarsals and on the mid tarsal bones and multiple fractures, because the bone is fragmented. Um, it's dissolved, so it's prone to fracture. It has. It has It has fractured. Um, so well done, guys. Well done, everyone. That's great. So, um, that was the last slide of this evening. And that was the last question. Um, so on behalf of also the academy and Nicky, who suddenly lost, um, I would like to thank you all for attending and for bearing with us. Um, first session. We're using metal. That's wonderful platform. Professional medics set it up, and we're very happy to be supporting them. And they are supporting us on this, uh, on medical education. So thank you guys for attending. I wish you all enjoyed and learned this video recording will be available as a catch up content for free. Um, And you say Nikki is back, so I'm just letting get in. So the catch up content will be available for you on your account on metal heineke. Hi. Sorry about okay. That's fine. I took over and I said, the correct answer is all of the above. It was all of you, correct? It was all of the above. Yeah, that's fine. And that was your side Last slide, isn't it? It was. Yeah. Great. Great. So I was just thinking everyone for attending and just explaining that video content recording will be available as a catch up on their account on metal. But also, for those of you who registered through, uh, are you k, they will send you your own individual link. Um, please provide your feedback. Um, help us, um, and give us your opinions, and you will be provided everyone who attended, um, will be provided with the cpt certificate. Um, for attending today. Um, any final comments, Nikki? No, I hope that was okay. It's quite perfect, you know? Perfect. You know, it's very complex. Foot and ankle radiology. Very, very complex topic. And that's why we ordered a CT and an MRI a lot, isn't it? You've managed to explain it very well. Went through a normal anatomy and common condition is really very nice to watch. So I think you said it already for us. But, you know, if there's something that you have an interest in that you want us to cover, we're open to any suggestions. Um, this is a new platform for us, so, you know, there's something that you'd like to know more about. We can We can cover it. Um, just let us know. That's that's very good idea. Please communicate with us. So we have this course and we have other course called principles of orthopedic course. Um, and we we try to cover, um, the gaps in orthopedic education. Um, so please, guys, this is built the whole course. This whole course is built on feedback. Um, so please let us know what you need. Um, what gaps there are. And we'll try to cover everything for you. Okay. Well, uh, I've left the email address if someone wants to contact us, but apart from that, uh, thank you very much again, Nikki. And thanks for everyone attending. And hopefully we'll see you in the future. Um, teaching events with also the academy. Good night. Bye bye.