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Hello, everyone. Uh My name is Ria. I work for me support team. Um I'm a penultimate year medical student at Imperial and it gives me great delight to introduce our speaker for ankle fractures today. It's Kareem Edris who is an orthopedic registrar. So, if you'd like to take it away, that would be fantastic. Thank you very much for you. Hi, everybody. My name is Kareem Ris. I'm one of the orthopedic registrars in the east of England Deaner. I currently work at the North Norwich University Hospitals and I'm uh SD four. First of all, I wanted to thank me all for their effort uh with uh these lectures. Um I hope that uh everybody is uh safe and sound and that uh this effort is uh is useful for you as well. And uh today we're going to be discussing ankle fractures. So I'm going to go straight to it. Let me just share my screen and hopefully you can see the presentation. Ok, Maria, can you see my screen, please? Yes. Excellent. Ok. So we're going to be discussing fractures around the ankle and I've already introduced myself the objectives of uh this topic learning objectives are to understand the anatomy of the ankle joint and the surrounding structures. Recognizing risk factors and the incidence of ankle fractures, identifying the signs and the symptoms of these injuries. When you see the patients in the emergency department, uh it's important to be able to select the appropriate modes of imaging that are needed and the correct views that are relevant to this injury. To classify these injuries and to treat ankle fractures both in the acute setting and then how to treat them definitively as well, identify the possible complications and how to best rehabilitate the patients post-operatively. Please feel free to send questions that you have in the chat or if you have any comments and I will pose every once in a while and ask for you to let me know as we go along. Ok. So first thing we're going to talk about is the anatomy of the ankle joint. The ankle joint like any joint is formed of bones, muscles and ligaments mainly. And then there are surrounding structures such as nerves, blood vessels and there are structures that are in the joint such as the cartilage that covers the joint. So to start off the bones in the ankle joint are uh the tibia, the fibula and the talus. These are the three, the three contributing bones and all three together form a modified hin joint that moves in dorsiflexion and plantar flex flexion mainly and provide a little bit of sion and inversion as well. Inversions, meaning your sole of the foot is towards the inside of your body. Sion is when the sole of the foot is towards the outside of your body. Ok. Uh The contributing part of the tibia is the tibial plafond. Ok. Uh So it's the base of the, of the tibia bone which you can see here, it's called the tibial plafond. I don't know how many of you are um involved in uh orthopedics or have an orthopedic background. So I can go slower if that is useful. So let us know if this is too fast or too advance, then I can break it down a little bit more. Uh So just let us know in the chat and rea will let me know if, if there are any comments, please. OK. And the other part of it is the talus, OK. Both of these are broader anteriorly and wider laterally. Both of these bones and have conforming shapes to allow for the movement. The talus is a wedge shaped bone. Ok. So it has a wider, anterior, uh sorry, broader, anterior part and then it becomes narrower in the end. And this is important when you look at the x-rays to assess whether the foot like on this lateral here is in a neutral position, whether it's dorsiflexed, whether it's plantar flexed and how it affects the shape of the talus within the joint and how it is uh uh affects your x-rays. So when you're making a decision, you know what you're looking at, you don't get fooled by the picture. OK. Here you have the lateral malleolus, it's part of the distal part of the fibula. OK. And like you said, the talus, the median malleus of the tibia and the tibial plafond. OK. Now, looking at the lateral view, this is the talus, again looks like a wedge. There is, this is the tibia and this is the tibial plafond forming the tibiotalar joint. And this bone here overlapping with the tibia is the fibula. Ok. Moving on, we've got the muscles around the ankle joint. You have tendons that surround the ankle joint. The tendons are the perineal tendons laterally, peroneus, longus, peroneus brevis. And these run behind the lateral mallus and attach themselves to this to the bones of the foot. OK? And then you have the medial side, you have the tibialis posterior, which runs along with the uh flexor haus longus muscle. OK? And the flexor digitorum tendon as well. And all of these run behind the medial malleolus along with the blood vessels and nerves of that uh structure. OK? Or that bundle. And then finally, you have the anterior structures like tibialis, anterior and extensor Haass longus, extensor digitorum longus and the bund neuro vascular bundle that run with it as well. It's important to know where these uh tendons are along with the blood vessels and nerves when you're approaching the ankle joint. So whether you make using portals for ankle arthroscopy or whether you're making incisions for your definitive fixation of ankle fractures or fusions. You need to be aware of where the tendons and the blood vessels and nerves are. So you avoid damaging them and you can create your approach in between or around them. Ok. Any questions so far, there's no questions in the chart. Ok, lovely. Thank you. Next up is ligaments and there are three ligamentous complexes around the around the ankle joint as well. You have a medial ligamentous complex that looks like a triangle. It's called the deltoid ligament. The deltoid ligament attaches to the medial malleolus and then to various bones around the uh medial side of the foot. It's a very strong ligament and in many cases, it's even stronger than the bone it's attached to and can cause fractures of the medial mallus without itself rupturing. OK. On the lateral side, you have the lateral ligament complex which is uh attaching from the attaching uh to the fibula from different bones around the foot as well. So you have the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament. And these three ligaments are weaker than the medial side, weaker than the deltoid ligament, excuse me. And so they're more likely to rupture and that's why you're more likely to see uh ligaments spraying on the outside aspect of the foot of the ankle. You're more likely to see swelling around the lateral nauss or around the medial nall. And it's more likely for the ligaments to rupture than for the bones to break. And then the third ligament uh complex that you have is the syndesmosis. The syndesmosis is the ligament that attaches the distal tibia to the distal fibula. It is composed of three ligaments. The anterior inferior tibiofibular ligament. If there's an anterior ligament, then there's gotta be a posterior, inferior tibiofibular ligament. And there's a small transverse ligament that also attaches there. OK. If there's an anterior, there's a posterior. If there's an inferior, there has to be a superior as well, which is another ligament complex that attaches the proximal tibia to the proximal fibula. But that's for another chat in another day in between the tibia and the fibula, there's a large membrane or ligament that's called the interosseous ligament. And that extends from uh pretty much proximal tibia and fibula down to the distal tibia and fibula, very similar to the interosseous membrane of the forearm. And it helps control the structures and get add stability. Uh And it's something that you need to be mindful of when you're performing more complex fixations, more complex surgery that if the ligament is not ruptured, that you don't injure it. So you don't create synostosis, which means bone bridges basically between the tibia and the fibula. OK. Finally, you have neurovascular structures. OK. And the neurovascular structures around the uh tibia and the fibula are uh the anterior tibial artery and the deep perineal nerve. And the name gives away the location. So it's anterior to the tibia. It runs along with the uh extensor digitorum, longus extensor houses longus muscles. And it's at risk when you're approaching the joint anteriorly or using your uh portals for uh the A for ankle arthroscopy. Ok. Then you have the posterior tibial nerve and the posterior and the poster in the tibial artery. And those run behind the medial mallus along with the tibialis, posterior muscle. These are more at risk with the poster poster medial approach or if you're fixing the medial meus and you make your incision to posterior, then you are more likely to encounter them and then you're at a higher risk of damaging them. So it's something to be mindful of even with simple ankle fixation. There's the superficial perineal nerve and the short nerve. And both of those run laterally in the lateral compartment. The superficial perineal nerve runs a lot more proximal. It's about 10 centimeters above the tip of the lateral malleus. And it's more at risk with the posto lateral approach or the lateral approach. If you go proximal enough, while the sru nerve is at risk with the poster lateral approach and the la lateral approach, but more distal around the uh distal fibula, you can encounter the sru nerve and that will affect sensation to the lateral aspect of the foot. So these are the uh structures of the ankle that form and are around the ankle joint that you have to be mindful of. Now, ankle fractures are very common fractures. They happen in about 100 and 87 of out of 100,000 adults every year and they bid distribution. You can see them in young active male patients such as this uh Austrian football or Hens Wool who uh fractured or at least dislocated his ankle completely during this football match. Or you can see them in elderly female patients. Uh for example, I had a recent patient uh last week who was getting up from the toilet and without a twisting injury or anything uh or any trauma, uh fractured her tibia, uh quite severely and ended up with an open fracture, not very dissimilar to this one. You can break them down by fracture type. You have isolated malleolus fractures which is either medium nodulus, later mellitus or posterior malu. You can have bima which one or the combination of two or tri where everything is fractured. And inherently the syndesmosis will usually be ruptured with those as well. The risk factors to ankle fractures are usually in younger male patients because that's the age group and the gender that are more likely to perform uh risky and sometimes stupid activities that result in such severe injuries. Obesity is uh a common cause as well due to a lack of activity, increased bone weakness, increased loading through the bone that can cause the bone itself to fracture. Smoking reduces bone healing and can result in weakness of the bone and increased likelihood of ankle fractures as well. Alcohol consumption again because of stupid activities or risky activities that can result in these injuries. Now, you're in the ed department or you're in the emergency department and you're getting a patient who's coming in with pain around the ankle joint. How do you examine them in orthopedics? We have a simple rule. You look, you feel and you move. Ok. So what are we looking for? We are looking for difficulty or inability to ambulate. So a patient comes in, they're unable to walk or they're walking with great difficulty. They have uh bruising and they have swelling or swelling around the ankle joint. They complain that the ankle joint itself is tender. There is an obvious deformity that you can see. So similar to the last picture we saw with the Austrian foot bower, we can see that the ankle joint. So the foot is pointing in the completely wrong direction. Ok. That is a very obvious indication of an I have an injury around the ankle joint, uh soft tissue injuries, someone who has a tear who has a large brisk blister, an open wound, uh or yeah, fracture blisters are an indication as well. So these are things you need to look for and to assess when you're examining a patient who's complaining of ankle pain. Next thing you want to do is you want to feel and what are you feeling for? Well, you're feeling for neurovascular supply, you're feeling for the distal pulsations around the foot. Usually the uh dorsalis pens which you'll feel between the 1st and 2nd metatarsals of the foot or you can feel for tenderness, whether the patient has an area that is sore when you're pressing it, crepitus is the feeling of gas underneath the skin that can come with fractures as well because they release these gas bubbles uh with the break, uh you can you need to palpate the proximal fibula. So in some cases, there is a specific fracture called the mao fracture that can cause a uh rupture of the syndesmosis distally. So, ligament injury distally and a very proximal fibular fracture. And that's something that it's important to assess for because it's an indication for surgical management. And finally, you feel for skin skin 10, can you feel any bits of sharp bone directly underneath the skin that can potentially rupture the skin and cause the fracture to convert to convert itself from being a closed injury to an open injury, which is an indication for a more urgent uh response and a more urgent intervention to avoid further damage to the neurovascular structures. Finally, you need to move the ankle joint, you need to see if the patient can weightbear and you need to see what the range of movement that the uh the patient has after this injury. If the patient can weightbear and they have excellent range of movement, they are more than like, more likely than not have, have not broken their ankle. Even with the sprain, you'll have a great difficulty mobilizing the patient's ankle without causing them a great amount of pain. Ok. So just remember if any examination in orthopedics, it's look, feel, move and it's usually the same things that you're looking and feeling and moving for, especially in trauma. Any questions so far? Are you, someone in the chart has asked if they could have a little bit of help reading x-rays if you could provide a small bit of guidance. Yes, of course. And this is what we're coming to now. So what we're coming to now is, is x-rays. Ok. There are imaging generally not just x-rays and the imaging that you want to get for ankle fractures. Most like like anything in the orthopedics are you have limited options? You have got x-rays, you have CT scans, you have MRI scans and then you can do ultrasound scans as well as MRI S. Ok. What we're going to mainly focus on is those three modes of imaging that you can see on the screen because these are the ones that are gold standard for, for managing ankle fractures. X-rays. Are you ha you have a good amount of views that you can get. But these are very important with ankle fractures. It's co choosing the correct view that will provide you the best in amount of information that you need to make your decision. Ok. So the first view that you need to get is an anteroposterior view. OK? Which is the one you can see here on the left that will let you see the median malleus, the lateral malleus, the talus. But the problem with the A P view is this area here. OK. I don't know if you can see my cursor. I assume you can is you have this increased area of overlap between the fibula and between the distal tibia and the talus. So what I'm seeing here is not the correct and accurate view of the joint. What I'm seeing here is this view then will show me whether there's a fracture or no. The reason I want to see the joint well is if you can imagine the ankle joint is the way I think of it is like holding a box against your chest with your two hands. OK? Now, what I want to see is I want to see if I've broken one hand, if I've broken two hands or if I've broken my chest as well. So there's nothing that is holding the box in place. OK. These will indicate how much the fracture, how, how much the fracture will affect the stability. And the second thing I need to do is check for stability itself and the way to do that is to have a correct view of the box within the two hands in the chest or the box here being the talus bone between the medial and the lateral meus and your chest is the tibial plafond. OK. I need to see where the, where the talus is situated in between those three areas of bone. Ideally, in most people, you will have an equal amount of space between the talus and the tibia superiorly. OK? The superior clear space will be equal to the amount of space you have between the medial ulus and the talus medially. And that's the medial clear space. It's important to be able to, to assess that to get this specific view. This view is called a mort's view. A mortis view is when you have your foot in 15 degrees of internal rotation. So you take the big toe of the patient, OK? And you pull that in, in, in towards the other leg, 15 degrees that should give you more or less this view here where you can see the entirety of the distal fibula, the talus is not overlapped by the fibula. There is minimal overlap between the me uh between the fibula and the distal tibia. And you can see the median matters clearly, you can see the joint spaces clearly as well. So this is called the mortis view. And you need to ask for that explicitly. I remember when I, when I used to work in Egypt. This is something that I needed to ask for every time I asked for these views in some places and some countries II, I assume they will do them without you asking. It's important to ask though. Finally, you need to have a lateral view of the ankle joint. And that will give you an idea of whether there's any fractures that you couldn't appreciate on these two views such as posterior maus fractures, for example, talar fractures with the, there's a subluxation or dislocation of the tibial joint in the A P direction. Ok. So these are the x-ray views that you need to get. Now you can get more advanced x-rays such as the, these are stress views, ok? Stress views will give you an indication of whether the fracture itself is stable when you put a little bit of pressure on it. Ok. So you have dynamic stress view, meaning you're stressing the ankle, you're moving the ankle from one side to side or manual stress view where you take the ankle in one direction and leave it there and then get an x-ray. And that will give you a bit of uh an indication of stability. Gravity stress view is where you let the foot drop and take an x-ray and see how that affects the continuity of the ankle joint itself. Finally, uh you need to, you can, oh sorry, you need, you can also replace gravity stress views or dynamic stress views or manual stress views with weight bearing views. In case the patient is able to mobilize or able to weight bear through the leg, you can get a weight bearing view and that will show you whether again the fracture displaces, like you can see here where the talus shifts laterally and you have much more clear space medially than you do superiorly, which is an indication of instability. Ok? Or whether everything stays where it is. And that indicates that this is a stable fracture where you can uh be more aggressive with mobilizing the patient treating them conservatively without having to worry too much about displacing and having to go back in for surgery. Later on, you need to also get full length tibia radiographs. OK? So you need to be able to look at the proximal fibula. When you are assessing these injuries. Here, you have a large medial, clear space much bigger than the superior clear space indicating that you have an increased space or increased distance between the distal tibia and the distal fibula, which means there's a damage to the ligaments here at the syndesmosis. OK. Now, this is part of an injury called the meno injury where you have a proximal fibular fracture around this area here around the neck of the fibula. If you can see those, if you see those two things, OK. If you see a proximal fibular fracture, somebody complains of pain around the proximal fibula, you need to x-ray the ankle. If somebody comes in with pain around your ankle and you can't see a fracture here. But you're worried that uh they might have torn their syndesmosis for always get weight bearing views and get full length tibia radiographs. So you can take a look at the proximal fibula and see if there is any fracture there. We will also talk more a little bit more about the other x-rays uh for uh different injuries that you get. So hopefully that will help. Let me know if your question remains unanswered in the chest and we can go back to it. OK. The next mode of imaging that you can get is AC T scan. AC T scan is a more advanced sort of x-ray in my, in the way I see it, it's a 3d x-ray. It gives you better views and different uh uh cuts. So you get coronal views, you get sagittal views and auxiliary views and all of these give you a better idea of the fracture that you're dealing with. Now, it's not an indicate there's not an indication for when you get an A AC T scan, not every ankle fracture requires AC T scan. OK. The more complex the fracture is the more detailed information that you need in order to be able to make a correct decision. And the best way to go about that is then look at, you know, what are the more complex injuries. Trim mae or ankle fractures are quite complex. OK? If you have a large posterior malleolus fr fragment, which I'll explain again in a little while, you need to get a uh AC T scan. There are now uh basically papers that are coming out saying or expert advice that is coming out saying that AC T scan is indicated for any posterior maus injury. Um and also uh for injuries that are a little bit more occult. So if you have everything says that there's a fracture, but you can't see clearly on the x-ray and you want to make sure ac T scan can be indicated for that as well. But if you have a fracture where you, that you can't see very well on an x-ray, I would be more aggressive and treat that conservatively unless there's a reason for you not to, you know, to choose not to anyway. So, primar ankle fractures for operative planning. So you can choose, you know, your poison, how you're going to treat this fracture, how you're going to put the bones back together, supination, abduction injuries because you have a large area of an intermedial uh impaction of the tibial plafond itself. So you're fracturing into the joint and you need to assess how much of the joint is implicated in this fracture and how much uh the the articular cartilage has has been damaged. So, you know how to go about fixing these as well. Ok. Supination, abduction injuries. For those of you who don't have a great background of with orthopedics is uh a specific type of injury where you would w where you ha excessively invert your ankle joint. And so the talus will drive into the medial malleus impact into it and drive upwards and cause this vertical shear fracture. That is usually it, it's, it's something that, you know, you see and you diagnose a supination abduction injury that way. Ok. It can be quite an aggressive injury and it can involve a lot of the joint. So if you have any fractures that extend into the tibial plafond as well, that's another indication for AC T scan, axial and sagittal views are very useful when you're looking at the posterior modus to assess how much the injury extends into the joint and how to best treat it. What bits of bone in the tibia, the distal tibia and the distal fibula are implicated in this fracture. Uh The findings like I said, the size and the shape of the post of your mouth. And if there's any entrapped loose fragments that are within the joint that you need to fish out before you put the bones back together and you don't have as much access or whether there's any com uh within the uh the fracture that you have not appreciated that will change your decision making. Ok? Uh Some studies say that up to 50% of cases have a different uh or have a change in operative management. Uh After getting a CT scan from the one that was originally planned before the CT scan and these are the different views that you can get. So uh this, this is a 3d reconstruction of an ankle joint fracture showing uh extension into the tibial plafond with this uh anterior tibial fragment that goes with this. If anybody can tell me what's the name of this uh fracture there? Uh Yeah, you get brownie points and this is the uh s views looking at the poster value fracture and these are auxiliary views looking at the uh ankle fracture, sorry, poster this fracture as well. And you can need that. There's quite a lot of extension. Uh and that would change your management, whether it's going to be just screws or whether you put on a plate as well. OK. Finally, let me use their MRI scans. MRI scans are useful to evaluate the soft tissues across the structures and patients who have a lot of pain don't have a fracture and you need to evaluate for soft tissue injuries like deltoid injuries, syndesmotic injuries. So this is a a deltoid injury here. OK. And these are syndesmosis injuries, lateral complex injuries, peroneal tendon injuries or leads of the talus. So, cartilag fragments that are stuck within the ankle joint itself. Any questions so far? Are you sorry? Um There's someone who's asked um if you could explain Tri Mao the fractures. Yes, we're going to speak about that next. Uh Just please let me know if this is too, if this is too fast or too advanced or if it's too slow or too basic. Just let me know and I can change my paces uh or the depth of the talk as we go along. Of course, for the next fracture, for the fracture that you just showed. Someone's asking if it's a T fracture. That's right. That's a telos Chappel fracture. Well done. Very good. So, classifications of fractures. OK. We can start talking, we can start classifying according to a fracture configuration, the fracture configurations can be isolated, malleolar fractures such as this one. This is a medial malleolus fracture. OK. Medial mellitus fracture. You can see it's on the medial side of the foot. It's here. This is a transverse fracture. OK? Which means it's an avulsion fracture. Avulsion fractures are typically transverse. This is different from a shear fracture which is vertical as I've just described. OK. The problem with those fractures is that a they have a poor blood supply because they're most distal in the tibia. OK. They also have strong surrounding soft tissues that can be transposed in between the bone fragments by transposed, meaning the soft tissue can stuck between the bone fragments. So the way I like to think about bone healing in simple terms is the way we say a word that we use for healing is union you cannot unite two things that have a big uh space in between or that have an obstructing structure in between. So you cannot unite people that are at the very di different parts of the world. And you cannot unite people if you have a wall in between them. So you have to remove these obstructions. OK. So this is why with any fixation, we aim to bring the bones very close together or, and we aim to remove anything that would be obstructing the bone healing. And in this case, that would be the uh soft tissues or the periosteum. OK. These if they're isolated, can be treated nonoperatively. In some cases if they're displaced or if the uh for example, the patient is young and active and needs to go back to function quickly, then you can use a lax crew compression uh or a plate in ant mode or tension band wiring to bring those two bone fragments together and promote healing. And this is all done via medial approach to the uh to the ankle. So this is the medial values. Next we've got again in the same uh uh vein of unal fractures. This is a lateral mallus fracture. OK. There is no fracture here in the tibia, the whole tibia is fine but you can see the fracture here and the distal fibula. All right. So let me those fractures. We use the classification to, to classify those or uh and paint the picture uh to whomever the person is that we're talking to. So we'll talk about the we classification in a small while. They are, they have sometimes associated syndesmotic ruptures or tibial avulsion like the el fracture that we've just uh had a look at or what's the other, what's the opposite fracture to a ello fracture? So, a fracture of the anterior uh fibula that comes with the syrup. Let me know in the chat if you know that one as well, the talocrural angle is the ankle between is the angle between the uh basically the base of the ankle joint. So if I draw a line along the axis of the long axis of the tibia, and then I draw a line extending from the tip of the fibula to the tip of the median malleus, a line that extends that way and I measured the angle between the two axis that's called the talocrural angle. The talocrural angle has been described classically as the angle that you need to use in order to see if you've restored the correct anatomy of the fibula and corrected the shortening that happens to the fibula when you're fixing it. OK. Studies have shown that it's not very reliable uh as an indication of whether you've of your corrected defi or not the correct de fibular length uh or not. Uh However, it's something to be aware of because it will be something that is about in meetings or in you know, in theater. So the tailor, what is the tailor cruise running? Sorry about the san outside. It's just quite warm and uh I have to have a window open. Uh Next. So the treatment options for that is non operative management. You can treat it uh without an operation in case you have a young well functioning patient, but the fracture is stable, it's minimally displaced and you've done your stress views. You can see that the fracture is displacing. Then you can choose operative man, non operative management. If the fracture is displaced, you have large medial space, like you can see here and the tail is shifted laterally, then you need to consider fixation. And that can be using a lag screw, lax screw with the neutralization plate overlying. So with a plate and screws along with the lag screw as well. So uh for the people who are, don't, don't have a best uh background in orthopedics, these are ways to fix the fracture. Essentially, it's operative versus non operative management. We if, if we get another chance to meet, hopefully in the future through uh metal's effort, we going, we can talk about different modes of fixation. OK. Um And finally, all of that can be done via the lateral approach to the, to the fibula. So whether it's uh more distal or more proximal, it will be more or less the same approach. Last one of the unal fractures is a posterior mallus fracture, the posterior mallus can be contributing to the joint. So it can be articular or it can be extraarticular, meaning it's a small fragment that doesn't really contribute to the joint. The reason we talk about the joints and we say whether the fracture is within the joint or outside is because the joint surface is a weight bearing surface that has to be smooth. If you can imagine, uh for example, if you have a uh crystal or glass ball, if you're rolling it on very, even very smooth ground, it will run perfectly. If you're rolling it on very rough ground, it will break and it will shatter and it will chip and it will not run smoothly. And a joint that does not run smoothly is a very painful joint. That's how you get arthritis in some cases. And so you have to be aware of whether the fracture is within the joint or outside the joint. If it is within the joint, then you have to be aggressive with your treatment. And we want to restore the joint to its natural anatomy as much as possible. Of course, depend of course, depending on the severity of the fracture. The uh the poster mellitus fractures can be uh have classically been classified according to the size of it or the amount of involvement in of, of the poster fragment into the articular surface. So if it's less than 25% it's not significant, you don't need to fix it. If it's 25% or more, then you usually need to fix it. And the ways to fix it can be again through a plate uh or using screws uh or a combination of the two. OK. There's a recent classification called the Mason Malloy classification looks at the configuration and the size of the posterior uh malleolus fractures and uh then gives you a better idea of how to best fix it. I suggest people who are uh studying orthopedics or uh or, or, or on the ways to become surgeons to take a good look at that. It's very useful in the decision making and the, the ways to see it is through something called the double contour sign where you see a uh sort of and I've got an x-ray for it that will come up in a little while and I'll show you or a Misty Mountain sign. So I'll talk to you about the double contour side and the Misty Sound Mountain sign shortly. Now, if you don't have you, you can have in this picture a uh an enlarged medial clear space. No, no, uh sorry, enlarged, medial clear space that is much bigger than the superior clear space. You have very little overlap between the distal fibula and the distal tibia or no overlap. In this case, you have a talus that does not look like it's sitting underneath the tibia. This is a syndesmotic injury since most injuries can be associated with meal fractures. So what you need to get is you need to get a full tibia view. Look at whether there's any proximal fibular fracture that comes with it. Like I said, increased, medial clear space, increased tibiofibular, clear space. And uh this is usually an indication for surgical management. Unless the patient is unfit for surgery, you want to make sure that the two hands are closed together, they're connected to the, to the body and can hold the box in place. So if you have no ligaments that are holding the two bones in between, every time you weight bear the space between them, increases the talus strives upwards and it's very painful for the patient and will most definitely cause severe arthritis within few months that might result in the patient, uh being unable to weight bear or requiring further interventions that are quite severe such as an arthrodesis or uh an arthrodesis is joint fusion. Now moving on to more complex injuries, these are bi bimalleolar fractures, bimalleolar fractures, as we've described with everything else, they can be stable. Ok. What you need to get is you need to get a mort's view for any of these fractures. And if you see them, you think they're stable, you want to be sure, ask for stress views, gravity, stress views, weight bearing views or uh manual stress views and see whether the fracture is moving, whether you're having increased medial, clear space and if that's the case, then you need, you know, you know whether to fix it or not a tri maar ankle fracture is a fracture of all three structures that we've talked about. Plus a syndesmotic rupture. So you the medial mallus is gone, the lateral malleolus is gone over here. You can see the double contour sign, ok? You see you can see an increased contour around the distal tibia. OK? That should not be there. That's the posterior malleus fracture. OK? And you have a clearly, if not dislocated, it's a sub luxated joint with gross deformity. Ok. So a it's a severe fracture. B it involves all the, all the joints of the, of the ankle joint and uh three, it's a fracture that is unstable and that's proven on the patient's presentation and on the imaging. Ok. So the management for it has to be surgical. It's a higher trauma. You need to get a CT scan to assess how you're going to fix it. You know, it's unstable. You know, there's a higher risk of the syndesmosis being ruptured with all of these structures being broken and the amount of force that has gone to the ankle, the ligaments are bound to be damaged as well and the way to fix it is usually through open reduction and internal fixation. Through a combination of the various options we've talked about before for the for the different Metula. So you can fix the medial maus for example, with a lag screw or two, you can fix uh the distal fibula with a lag screw and a neutralization plate. And then the posterior malleus, you can place some screws or an antique plate or you can have different variations of different things, for example, uh around this uh or to treat this fracture. So this is what a trill fracture is. And unless the patient is very elder, elderly and very frail and not su suitable for surgical intervention, you will treat them with an operation if a patient is flaring elderly but can survive an anesthetic. There's another option called the hindfoot nail where you do intramedullary nailing through the calcaneus into the talus, into the tibia and you hold it all together with screws and that's a way of joint fusion that will help the patient mobilize. So they don't die of all the complications of being in bed without having massive surgery with large open wounds. Is that all clear? So far? Any questions so far? None so far? Ok. Now, the web classification classification that we've talked about, it pertains to the lateral malleus fractures. Ok. Dennis Webber was an orthopedic surgeon who described this uh I think in the early 20th century and he talked about the different uh types of or different configurations of lateral meus fractures that you can see. And he used this configuration to decide whether this is uh what mode of management or how to best manage these injuries. These are the Webber A Weber B and Weber C ankle fractures. Sorry, this is mislabeled. So it's Webber A B and C Weber A is below the level of the syndesmosis. So if you look here, the fracture extends below the syndesmosis. It does not go into the syndesmosis. OK. So it's a fracture of the fibula distal. It's a stable fracture pattern because the box is still within the two hands. Only the tip if you get, I think the way you think of it is like the tips of the fingers are broken, not the whole hand. And so the box is still intact and in place, the way the to best manage it is conservative management in a boot and to mobilize the patient for the weight bearing. Ok. Now, moving on, you have the Weber B ankle fractures, we b ankle fractures extend into the liver into the syndesmosis or their fractures at the level of the syndesmosis because they're higher up. The talus can shift laterally or medially because it doesn't have any bony constraints. And so these can sometimes be stable as we've discussed before. They can be unstable as well. And based on their stability, you will decide whether to fix them or not. OK. The best way to assess for stability in case the x-rays, the mortar view looks happy is to get stress views. OK? I'll just keep repeating myself about these things because this is the way think it's sort of an algorithm. OK. Finally, we've got the uh Weber C ankle fractures and these are proximal to the level of syndesmosis. Please let me know in the chat if you can think of a type of Weber C ankle fracture that we've already discussed today that we can uh that, you know, we have to have surgery as well. OK. So which type of Weber C ankle fracture did we already mentioned today? So it's proximal to the level of the syndesmosis. It's an inherently unstable fracture because there's nothing connecting the two hands, holding the box together. It's associated with syndesmosis injuries and can sometimes happen with medial nis fractures, deltoid ligament ruptures. And it's an absolute indication for surgical intervention because it inherently is an unstable injury. Ok. Now, there are some variants of ankle fractures that we uh that we see the Bosworth fracture dislocation is a rare type of fracture where the distal fibula becomes lodged behind the distal tibia and will not produce. And you do, we, you can't reduce it in the emergency department. No matter how hard you try, you have to do an open reduction of the fibula and turn it back to the original position and usually you will fix it in the same in uh same setting unless there's something that will stop you from doing that. There are carps, stone fractures where you trip and you land awkwardly on the tips of your toes and you have an a vulg and fracture because of the increased pull of the posterior tibia and uh basically get a fracture. So you're at the, if you imagine you're going over a curb, ok? And this is your foot, you put your toes on the curb, but you trip backwards, the pull of the uh ligaments and the muscles in the back will cause the posterior tibia to fracture. We've talked about the T Chapo fracture at the, at the end. And the opposite of it is the LeFort wax staph fracture, which is an anterior inferior tibiofibular ligament, a vulg off of the anterior fibula. OK. So the LeFort, LeFort is a fibular fracture. The te lo is a tibia fracture. Ok? I hope that makes it easy. Finally, there are complications that happen with every injury that you will see every fracture has a complication. The more common complications are nonunion, especially in the medial matu fractures. For the reasons that we discussed being uh poor blood supply, transposition of uh fragments as uh transposition of soft tissues maun meaning the bones don't heal well. A because you tried to do an operation and you didn't put the bones back together correctly or b the, you tried to close reduction and the patient healed in a position that is uh not very well reduced neurovascular injuries. So, we've discussed where the neurovascular structures are and how to best avoid them irritation due to metal work. The area, especially around the distal, the the lateral malleus and the media malleus is very bony. You have very limited skin around that a very limited soft tissue to cover the plate. And a lot of patients come back saying, oh, the metal work is bothering me, I can feel it or it's bothering me on my shoes. And that can be an indication for removal of that metal work arthritis with any joint fracture, you can get arthritis stiffness. These patients will be in plaster for a long time and they can become very stiff. That's not the end of the world. You have a stable ankle, the stiffness you can work through over time with physiotherapy and exercises. Finally and very important are thromboembolic events. Thromboembolic events like DVTs and uh pulmonary embolisms are quite prevalent with ankle fractures or ankle injuries when they're not. Uh when you don't give the patient the correct anticoagulation, it's very more important to be mindful of that because this can be life-threatening for a patient. So giving the patient Delta and for example, or uh Rivaroxaban, it depends on where you are, what the guidelines where you work are. But it's very important to remember to give the patient uh the anticoagulation medication to avoid these events due to their reduced mobility and uh and limited function. And that is it. Please let me know. Do you have any there, are there any questions would you like me to go over anything again, I'll let you know, um, when people type questions in the chat as of now, there aren't any. Ok. He did. Uh, did you feel like you are more confident, uh, looking at, uh, x-rays, would you like me to go over anything again? I'm just sending the feedback form in the chat so that people give you feedback for your talk. And if I could just encourage everyone to ask questions if they do have any Lily. And I think uh the topic will be uh has been recorded and will be available to review. Uh Also, we have done a, I've done sort of very similar uh discussion to that to this uh through east of England orthopedics page. Uh We, so everybody, you are very welcome to attend the weekly teaching sessions uh via the uh uh east of England Organization uh for orthopedics. We are running weekly sessions every Tuesday from seven pm to nine pm. Uh Greenwich time and we discuss orthopedic topics at the level of the final year medical student and the junior um junior doctor. We are hoping to go through all of trauma. So, so far, we have discussed introduction to fractures, uh biology of bone healing, ankle fractures, um uh Diapy tibial fractures, tibial plateau fractures. And we've also discussed humeral injuries for both proximal Diapy as well as distal fractures. And this is available to everyone every week from seven pm to 9 p.m. So if you uh follow in east of England orthopedics. You hopefully will have access to that. You are more than welcome. Ok, I'm not seeing any questions. Thank you very much for having me. I will and uh I hope to speak to you all. Thank you so much for coming. It was an amazing talk. Thank you very much, much appreciated.