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Orthopaedic X-Ray Interpretation - Foot & Ankle
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Orthopaedic X-Ray Interpretation - Foot & Ankle
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Segment:0 .
FIRAS ARNAOUT: Good evening, everyone. Welcome to this evening of orthopedic teaching. The 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.
FIRAS ARNAOUT: And this is just a continuation 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 7 o'clock, you'll be finished. Very important always in all our sessions to be interactive.
FIRAS ARNAOUT: So please, if you have any questions, any doubts? Please write them in the chat box and we will not leave today until all your questions are answered. We'll ask you to fill out a feedback form and you will automatically get a certificate and of course we will try obviously to make this recording available for you, obviously free of charge as part of your registration.
FIRAS ARNAOUT: My name is Firas Arnaout and I'll be hosting this event and we're very proud to be hosting this for the first time ever on medal. And I'm very honored that speaker for our first major event is Nikki Evans, who is our colleague, orthopedic surgeon, and she is one of the founders of Orthopedic Academy, and she's been educator with us for a long time.
FIRAS ARNAOUT: And she's taken on today the topic of radiology 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 throughout the presentation. Over to you Nikki.
NIKKI EVANS: OK thanks very much Firas and welcome, everyone. So what I'm going to do is just go through the radiology of the foot and ankle and maybe some common conditions
NIKKI EVANS: 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 AP 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 talus.
NIKKI EVANS: So this saddle shape here is the talus, also known as the talar dome. 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 mortise view for that. But what we can see on this view is we've got the lateral process of the talus down here.
NIKKI EVANS: We've got the distal end of the tibia or the fibula, sorry, also known as the lateral malleolus. On the medial side, we have the medial malleolus, which is the distal end of the tibia. 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 plafond because it's flat or tibial
NIKKI EVANS: pilon and again, just describing the way that it sits in the mortise of the ankle joint. 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 in this X ray, we've got a double shadow for the talus here and here.
NIKKI EVANS: So the medial lateral margins of the talar dome are 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 talus, in particular the subtalar dome, which comes around here.
NIKKI EVANS: We've got this indentation here, which is the talar neck and then we're going to come on to the anterior process. This kind of rectangular bone here is the navicular. And this one here is the calcaneus and the joint below the talus between above the calcaneus. This is the subtalar of joint. The joint that we're seeing here is the subtalar navicular joint.
NIKKI EVANS: And we go further down. This is going to be one of the inter-metatarsal joints. At the back here of the talus, sometimes you can see a little projection, which is the posterior talus, posterior process of the talus, 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.
NIKKI EVANS: 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 talus. 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.
NIKKI EVANS: You've got the area between the tibial platforms and the talar 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 ligament injury, then this clear space should be symmetrical on all sides. There is always a little bit of overlap between the tibia and fibula here. And this is the tibia subtalar ligaments, which constitutes an anterior posterior and a middle component, also known as the ankle syndesmosis.
NIKKI EVANS: OK, we've got lateral ligaments from the distal end of the fibula to the talus and also to the calcaneus calcaneleal. So that's a lateral ligament complex and on the medial side, we have a deep and a superficial deltoid ligament. You might see somewhere that if this space is greater than 5 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 ankle fractures.
NIKKI EVANS: 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 an AP. So, you're going to look for this rounded bit here, which is going to be the anterior process of the talus. And that is going to articulate with this kind of rectangle here, which is the navicular.
NIKKI EVANS: And here we see it on this side, on the lateral side, at this level, you've 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 distal to that, you've got the cuneiform forms 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 cuneiforms.
NIKKI EVANS: 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 slot for the base of the second metatarsal to slot into and then you go along the lateral down to the cuboid all right.
NIKKI EVANS: And there's an important ligament that 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 3 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.
NIKKI EVANS: So then we come to the metatarsals, here we go, the first one is easy to recognize because it's the biggest. Then we've got second, third, fourth, fifth, and they're going to go on to the phalanges of the toe. So the toe, like the thumb, you've got a proximal and a distal phalanx and then you've got proximal, middle, and distal for all of your lesser toes.
NIKKI EVANS: And there we go, there they all are. OK? Sometimes it can be very difficult to see a fracture in the foot, which is why we use CT scans a lot of the time to give us a clearer anatomy, because if we look at the lateral, the lateral of the foot is quite good. If you're looking at the ankle joint like we see. Here is one with the posterior process of the talus here.
NIKKI EVANS: We've got our talar dome anterior process and talus, we've got our calcaneus here and then we're going to look at the navicular which is here and then we're going to move on to the middle cuneiform and then we're going to 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? If there's any disruption of the talar navicular joint or the subtalar joint, if there's a Lisfranc fracture dislocation, which involves the tarso, metatarsal joints of the foot, what you might see and we've got an extra INAUDIBLE and this will be sitting asymmetrical.
NIKKI EVANS: The calcaneus, which is this bone, we sometimes get this axial view of the calcaneus, particularly when we're looking for fractures and it's done as a kind of axial view in order to see 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 calcaneus cuboid joint, often we use a CT to give us a better idea of what's happening there.
NIKKI EVANS: 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 a mild ankle sprain, which would be usually a tearing of the calcaneus fibular ligament or the anterior talar fibular ligament to something really nasty, also known as a tibial pilon fracture.
NIKKI EVANS: 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 and middle and a posterior part to this. The posterior part of it is the strongest and often you can pull off the posterior part of the tibia if that ligament is very strong.
NIKKI EVANS: So we're going to look at the ankle. This is also known as the syndesmosis. This is important when we start to look at classification of fibular fractures. So we're going to keep an eye out for this area here. The interosseus ligament runs from above the syndesmosis between the tibia and fibula almost all the way up to the neck of the fibula.
NIKKI EVANS: Now if you have something called amazer 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 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.
NIKKI EVANS: Here we have the medial malleolus, we've got a superficial and a deep deltoid ligament. They attach to the talus, and they're going to maintain our talus within our ankle mortise, if you like. OK, so there's some ligaments. Let's have a look. So this is the Weber classification of ankle fractures.
NIKKI EVANS: 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 syndesmosis and the rule is below the syndesmosis is an A, at the level of the syndesmosis is a B and above the level of the syndesmosis is a C. Now, when we say the level of the fracture, what we mean is the most distal part of the fracture.
NIKKI EVANS: So if you've got a fracture line that's starting up here, but it comes down to here, that would be a B. All right. So normally we look at the diagrams. We've got our syndesmosis, our lateral ligaments and our deltoid ligament. Here it's normal. It all looks nice. There's a good space. In a Weber A fracture, we accept that the ligaments are probably intact because your fracture goes through here
NIKKI EVANS: so it's below your syndesmosis. 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 syndesmosis and sometimes they don't. So we have to make a judgment call based on clinical findings and other radiological findings, and we will have a look at some of those.
NIKKI EVANS: The question is whether there is the, the integrity of the syndesmosis is intact, thereby 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 Weber C is relatively straightforward because they're above the syndesmosis. The syndesmosis is gone.
NIKKI EVANS: They can be quite dramatic. The ankle might be dislocated. And on this view, you've got a fracture of the medial malleous here but alternatively, you could have no fracture and disrupt your superficial and deep deltoid ligaments. These are nearly always unstable, and you nearly always need an operation. So A, we don't need to operate on, C we do need to operate on and the ones in the middle, we have to make a clinical judgment.
NIKKI EVANS: So let's have a look. So this is a Weber A fracture. They're usually transverse. So here's one here. Sometimes it's a medial malleolus fracture, usually a transverse at the same level. And the ligaments are usually intact. The, if you look at the mortise view, here it is.
NIKKI EVANS: Our clear space is fine. And they're usually stable so we can treat them, depending on how much pain the patient's in, we can treat them in a walking boot or we might put them in a backslide for a couple of weeks to let the pain settle down and then let them go into a boot, start walking. And as we can see, our syndesmosis is going to be in this area here
NIKKI EVANS: so we're below, we're transverse, our joint space looks fine, our ligaments look intact, we don't need to operate on this patient. Let's have a look at a B OK? So these are the typical kind of configuration that you see with a B fracture. If you look, the fracture line goes into this area, which is the syndesmosis. 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 talus.
NIKKI EVANS: What we can see is that there's probably a little bit of space 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.
NIKKI EVANS: So this is one that we are going to examine carefully, and we may do some more x-rays or we may decide on clinical examination this is one that should have fixation. 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.
NIKKI EVANS: So this one also has no 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. On the lateral this doesn't really, it doesn't give you a lot of information, but you can see that the ankle joint is located.
NIKKI EVANS: And if you look at the overlapping fibula, you can just see the tip of the fracture there, existing posteriorly, which is what they normally do. So we move on to a Weber C. So this is a Weber C fracture. Above the level of the syndesmosis and if we look at the distance between the tibia and the fibula, it's wide. OK? It's, that syndesmosis.
NIKKI EVANS: 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, which often happens. So your fibula fracture is above the level of the syndesmosis. Here is it's a Weber C type fracture. You've got widening of the ankle syndesmosis also known as dire stasus, which means the two bones have come apart.
NIKKI EVANS: And in 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 its nice dome. And here is the subtalar 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 closed reduction to reduce the whole fracture
NIKKI EVANS: 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 Maisonneurve fracture. So these are the ones when I talked about that interosseous membrane that goes between the tibia and the fibula for the whole length and how a simple X-ray could lead you down a false path.
NIKKI EVANS: So if we were to 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 oh, I can't see a fibula fracture. Well, the answer is you need to look further up. So this is an ex 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 OSHA's ligament, through the syndesmosis and out through the medial ligaments, namely the superficial and deep deltoid ligaments.
NIKKI EVANS: 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, get some kind of fixation across the syndesmosis to reconstruct this 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
NIKKI EVANS: so we have to open the medial side and actually pull out the deltoid ligament and often the deep is gone and the superficial can remain intact. If you've got a superficial and you reconstitute the syndesmosis, 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 A0 classification, the Lauge-Hansen classification.
NIKKI EVANS: I mean, I don't think it's particularly useful because the Weber classification is simple and it guides treatment. And if you talk about it, everybody knows what you're talking about. The LaugeHansen, it's nice because it explains how you get the different patterns of injury, basically as you. supernate and aduct you go
NIKKI EVANS: lateral ligament or lateral malleolus and then you go round till you get to the medial side. And again 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. And again, the AO 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 AO classification, it's either extra articular, partial articular or intra articular, you know, and most of you are going to be in the type-a
NIKKI EVANS: so that doesn't really help either. So what do we do? So we've got the Weber, the Weber A. That's usually going to be a boot. And we're both tolerated. We've got the C, which is usually going to be surgery and non weight bearing and then we've got the Weber B's and we need to determine whether they are stable or unstable.
NIKKI EVANS: And you can do a stress view 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 Weber C, because you can see the fracture up here. So I'm not sure why they've done a stress view on this, but there you go.
NIKKI EVANS: And what this one, this is what we would do in the operating theater with the patient asleep. I think this would 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.
NIKKI EVANS: And in this case, it does. If you compare that distance to this distance, you can see it's a lot wider. This would be unstable. Here's a Weber B, 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 talus drops with the distal end of the fibula.
NIKKI EVANS: 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 bear. And when they wait bear if the tibia and fibula have got an injury to the syndesmosis, then what you'll find is on weight bearing
NIKKI EVANS: there will be an increase in the gap between the tibia and fibula and you may see increased medial joint space, but you're looking at the gap between the two of them, and in fact 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 weight bearing views after a week and it actually opened up a little bit.
NIKKI EVANS: 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 view was quite remarkable, just the weight bearing and it showed that the ankle mortise, the ankle joint opened up quite a lot. So they are useful.
NIKKI EVANS: How do we fix them? So here we go, we have here, we've got a Weber C fracture Sorry a Weber B fracture down here. We've also got a 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.
NIKKI EVANS: And you haven't disrupted the deltoid ligaments, but you've fractured the medial malleous 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.
NIKKI EVANS: So if you have to try to imagine this in a 3D, but if you reduce the fracture and the fracture lines 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 fix the medial malleous on this side, usually with two screws through there, and then we test the stability of the syndesmosis.
NIKKI EVANS: And if there's any concern, then we put what's called diastasis screw in, which is one that goes from the fibula into the tibia. Some people use two, 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.
NIKKI EVANS: We keep them non weight bearing for at least six weeks until the fracture's 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 they're causing any symptoms.
NIKKI EVANS: So, you know, I've got a patient that is about six months after having fixation for a fracture very similar to this. He does a lot of hiking and what he can feel is clicking and grinding. And that's probably because the screw is not broken yet, but it may be that holding these two bones together and then allowing your foot to do dorsiflexion and plantar flexion if you're climbing up and down hills might give you some restriction and some discomfort.
NIKKI EVANS: So here's someone that we are going to remove the screw for, but it's usually on a case by case basis. So the other end of the spectrum are these tibial profond fractures, tibial pilon fractures, distal tibia fractures. They're usually quite bad. 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.
NIKKI EVANS: 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 external fixator on, and then you want to try and reconstruct the joint surface as much as you can
NIKKI EVANS: 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. OK so here's the first question. I've got this X-ray here. We've got a 23-year-old female who falls down the stairs and complains of a painful ankle.
NIKKI EVANS: So your X-ray shows and you've got some options: a fibula fracture, a tibia fracture, a Lisfranc injury, talar shift prompting further investigation or is it a normal X ray? So what we're looking at is an x-ray of the ankle and we can see here's the distal fibula. There's no fracture here. We're looking at the distal tibia. We can't see a fracture there.
NIKKI EVANS: Lisfranc injuries in the foot that we 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 and 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 at further investigation and what do we need to look for?
NIKKI EVANS: 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 and x-ray the whole of the tibia and fibula. So the correct answer is talar shift prompting further investigation. OK, we'll move on. So I'm just going to talk briefly about these because the fractures was the main one I wanted to talk about, but ankle arthritis.
NIKKI EVANS: Here's some ankle arthritis, it's got the typical features of arthritis. You've got joint space narrowing, sclerosis, sub-chondral 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 in the western world
NIKKI EVANS: and the classic features of Charcot are that you get fragmentation, bone destruction, dislocations and a very abnormal looking X-ray. So if we look here. You know, our distal tibial joint is more or less gone, it's collapsed. There's no end of the fibula and there's all these kind of areas of where the bones fragmented.
NIKKI EVANS: Could this be infection? Yes. 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. So I haven't gone through the Salter Harris classification because it was covered in one of the other lectures.
NIKKI EVANS: 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. Our fibula fracture is up here. So we've got a distal fibula fracture. And if we look at the tibia, we've got the epiphysis here with the medial malleolus, we've got this metaphyseal fragment here and our fracture line has gone through here and through here
NIKKI EVANS: and here's the other fragment. So the ankle has gone into valgus. You have a metaphyseal triangle of bone attached to your epiphysis, which makes it a Salter Harris, two. 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.
NIKKI EVANS: So a couple of fractures that are particular to the pediatric population and the first one is the triplane fracture, which is usually happens in roundabout 12, 13-year-olds. And it's because of the way that the growth plate fuses so you don't get this kind of appearance in the younger children or in the older children. It's only really this particular age group, and it's called a triplane, because the fracture is in 3 planes.
NIKKI EVANS: So you have on the lateral, you have the fracture, which is metaphyseal, which is similar to a Salter Harris two. So you've got a triangle of bone, you have a fracture below the growth plate in this plane, which is here, which is similar to a Salter Harris 3 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 epiphysis.
NIKKI EVANS: And the best way to visualize these is on a CT scan. So if you look at the CT scan here, you can see this part, the equivocal part of the fracture is there. So you've got a gap of about 3.3 millimeter there. You've got this component of the fracture, which again is a Salter Harris two, 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.
NIKKI EVANS: So these usually, depending on what they're like you usually need to reduce them, usually because if you have a step or a gap in the joint surface, you want to try and correct that. So if it's only one or 1 to 2 millimeters, you may be able to get away with not 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
NIKKI EVANS: which is known as the Tillaux Fracture. And it's this component here. So, because the growth plates and we're looking at the growth plate here, the growth plate fuses from medial which is here and then it goes around the back post area around here. And the last part of fuse is the anterolateral part of the distal tibia.
NIKKI EVANS: So what happens in a Tillaux fracture is you've got more fusion of the growth plate than you do in the 13 year old's. So you don't get the triplane, 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'd get a syndesmosis injury. In a younger child, you'd get probably a Salter Harris 2 type fracture.
NIKKI EVANS: But in this age group, which is usually a little bit older than the triplanes, you get this Tillaux fracture. When do we need to operate on them? When there's a step or a gap in the joint surface of 2 millimeters or more. And again, 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.
NIKKI EVANS: What does this x-ray show? Does it show? A Tillaux fracture, a triplane fracture, a Salter Harris one fracture of the distal fibula, a Salter Harris three fracture of the distal tibia or a Salter Harris two fracture of the distal tibia and a fracture of the fibula. So E is the correct answer. So why is it not a tilleaux or a triplane?
NIKKI EVANS: Well, the kid's seven. So if we remember, the triplane is round about 12/13 a Tillaux around about 13/14. And because of the nature of the way that the growth plate fuses this kid's seven so his growth plates are wide open. So that rules out A and B, nobody picked C, which is great because it isn't. Salter Harris three fracture of the distal tibia. So Salter
NIKKI EVANS: Harris 3 is one that is through the epiphysis rather than the actual metathesis. It's really epiphysis through this part. So it's not that one. So it's a Salter Harris two, because we have this metaphyseal fragment of the distal tibia. So it's a Salter Harris, two fracture of the distal tibia. And we also have a fracture of the fibula up here. So well done everybody that got it right.
NIKKI EVANS: OK, so the next ones can be quite complicated. I'm going to try and make it simple and don't overthink them too much because the talus and the calcaneus and a lot of the foot things, we will do a CT scan to get 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,
NIKKI EVANS: so that's what you might come across in the emergency department. So let's have a quick look. Right, now so The talus is a complicated bone, all right? It's difficult to see clearly in plain X-rays. And CT is good for fractures. An MRI scan is good if you're looking for something else like avascular necrosis or osteochondrial lesions.
NIKKI EVANS: So it sits in here and it sits in there and it's got three joints. It's got the tibiotalar joint, which is one; it's got the subtalar joint, which is the joint between the talar and the calcaneus. And it's got the talar navicular joint, which is the joint between the talus and the navicular. If you remember, the navicular is the rectangle on the cuboid is on the lateral side and that's the cube one.
NIKKI EVANS: And we'll look at that in a sec. All right? Why are we bothered about the talus? OK? So the problem with the talus is it's blood supply and it's got this, it's a bit like the scaphoid. 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 talar neck
NIKKI EVANS: and you take out this arterial supply, you're losing the blood supply so the anterior part of the talar dome and further down here, because the supply from your posterior tibial is only going to go so far. So the talar neck fractures are the ones that we get a little bit excited about and here it is. OK?
NIKKI EVANS: Talus, tibia and fibula, calcaneus, subtalar joint, talar navicular joint here. There we go. All right. Let's have a look at some of these. Now, this is the classification system. I don't expect you to know the classification system, but it helps to understand
NIKKI EVANS: why these can be concerning, let's say. So we're talking about the talar neck here so that little indentation. So when we've got one that's undisplaced chances are the blood supplies are right so the risk of getting avascular necrosis is between 0 and 13%. A type 2 is where we have a fracture through the neck and the subtalar joint is dislocated - slightly higher risk of avascular necrosis.
NIKKI EVANS: Now we get on to the more exciting ones. So the type 3 has got a subtalar and a tibiotalar dislocation. And often with these, the talus, this part of the talus ends up either open on the road or at least out the back on the X-rays. That's that's a type III and then the type four, which is sub talar, tibio talar and talar navicular dislocation
NIKKI EVANS: and again, this fragment can be excluded out the back, this fragment can be extruded out the front and these have got a much higher risk of avascular necrosis. That says type 2 there, I'm sorry about that. It should say type III. So one, two, three, four. So one is not too bad. 4 is terrible and the other two are in between.
NIKKI EVANS: Let's have a look at some X-rays. Right, so,here we go. He's a type 4. Here's the distal end of the tibia. Here's the calcaneus, here's the navicular, and we've got the talus fractured and popping out the front. And if you look at the skin line here, this is going to be open.
NIKKI EVANS: All right. It's a type 4. This is going to have a bad outcome. Here is a type III. So we've got a fracture through the talar neck. There it is. We've got sub talar joint disruption, and we've got tibiotalar disruption as well.
NIKKI EVANS: And you can see the talar dome is actually kind of spun around where it is. He is a type I. So if we look at this one, we've got a fracture through the neck but our tibia subtalar joints OK, our subtalar joint is probably OK and our talar navicular joint is OK. Here's another one. This is type 2. So we got a fracture through the talar neck and we've got disruption of the subtalar joint, talar navicular joint is OK.
NIKKI EVANS: And this one, you can't always trust this view because it looks like the tibiotalar joint is in joint, but it can't be because we're, the anterior process of the talus is out here. It's actually come out and spun around. So the tibiotalar joint must have gone, subtalar joint must have gone, the subtalar navicular joint must have gone
NIKKI EVANS: 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 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 talus fractures and it's just a lateral process of the talus. I don't know about this country: in Australia we used to call this a snowboarders fracture because snowboarders used to get it.
NIKKI EVANS: You don't need to do anything for it. Treat it non operatively, symptomatic, maybe a boot if they've got a lot of pain and swelling over their ankle subtalar dome lesions. Again, it's only here because you might hear people talk about it. You can have medial and lateral, the lateral ones are the, sorry, the lateral ones, are the more likely to be traumatic. So somebody that's had an ankle sprain that just hasn't got any better might have a talar dome lesion.
NIKKI EVANS: 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 missing there, because what's happened is with avascular necrosis, you get collapse of the underlying bone.
NIKKI EVANS: the cartilage is over the top, and then with time and wear and tear, the cartilage will collapse as well. Tarsal coalition happens in kids. Usually the kids present in adolescence with recurrent ankle sprains. Just so you can see it on an x-ray, there's two types. There is the,
NIKKI EVANS: sorry, this one which the subtalar calcaneus and it's a C shape here. So what you've got is an abnormal connection between the talus and the calcaneus. And then you've got this other type, which is supposed to look like an anteater. 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 synchrondrosis between it.
NIKKI EVANS: Again, treatment is symptomatic. MRI scan will give you a better idea of what's actually happening but in case you come along something and someone says oh there's always a coalition, it's got a C shape or it's got an anteater. That's what it is. OK so here's another question.
NIKKI EVANS: 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 and orthopedics? Does this have an AVN rate of 10%?
NIKKI EVANS: Is the subtalar joint reduced, it 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? Back slab and fracture clinic, follow up with seven days. Oh, god, no, please don't do that. It has been done, but I'd probably say not in this case.
NIKKI EVANS: So if we look at the X rays, here's the tibia. Where's the talus? Oh, my God. It's over here. So tibia talas gone, subtalar joint is gone because it's over here, and he's a navicular so the tibia talar, the talar navicular joint is also disrupted
NIKKI EVANS: so that puts us in to a Hawkins type four, which is the worse type, which has an AVN rate of 70% to 100%. So if the subtatlar joint is reduced - absolutely not, it's gone. Urgent CT scan. It probably does. But your first thing that you're going to do is assess the neurovascular status and advise trauma in orthopedics because this is something that needs urgent reduction in the operating theaters.
NIKKI EVANS: And even if it looks open, we get this to theatre, 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 at a later stage. But it needs to be reduced. You've got three joints dislocated in the ankle. Your guy's 38, you want to get onto this as soon as you can and you want to know if there's any nerve or vessel compromise.
NIKKI EVANS: 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 talar neck fracture,
NIKKI EVANS: a tarsal coalition, calcaneus fracture. lisfranc injury or hallux valgas? It's a tarsal coalition. We're looking at the C shape. Talar neck fracture? No, not really. Tarsal coalition, yep and we've got this nice C shape. We've got all the arrows pointing to it.
NIKKI EVANS: Calcaneal fracture? Probably not. Calcaneus looks OK. Lisfranc injury. We haven't covered that yet, so it's not going to be that. And hallux valgus, we haven't gone into the big, big toe. And also, he's got a history of recurring 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 tarsal coalition.
NIKKI EVANS: Calcaneus fractures. Again, one of those things that we usually get a CT scan to better identify, there's a huge range of them, usually a fall from a height, sometimes bilateral, sometimes associated with vertebral fractures. Typical ones are quite fragmented. Go into the subtalar joint. Here's that axial view that we talked about earlier.
NIKKI EVANS: 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. The old Essex Lopresti. Top classification classified them as two. One was intra articular with joint depression, and the second one was a tongue type where the Achilles tendon had pulled off a beak of the calcaneus back.
NIKKI EVANS: And you do sometimes see them and they're relatively easy to fix, but we usually CT them anyway to make sure the subtalar joint's intact. Here's some more. So here's one going through here. So this is probably, you know, the kind that it's difficult to see. This is why we CT scan them.
NIKKI EVANS: But the subtalar joint might be all right there, it may just be this part that's lifted up and it's possible we be able to treat that non operatively or just with a couple of cannulated screws. The main thing about calcaneus fractures 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. Tarsal fractures,
NIKKI EVANS: OK again, you wouldn't be expected to know all of this, 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. Why? well, here's the navicular. This nice rectangle. And here's this.
NIKKI EVANS: Why is this not a fracture? Well, it's, it's in the tendon. It's got smooth edges. There's no soft tissue swelling 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 naviculars or little bits all over the place.
NIKKI EVANS: 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 tendon. So that is an accessory navicular. Let's look at a fractured navicular. Here's one. Is it right? Nice rectangled bone. Here's the talus.
NIKKI EVANS: And we've got a fracture through the middle of it there. Sometimes these can be undisplaced. Sometimes they can be open and usually we can treat them operatively or non operatively. Often it's operatively and we just get some fixation across here. Cuboid fractures. Remember the cuboid's on the lateral side articulates with the calcaneus.
NIKKI EVANS: Here's a fracture through the cuboid here. And here's another type of cuboid fracture, which is a small avulsion fracture at the base here. So perineum, brevis attaches here. So if you get a forced inversion injury to your ankle, you could 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.
NIKKI EVANS: OK, 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 talas, the fractured cuboid, or at a Lisfranc injury.
NIKKI EVANS: Accessory navicular, it's the X-ray that I showed before. It's got smooth round edges, here's the navicular. It looks OK. It's in the line of the tib post tendon. You know, it's not the best X-ray of the talus. You can't see the cuboid because it's on the opposite side and it's not a Lisfranc injury.
NIKKI EVANS: So here's the Lisfranc. 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 and if we look between the medial cuneiform and the base of the second metatarsal, there's an increase in this gap here.
NIKKI EVANS: That is the basics of a Lisfranc injury and here's a diagrammatic representation of it. Now, there's lots of different configurations of this, but that is the mainstay 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's your navicular and you can see that your tarsal metatarsals have subluxed off the top.
NIKKI EVANS: And here's another version of it. So here's your medial cuneiform and look where your first metatarsal is, it should be over here, but it's shifted all the way up to the hole of the tarso- metatarsal joints and ligaments have all moved to the side. This is a very nasty injury, and not only will you need to reconstruct that ligament, but you'll probably need to put some kind of fixation in to hold the rest of the tarsal bones back to the midfoot.
NIKKI EVANS: 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 callus formation. And there it is a little bit more. So three weeks later, you might start to see callus. Treatment again,
NIKKI EVANS: the treatment is just symptomatically, you just need to think about it. If somebody presents with that history. Rheumatoid foot, we're coming to the end now. Rheumatoid foot, the rheumatoid disease destroys the joints, synovitis destroys the tendons and the ligaments and you get progressive subluxation and dislocation and that's what's happened here.
NIKKI EVANS: 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 midfoot. So you get these abnormal appearances, you get this kind of rock bottom appearance, you get ulcers
NIKKI EVANS: and if you look at a diabetic foot X ray, you can see this patient's had amputation of his big toe, amputation of the little toe, he hasn't got very many midfoot changes on there, to be honest but you'd be looking for that kind of appearance. OK and the last question, if we can. We've got a foot X-ray, there you go. Does it show fragmentation, dislocations, osteolycis, fractures or all of the above?
FIRAS ARNAOUT: 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, metatarsals and metatarsal bones. There are dislocations and loss of normal alignment of the bones, loss of the joint, normal joints. Osteolycis as well as the bone has clearly been dissolved in multiple places
FIRAS ARNAOUT: but particularly around the bases of the metatarsals and the metatarsal bones and multiple fractures because the bone is fragmented, it's dissolved so it's prone to fractures. It has fractured. So well done, guys. Well done, everyone. That's great.
FIRAS ARNAOUT: So that was the last slide of this evening and that was the last question. So on behalf of the Academy and Nikki who we suddenly lost. I would like to thank you all for attending.