Good evening. On behalf of AOFAS, I want to welcome you to the third webinar of the 2021 Foot and Ankle Focus Series. Tonight's program, Forgotten Fractures of the Foot, will be moderated by Dr. Brian Weatherford. Dr. Weatherford will be joined by Drs. Jeff Marysak, Laurie Reed, Michael Givens, and Michael Swartz. You can find their full biographies and disclosures in the program document posted in the PRC. I'd like to run through a few housekeeping items before we kick off the presentations. Please make sure your speakers are turned on and that the volume is turned up. For technical assistance, you can reference the Help tab at any time. If you have any technical difficulties, your best bet is to close all of your browsers and log back in the same way you did the first time. If you experience any buffering issues, please refresh your browser. Registered physician attendees may earn one hour of AMA PRA Category 1 CME credit by completing an evaluation and CME claim form at the end of the webinar. You can find the link to claim CME in the chat tab. You will also be sent an email with the instructions following the webinar. This webinar is being recorded and will be available in approximately one week. You will be able to watch the recorded version of this program at any time by visiting the Physician Resource Center at www.aofas.org. You are encouraged to ask questions during the presentations. To send your question to the faculty, please click on the Q&A tab on your navigation column. I'll now turn the program over to the moderator, Dr. Brian Weatherford, to begin. Thank you. Thank you for that, Jennifer. First of all, I want to say thank you to the AOFAS for letting us do this sort of random esoteric topic, which I think hopefully will be interesting to you guys. Happy St. Patrick's Day. Thanks for partying with us here at the AOFAS. I'm really excited about this, actually. We've got a great group of panelists. I have the easiest job, which is to sit back and watch these people talk about injuries that I'm not sure I know how to treat. But I hope that you guys enjoy this. I think these are interesting fractures. I think we all see these. And then, you know, we just don't know what to do with them necessarily. And I think our panelists here are going to give us some great ideas. And this is a lineup of folks that really do treat these injuries and I think know a lot about it. And so I'm excited to have them tell us what to do about this. So without further ado, I'm going to turn it over to Jeff Marasek, who is trauma faculty at Cedars-Sinai, who's going to be talking to us about the joy of cuboid fractures. All right. Thank you very much, Brian. It's an honor to be here with you guys tonight. I'm Jeff Marasek. As Brian said, I am over at Cedars-Sinai. And here are my disclosures for all of you. So one of the transformative patient encounters that I had started with this gentleman who came to my office after having his femur fracture nailed by a surgeon who I respect here in Los Angeles. And it was a great nail, but, you know, he gave me one of those, by the way, doc, my foot kind of hurts too. And he had this x-ray and I was able to dig around and find out what happened. And this was his foot x-ray when he was sent out of the hospital with instructions to follow up in one to two weeks. And it really felt like we could do better than that as a group and individually. And so I don't want to see this happen again to anyone else here. And so hopefully this talk will help with that. So I want to talk about the importance of the cuboid to lateral column function, talk about stage treatment of cuboid fractures, and then talk about how to obtain and maintain reduction of the cuboid to union. So on an AOFS webinar, I don't have to tell you about the cuboid, but in case there's any residents on here, we've got sort of three main articular surfaces, two facets for the fourth and fifth metatarsals, and then one large articular surface at the calcaneal cuboid joint. Plantarly, you have the peroneal sulcus and dorsally, the EDB sits there. And Hansen referred to these as non-essential articulation. So we'd like to preserve the motion, but it's not critical. And as you can see here, the cuboid is sort of the key intermediary to the lateral column. And so if the cuboid shortens or loses its integrity, then you'll have lateral column shortening. And if your lateral column is short, that can lead to a number of different issues. So just general lateral column overload and pain, specifically pes planus, forefoot abduction, and how those two are intermixed, and general discomfort, difficulty walking in pain, and patients are not very happy. So how do cuboid fractures show this? Well, the majority of cuboid, or about half of them, are pretty benign, and we probably don't even really think of them as cuboid fractures. And these are what you'll see are classified as type one fractures. They're just small avulsions adjacent to the CC joint. But larger cuboid fractures are particularly problematic because these are often associated with other foot and ankle injuries. And when they're left untreated, it can really impact TMT complex stability, and then can also involve the lateral column plus or minus associated medial column injury. So we really got to be on the lookout and scrutinize the entire foot and ankle. Fenton proposed a classification system in 2016 that I have to admit I don't particularly use with my residents or teach them, but I think it's in some ways instructive because it highlights the different problems that you can have. And so as we mentioned, type one are these small avulsions, typically near the CC joint. Two are extra-articular, and three are intra-articular. And in their series, both of these were mostly treated non-surgically. And so as long as the lateral column is at length and the joints are stable, you can treat these non-operatively. Type fours involve the TMT articulation and instability. And so typically you'll see the fourth or fifth metatarsals create sort of a fracture subluxation dislocation, and type fives are more crushed that will potentially involve medial column injuries. I think it's always useful to set your treatment goals before you decide what to do about something. And in this case, when I'm treating a cuboid fracture, I want to make sure that the lateral column is at length, that there's no shortening, and that the TMT complex is stable. And then I want congruent CC and TMT joints. And if I can accomplish all of those things without surgery, then that's great. And we can give the patient a hard-soled shoe or a cam walker. Even if maybe these things are lacking, but the patient's a really poor surgical candidate, we may consider that. But like we saw in our example patient, we don't want anyone to be a cuboid nihilist. It's actually pretty important. And so no cuboid nihilism, please pay attention to it. Please don't allow lateral column shortening or instability. And as I mentioned, late treatment of this or salvage options for this, which could probably be the source or the subject of a different webinar, are not particularly satisfying. And so generally the best time to do something right is the first time. And that's what we want to do for these patients. So as a trauma guy who works, you know, part of the time on the bigger bones and some of the times on the smaller bones, when I see a lateral column injury like this, what I really see in my brain is a biconilateral tibial plateau fracture. And I can't think of any trauma surgeon who would send this patient out of the hospital like that. And so I don't understand why we would do it to the patient on the left. And, and so to me, lateral column external fixation is a really useful tool. And if people take one thing from tonight or maybe not the foot and ankle surgeons listening in would be how to get people out to length so that they can get to somebody who can treat these injuries. And so I look at this in a few steps. The first thing I want to do when I'm putting on a lateral column X fix is to restore the relationship between the fourth and fifth metatarsals at least provisionally. And you can hold that with some Kirschner wires or a percutaneous clamp. And then I try to mark out my anticipated incision and then place a pin in the calcaneus and then a pin across both four and five and pull length. These pins won't be parallel to each other, which is fine. You can do that, but it'll make it difficult for the patient to walk. And the patient has an associated medial column injury. You can use a transcalcaneal pin and then a pin in the first metatarsal to stabilize that. And so this is not the prettiest external fixture that's ever been placed, but I included it because you can see the radiographic signs of struggle to get that fourth, fifth pin in. And so hopefully this particular pearl will help you on most of the small fragment drill sleeves that you have. You can, you'll, if you look closely, you'll notice that there's a little K-wire hole next to the drill sleeve. And so if you sort of sound out your desired trajectory with a small Kirschner wire, one six or smaller first, along your desired trajectory, you can make sure that you've crossed both cortices of five and both cortices of four. You can then parallel that wire by using your drill sleeve and then insert the Shands pin along that drill path. And so that will get you into both four and five and keep those both out to length. So here's a patient who had, whose medial column injury was a Taylor head fracture, as well as this cuboid. And here you can see some different views and a CT scan showing particularly the CC joint injury. And then again, here we are after somebody has put on an external fixator to get both the medial and lateral columns out to length. So now it's time to talk about definitive fixation. And definitive fixation again is really about restoration of length, articular reduction. And then you want to restore the central defect with grafting and figure out some way to keep it out to length afterwards, whether that's through inherent structural stability or accessory means. So the plate that we can potentially apply can act as a washer for lagging together any large fragments. And so in trauma surgery, we want to always be compressing ABC. And so if you can lag large fragments together, that's very helpful. Otherwise again, similarly to a plateau, we can place a subchondral raft behind the articular injury to support it and prevent it from subsiding. Generally, you can bring a plate down to the bone and generate a good apposition with cortical screws and then exchange them for locking screws when applicable. So this dorsolateral incision to the cuboid is very utilitarian. You need to watch out for the sternal nerve. And again, here you can see basically restoring the articular surface by pushing it out, putting on a pre-contoured plate. In this case, it needed to be backwards for some particular reason. And lagging everything together. And then there's enough inherent stability and congruence that we can leave it unsupported. Sometimes you may need to maintain a fixator to prevent late shortening or collapse. And that's been around for a while. Hanson described that in his textbook. This is a great example from my good friend, Jeff Earhart, just because he walked through all these steps so nicely. So you can see again, a tarsometatarsal subluxation or fracture subluxation. And here, the external fixator is placed to restore length. And then subsequently, the articular surface can be reduced with the aid of some freer elevators. After that, it can be grafted, followed by placing a plate to compress and raft. And then you can leave the external fixator, wire everything else, and keep it out to length. And then that can be taken off in the office in about six weeks with good results. And here, the patient is six months out. Maintaining lateral column length doesn't just have to be about external fixators. Bridge plating from the calcaneus to the fourth metatarsal is an alternative. In theory, this needs to be removed, but I certainly have cases where it has not been. I personally like to avoid fixation into the cuboid just so that in theory, maybe it can wiggle underneath the two at the CC and TMT joints. But I don't know if that particular plays out. So here's one particular case example, a patient with a bad open fracture and a SAD ankle fracture and this lateral column injury. So again, you can see someone put them in an X-fix, somebody tried to get four or five out to length. And then he got transferred to my care and we restored that four or five articulation. And then he had massive bone loss. And so we made him a new cuboid out of montage and kept it out to length using a bridge plate from the calcaneus to the fourth metatarsal. And eventually the metatarsal fixation was removed, but the bridge plate was not and he had a flap over that. Here's another example of a patient with a complex foot injury and a large soft tissue degloving. So again, he was brought out to length, later stabilized, each of the bony injuries fixed. And then that lateral column was held at length with the bridge plate. You can see the soft tissue wound here, and then he gets a flap over it and is able to go around. So post-op, we want these to be non-weight bearing for somewhere between six and 12 weeks, depending on how complex the injury is. Make sure that they don't get Aquinas. And then once you let them start walking, they can gradually advance in a CAM boot. The outcomes are reasonable. Again, Fenton described different outcomes for these series. So you can see the AOFAS scores. So in summary, again, lateral column length is critical. Stage treatment is helpful. Articular reduction and bone grafting is the mainstay. And then keep that length post-operatility with an X-Fix or bridge plate and make sure that you hashtag save the cupoid. Thank you. All right. So thank you, Jeff, for that. So one thing I want to mention for all the participants here, so we're definitely open for any questions you have. I feel like you have to wait till the end of all this to start firing questions. I'll be trying to get to them as best I can, and we can hopefully answer some between the talks as well. And so that's a great talk. So we're going to, I think, save some questions for the end, because I think a lot of these things come together and there's some similar themes you're going to see for these. And so next up, we have here, before I mention that, actually, I'd like to say I chose this panel specifically because we have two traumatologists and then two foot and ankle surgeons who do a significant amount of trauma, especially of the foot and ankle. So I'm really excited about this, and I hope we can get some good discussion. And then the last piece I'll say is that Dr. Givens is saving lives in the operating room right now. So he may or may not make it. If he doesn't make it, I'm fully prepared to do a bad job with this talk. So, all right, next up is Dr. Lori Reed, who is coming to us from Ole Miss, and she's going to be talking to us about navicular fractures. Okay, can you all hear me. So I'm going to talk to you. We're going to move on to navicular fractures I want to say happy St. Patty's Day, as well. And we'll try to make this interesting so hear my disclosures. So just a brief slide about anatomy, the navicular is broken up into the broken up into the tuberosity. Normally tuberosity fractures are relatively straightforward sort of simple injuries. It's the body fractures that tend to be much more difficult and complicated or complex injuries. These are oftentimes the crush injuries that you see across the medial column, they involve a much larger portion of the articular component of the navicular. And just remember that it involves the tail and navicular joint and this is considered an essential joint which is critical for hind foot motion so it's important to address early and to do your very best to get this right so we're looking for an anatomic reduction which is essential to prevent deformity and disability. So we'll talk a bit about surgical strategies for simple fracture patterns these are relatively straightforward so simple fracture patterns are usually treated with opening the fracture reducing your fracture and then usually treating this with a couple It's nice to have sets around that have small frag screws mini frag screws available, some mini frag plates potentially. And then every once in a while we'll use transarticular screws particularly across the navicular cuneiform joints and involving the cuneiforms for further fixation if you have, you know, small segments or small, small pieces of navicular. So this is relatively simple fracture pattern with lag screw fixation for this fracture. So what we're going to focus on a bit more tonight is these sort of complicated complex high energy injuries that are much more difficult to take care of. Oftentimes we'll treat these just like Jeff talked about with some type of staged fixation so oftentimes these crushing injuries that are high energy injuries come along with a fair amount of soft tissue injury and swelling even blistering so you know we may need to treat some of these with a spanning external fixator and then, you know, stage this with our, you know, RIF down the road in a few weeks. Sometimes we'll use K wires to supplement our fixation or supplement our external fixator. So, incisions for simple fracture patterns, usually it's just a simple incision directed over the fracture line CT scan oftentimes will help you sort of align your incision with comminuted fractures that we're working throughout the entire body of the patient so we'll usually use two incisions as you can see here with a medial incision and then a dorsolateral incision with full thickness flaps working between those two incisions. So this extraction can be incredibly useful if the patient has an external fixator on you can certainly use the external fixator, sort of an easy to pin construct you can use a four millimeter half pin into the first metatarsal, you can use usually a five millimeter half pin into the four or five millimeter half pin into the Taylor neck, and you can just attach a carbon fiber bar they're fancy small distractors out there that can make this a little bit easier but I would, I will tell you this will make your life, much easier when adding some type of distraction across the joint so you can see your articular reduction and see your joint surface. That's followed by mini frag plating. We can certainly, you know, before the advent of all of the pre contoured plates. We, you know, use different mini frag plates tea plates that type of thing that you can certainly bend yourself. Again, a lot of us probably these days use pre contoured plates and use that place those between the two incisions again using distraction, potentially on the medial and maybe even the lateral side to help with your visualization and your reduction. This is what that mini frag plating can look like. This is a just a mini frag plate that was cut and bent to fit the navicular. So just like Jeff talked about spending the lateral column we can spend the medial column. And if there is any sort of risk of you losing your reduction, or we'll go through a few cases where a spanning plate is helpful but usually a spanning to seven locking plate along the medial column with screws into the medial cuneiform and screws into the tailor net can be helpful for a period of time you do usually want to plan to remove this because of the motion across the tail and navicular joint. Another option is to leave an external fix it or in place for six to 12 weeks but I'll tell you. I find that a little messier external fix it or is on the foot tend to pin sites get a little soupy pin sites get a little drainage relatively early so I tend to use a spanning plate more so than leaving us an x fix in place. So, let's move on to a few cases. This is a recent recent patient of mine 56 year old that was in a motor vehicle collision woke up in a ditch and his foot hurt. Here are his x rays and so this is a little subtle if you don't look at foot x rays all the time this might be a little subtle but don't miss this because I have had this show up to my office at six months out and I will tell you this is not a fun So, you can see tail and navicular joint is dislocated. Here's Taylor head, you can see tail and navicular joint is dislocated on the lateral, and there's some fragment here that a CT will help us sort of delineate what that is. This is the patient's post reduction x rays so tail and navicular joint is reduced, both on the AP and on the lateral. And you can see this patient has this relatively large lateral fragment with a little combination, and a fair amount of articular surface attached to that. So this patient got a direct dorsal lateral approach to this fracture line was reduced and and a couple of mini frag light lag screws replaced and as you can tell in Jeff sex rays and my x rays these oftentimes are combination injuries injuries. So this patient also had a post your process Taylor's fracture that we'll talk about tonight as well. Here's the second patient this is a 29 year old male healthy guy and a motor vehicle collision with left pay left foot pain and deformity. He showed up to my office at about 10 days with a couple of sort of disconcerting x rays with, again, tail and navicular dislocation with this lateral sort of fracture fragment, as well as erosion of his medial Taylor head because he'd been sitting dislocated for 10 days. Now you can see there's a dorsal sort of that dorsal lateral fragment. Again, that essentially he'll sex lesion or erosion the medial Taylor head and then he also had a cuboid fracture. Here's a CT there's a fair amount of combination you can see in the navicular and his Taylor head again is sitting dislocated and he had an impacted cuboid fracture. So, think about this. And then we'll try to answer some questions at the end but he's 10 days out he's been sitting like this for a while, swelling doesn't look that bad at this point and so you know my question is what are your treatment options are you going to treat this patient with in a cast straight stage treatment so take him for a spanning external fix it or followed by open reduction internal fixation, take him relatively quickly to fix all of this, or some type of an arthrodesis or fusion. So my goals my goals and this is our to restore maintain the medial column length and anatomic reduction of the navicular to prevent a recurrent deformity and prevent the hind foot from falling into various, and then restore and maintain the lateral column length. So this is kind of how I went about doing that to incisions patient at a dorsal medial incision as well as an incision dorsal to the perineal tendons like Jeff talked about a reduced and pin the tail and a vicular joint to sort of hold it. Reconstructed the lateral navicular bridge, excuse me reduced and plated the navicular. This is one of those pre contoured plates that's out there. Bridge plated the medial column to prevent that Taylor head from falling back into that culminated sort of defect in the lateral navicular reduce a cuboid bone grafted behind it and then plated the cuboid. So this is what the patient looks like at five months out. I do try to take the medial plate out because there is motion across the tail, there is a fair amount of motion across the tail and a vicular joint and if you don't take the plate out one of two things happens. It. It reduces their hind foot motion significantly, and oftentimes you'll break screws this guy kept postponing his hardware removal I usually try to take it out in about three to four months. This is another patient, not to dissimilar injury. This sort of dorsal lateral fracture fragment, and he was treated with similar treatment with mini frag plating with just a mini frag plate that was bent and, and not pre contoured. And this was useful this was sort of what we did before they were pre contoured plates, and the idea behind this this is called barrel hoop plating and so basically the idea is we're kind of reconstructing that dorsal cortex, covering the entire dorsal cortex and then sort of holding that with this barrel plating technique, which has essentially sort of led now towards pre contoured plates. Thank you. So, thanks Lori for that. So, I actually I want to, I want to put a question out to the panelists that we have on here. And, and Jeff you can you can feel free to jump in or excuse yourself because this is more of a foot question but actually I would love your opinion on this as well. So, you know, I think the question has come up a couple of times now and I bet you it's going to keep coming up throughout this is at what point is acute fusion. The best option or a reasonable option for these patients who present with very comminuted articular fractures in these relatively small bones. When you look at it. I think you have to look at what joint it is so if you look at the cuboid four or five articulation, there is no fusion. So that side always needs to be reconstructed. And if you look at the calcaneo cuboid side. The goal is maintenance of length. And so if you can get your length and alignment back. I think that that's the important thing if that requires a fusion not a big deal. When you look at the medial side main maintenance of length is the same thing. Critically important for the structure but I think there's a couple of specific scenarios where the vicar injuries require or should be considered for primary arthrodesis one is if there's a corresponding impaction of the Taylor head because the Taylor head does not disimpact real well. You can't bone graft to replace it so I think those are destined to fail. And the other one that you'll see is where the Taylor head dislocate straight plantar breaks the inferior third of the navicular, and there's if you look at the anatomy there's no way to adequately plate that like you're putting a plate at the top and hoping the distal few threads hold that fragment. So those are two scenarios I think that primary arthrodesis is really indicated. Beyond that, I think it's more up to the operator. So thank that was a great explanation. And so from my perspective, the one thing I would put out there I think that, you know, acute arthrodesis for these injuries is, it's great conceptually and technically actually very difficult to achieve. So that's the issue is that like I get it I mean profound articular combination. I do think a lot of these patients will progress on to post traumatic arthritis, but the issue is what we're talking about is trying to first restore the anatomy, then prep the surface and then stabilize it. And I think that's actually sometimes technically more demanding than it is to just fix the fracture and then do a great job and hope that it works and know you can fuse it later if it doesn't. That's my, that's my two cents on the general kind of idea of that. I absolutely agree with both of you. I think it's like acutely fixing a really comminuted pilon conceptually that sounds like a great idea, but that is a, that is a sort of a complicated complex thing to do and difficult thing to do. I agree with Mike with that planner combination. I've got a few sitting out there that had, you know, for instance, they had, you know, trans calc Neal fracture dislocations and so, you know, even if it's even with those if it's primarily ligamentous or soft tissue injury I've had a couple that I haven't been able to open and fuse their tail and a vehicular joint because of soft tissue issues, or someone had already made an incision and I just couldn't go back through it. Tried to reconstruct their anterior process of their calcaneus even and tried to kind of reach underneath there and fix the planter navicular and as soon as they start walking, you just watch it continue to sag and so I've certainly gone on if I can to fuse those because I think it's really unpredictable. Yeah, I would, I would echo that I have been burned by the exact same thing, a couple of times. Now, I've got one right now I'm staring at but. Well, so, so thank you guys that was great so and again keep coming keep the questions coming in, please. And so now we're going to have says Dr Mike sword so again, I guess technically a foot and ankle surgeon but not really I think Dr source treats a wide range of orthopedic trauma injuries, and is great at them and I'm really happy to have him talking about what we would refer to as peripheral calcaneal fractures. Thank you, Brian, so we'll get started here, looking at peripheral calcaneus fractures all of us when we think about calc fractures we think of joint depression and and and tongue type fractures and sometimes the evolution fractures and beat fractures in the back. This is really a couple other small ones I excluded the anterior process calc fractures on the lateral side because that kind of falls more in the cuboid discussion. fractures, as well as the real rare bird the medial plantar to Rossi fractures, and most of our education will be done through case examples. With a sauce and tackling fractures, like, like the navicular and the cuboid they're generally associated with instability in this case, it's usually sub Taylor instability or sub Taylor dislocations, and often as part of a more complex show part injury as well. And the role of external fixation certainly plays a part initial management because similar to the previous topics. These are often associated with a great deal of instability so external fixation plays a role in early treatment, but more joint spanning and sometimes extending the foot. The x ray findings on these injuries are pretty sometimes uneventful so this is a 42 year old male, a patient of mine who was in a motorcycle accident. And when you look at the x rays they're they're really not all that overly impressive but when you will look at him clinically his foot was extremely swollen he had a great deal of pain. So we want to look at these injuries where we have suspicion with CT scan. When you look at his CT scan you can see he's got a very large sustenance tackling fracture off. And certainly this is associated with a dislocation at the time because you can see as a lateral process fracture as well. And so it's important to investigate these and make sure they're not missed the standard approach for these injuries. And the other approach when timing allows, based on your soft tissues is a meal approach you can see the nuclear tuberosity outlined as well as the medial malleolus, and it's a longitudinal incision just a little bit lower than your typical medial utility to put you between the poster tip and the FDL. This allows you to elevate the poster tip superiorly the FDL inferiorly and allowing you to visualize into the medial aspect of the subtalar joint of the sustentaculum. Oftentimes you end up working by taking the FDL above to actually get to the fracture because it's usually depressed and you can see an example to the right where we have the tendons exposed. The goal is obviously to reduce the fracture this is a small incision in a small area, direct visualization of your injuries important. So I would advocate use of a headlight. And as you assess your reduction support not only to visually see, but to stick a period and assess your reduction and make sure that it's nice and congruent. Using K wires into the sustentaculum fragment with a drill sleeve as a joystick is a real nice trick. And you can see in this case, we've opened it up with a K wire we're lifting the piece up and there's provisional fixation provided by a couple K wires In terms of fixation, screws are totally fine for simple or patterns that are not comminuted, and these large fragments can be simply lag screwed back to the main portion of the calcaneus. For more comminuted injuries plate fixation and coupled with positional screws is helpful on very rare occasions, as the fracture extends down the medial side of the calcaneus, you'll use a little buttress plate and I'll go back to the plateau analogy it's like a lateral buttress plate for a lateral plateau, where you restore articular congruity and then buttress your fixation. And then after you get the K wires in and you're reduced there because it's a small area, if you're going to plate you slide your mini fragment plate over your K wires. And in this example you sequentially remove your provisional fixation the K wires, you can see in the middle picture a K wire has been removed and a screw has been placed. And then you just go through and sequentially remove your wires and replace them with screws, whether they're lag or positional depends on the fracture pattern. And this is the final fixation that gentleman with his lateral process fracture and his sustentaculum fracture. Here's another case from a motor vehicle accident, you can see this is a pretty sizable component, you have in incongruency of the sustentaculum and comminution as well. Again, through the same type of approach, the tenants retracted inferiorly the piece has been reduced and held with K wires, the plate is simply slid over the K wires. And here's fixation here and you can see in this case, as you follow the central image, you can see where the fracture line exits there and you get a nice read on appropriate view of the congruence you should restore that arc. And you can see where this fracture exited right through the central portion of the joint it's a very large particular portion. Here's a more comminuted injury from several years ago, you can see the medial canal form is comminuted there's some associated instability in the medial column. And also as a common to tailor body injury and a fracture the sustentaculum for a variety of different reasons. He was treated with simply bridge plate fixation for the media column to maintain length fixation of the tailors, and then through the medial approach from the tailors, making that incision a little bit further plant are able to reduce the sustentaculum and fix it at the same time. You can also do the tailors and the sustentaculum at different settings. In that case you cheat your tailors incision a little bit higher, just depending on how much you need to do the sustentaculum. Here's another example this is just showing that not everything has to be fixed. Here's a person who has a highly common injury to lateral process, as well as to the sustentaculum, the pieces are very small not amenable fixation but you see the fragments in the joint. So this still needs a surgery but it needs excision and the fracture fragments. This is a case where the pieces are simply removed. When we look at medial tuberosity fractures, these are truly a rare bird. You won't see these unless you get good quality imaging and the lateral x ray of the foot isn't going to get it. Standard ankle series or foot series won't you really need an axial heel view, and you can see it on a CT. So here is what this looks like you can see the mortise view. You can see the lateral view, they show nothing. And then on the axial view you can see the fracture. And the trick to these things is sometimes they look relatively benign non displaced. And sometimes they look like this. If you leave this piece alone. This is going to upset the, the walking service the calcaneus, and this needs to be put back into the bed that it belongs in and get some rigid fixation into it. The reason these are tough to take care of and again here's another example of one that looks very subtle but on the CT scan you can see the planar surface of the calcaneus is significantly maligned. And the reason these are difficult, if you look at the attachment site of the posterior. Excuse me, the, the middle to Rossi the calcaneus plant really the planner fashion attaches there. So when this piece breaks off. It goes distal and it rotates, so it's a really difficult three dimensional reduction where you have to pull it back, rotate it, line it back up, and then hold it. And it's just a difficult reduction to achieve. You can orient your incision this way at risk is that medial calcaneal nerve branches that goes to the planner surface, or this way. If you orient it this way it's harder to get that piece and pull it back. So here's an example of a patient of mine who had a complex foot injury, including this displaced plantar medial to Rossi this is the incision that was used to pull this back and these are things that take a extremely long period of time to get the reduction it almost clicks into place when it's right. And then when you see your post out of x rays you have just a couple of screws and you almost like are upset at yourself that it took you so long to get something done that required two screws. But when when you're there you'll understand what I'm talking about. So here's this reduction it's a three dimensional reduction and pulling it back rotating and rotating around the side of the medial side of the calcaneus held provision with a series of screws, and then percutaneous lag screws to hold the piece in. And this is what it looks like. Here's the final fixation on this patient. And here is two years post up showing the pieces is back. This person had a bit of a more complex injury with an injury to the ankle as well as a mid foot injury as well so these like many of the other injuries we discussed are fairly commonly part of a more complex foot injury. So in summary, these peripheral calcaneus fractures are rare injuries. Sustentaculum fractures are associated with subtalar instability or showpart instability so you need to be aware of them and look for them. And that displaced medial tuberosity fractures need to be repaired to restore an appropriate weight during service to the calcaneus. Thank you. So, Mike that was a great talk so actually there's a question here, which I think is reasonable so why not just excise that medial tuberosity fragment. So, why. So I guess maybe analogous to, you know, a small electron fracture why not just excise and advance the triceps when I just excise and repair their plantar fascia. So you do that but you have to remember a portion of the glaberous heel pad is attached to it. And, and so you're going to lose some of the attachment site to that, and that is anyone who's managed a heel pad avulsion that doesn't always come back real nice. And the second part is when you take that piece out your plantar fascia is now not going to reach back to the calcaneus. It's a difficult thing so I think that you could if you wanted to. Yes, you could shell it out and put it back up but some sutures through it some suture anchors. I think that's reasonable. I think, removing its entirety would be a bit of a challenge and getting things to go back on. In terms of just excising and reattaching, I can't really speak to that because I haven't done that. Yeah. And then how often do you find yourself taking out the hardware in, or excuse me, the fixation, not the hardware in that situation, whatever your internal fixation is? For the plantar portion? Yeah. You know, honestly, I can't think of a time where I've had to. The only time that you need to do, that I've needed to do that is obviously because the orientation of those screws, it's the opposite of calcaneus beak or avulsion fracture. So you have to reach the far cortex, and which the far cortex is generally up the superior aspect of the calcaneus. There's not a lot of soft tissue padding there. So I have had to take a couple of the screws out because they irritated the person on the opposite end of the screw, not at the screw head. Outside of that, generally been able to leave those. Okay. All right. So thank you, Mike, for that. So it looks like Dr. Gibbons, unfortunately, is not going to be able to make it tonight. So I'm going to try to soldier on through his talk here. So let me go ahead and share my screen. Okay. All right. So I am not Dr. Gibbons, nor can I claim to be. So this is a fantastic talk. I've gone through this, and I'll try to do my best to get through it. So this is his disclosure. So he is giving us a heavy dose of Harborview Kool-Aid, which can taste kind of foul to me because I'm a shock trauma guy, but we're going to try to take it in here. So the indications and techniques, that's the outline for this talk, is for lateral process and posterior process fractures, the talus, these are frequently missed. And I would absolutely echo that. And these are just like a lot of these things we're seeing. These can be subtle injuries, but devastating injuries if missed. They involve articular surfaces. Neglecting these fractures can lead to arthritis, malunion, nonunion stiffness, and are very difficult to salvage in any meaningful way if they're missed or ignored. So lateral process articulates with both the distal figula, as well as the posterior facet of the calcaneus. And it's actually impressive how much of this, how large the articular surface is when you do treat these. It's the origin of lateral talus calcaneal ligament and a portion of the ATFL insertion. And this is the highlighted portion. It's a lateral restraint to the subtalar joint. And so in these injuries where you have a accommodated or impacted lateral process, you really can destabilize the subtalar joint. Again, the classic scenario in an isolated injury mechanism or in a multi-trauma patient where there's other things going on is that, you know, you get either an ankle sprain diagnosis or it's missed on the initial imaging. The mechanism typically is forced dorsiflexion with inversion or eversion, depending on the fracture pattern. And you absolutely, I think, CP scan is essential to assess these injuries and to be able to treat them appropriately. So there's no right answer for what requires surgical treatment. You know, I mean, we obviously can talk about the two millimeters of articular displacement, but, you know, I think that it's a very individual situation based on the patient and based on the surgeon as well. Indications for fixation are a large fragment, articular displacement of the subtalar joint or incongruity of the subtalar joint associated with the fracture. And then when it's associated with tail or neck or body fractures. This is the classification for lateral process fractures. I will be honest, I am not in any way familiar with this, nor do I use this in my practice to determine treatment, but there is a classification. So for isolated fractures, the sinus Tarsy approach, I think is a great approach for this. Plus minus use of a distractor of some kind to aid in visualization. I'm gonna be, for me, I'm not particularly using a distractor in this scenario, although I am fascinated by the concept having actually seen this talk. And just like a lot of things you're seeing here in these cases, this requires typically mini fragment plate fixation. A lot of these cases, you're gonna be designing your own plate to match whatever you need to get the fracture fixed. And so this is a case example of a 55 year old who has two weeks of ankle pain after a motor vehicle collision. And what you can see here is fairly subtle on the imaging. It's a very subtle, it's a mortise and a lateral view with not much going on, but if you look carefully, there's some incongruity of the subtalar joint and a CT scan, however, is pretty profound. The patient has a displaced and impacted lateral process with the subtalar joint completely out of alignment. And so I think this is, again, this is something I haven't used in my practice, but a really interesting idea, which is to place a distractor with pins into the fibula and into the calcaneal body to achieve distraction laterally, similar to what you would use for a laterally base funnel distractor for a tibial plateau fracture. You can visualize the impaction. This is the requirement. If you're at Harborview, I think he's actually missing a few wires here, but the important point is, I think similar to what Dr. Soares described, is you are maintaining the reduction or obtaining the reduction, maintaining it with your wires, and then gradually replacing your wires with your definitive fixation. And sometimes you do need to leave subchondral wires to support the reduction of the fracture fragment here. And so I think similar to Dr. Gibbons, we place this along the talar neck here. I think this T plate or something similar to it works very nicely to contain these fractures and it provides subchondral support. A lot of these are combined with talar neck and talar body fractures. So you have to modify the dorsolateral approach somewhere between what you would use as an anterolateral exposure for a pilon fracture and between a sinus tarsi. So it's kind of between the two and I would do the same thing. Again, a distractor can be useful and similar to what you've seen before, you apply fragment-specific fixation to fix the lateral process. The lateral process fractures are negative prognostic factor, okay? So they can increase the rate of development of subtalar arthrosis. And if you look at the study here, fixing it is important with a talar neck fracture. If it's, so in other words, they found 100% rate of post-traumatic arthrosis if lateral process was not addressed. All right, so posterior process fractures. So again, it's an articular injury. There are multiple ligamentous insertions. It's usually the sling for the FHL. And again, it's an important component of ankle and subtalar function. Again, frequently missed in an isolated setting. A lot of these can be associated with subtalar joint dislocations where this is crunched between the posterior tibia and the posterior calcaneus. Again, your goals are the same. A lot of them can extend into the talar body posteriorly. So preferred approach, all right? So you guys, I can't respond to the Q&A right now, but this was Dr. Githens' slide, and it's great, right? So for a posterior process fracture, how do you guys like to try to look at this? Do you wanna do a medial malleolar osteotomy, a posterior medial approach, posterolateral approach? I'll throw in direct posterior approach, maybe through the Achilles, or you're arthroscopically reducing or excising or whatever, and then you're deciding how to do it based on your subtalar joint arthroscopy. It hurt to say that, by the way. So the posterior medial versus medial malleolar osteotomy, so it's just talking about what you can visualize, and I think this is a great slide. And so the medial malleolar osteotomy is really for a body fracture, okay? And so it's not for these posterior process fractures. It's very difficult to see it, and it's virtually impossible to fix these fractures with a medial malleolar osteotomy. And so the posterior medial approach, and I think there's different ways to describe that. What I think of the posterior medial approach for this fracture is medial to the Achilles and lateral to the FHL, retracting the FHL laterally, or excuse me, medially, excuse me, but sometimes having to work in windows around the FHL. It's a great exposure for these. So similar to this, so I think prone position is the optimal way to do this. I think it's exceptionally challenging if you're trying to do the supine. A distractor or external fixator applied immediately into the calcaneus, into the tibia. I think it's great and can really assist with visualization. Again, you want a headlight available for this, and this is just showing that approach. These wires up there, some of those are actually retracting the FHL. You can see the plate applied right along the inferior aspect of the talus to secure that fracture. And so again, you can see visualization of the subtalar joint as well as the tibiotalar joint through this approach. So 36-year-old bouldering, here's your injury, extends into the talar body, but really a posture-based injury, so kind of an extended posture process fracture. Posture medial approach, femoral distractor or some form of distraction, Harborview-style wires. And there's your plate containing it with some independent lag screws that I'm sure were countersunk. So in this area here, and I've made this mistake and learned from it, is that you have to be very careful with your plate application if you're going to do it here. You can easily run out of real estate and impinge posteriorly. And so you want to keep it very low, just above the subtalar joint. And if you have to place fixation, which you certainly can need to, you just want to have independent screws buried or wires or something else to maintain that reduction. All right, so peripheral talus fractures are frequently missed. They involve articular surfaces and restoring native anatomy reduces arthrosis and nonunion promotes motion and helps people get back to their lives. And so thank you to Dr. Gibbons for giving us that talk. And again, I'm sorry he couldn't be here with us tonight because he's still working right now trying to help people out. All right, so let's see if we have a couple of questions out there. So I think these are, people are still hung up on the medial tuberosity for the calcaneus. I think that is definitely an interesting idea. So one of the questions is about positioning. And actually, before we get into that, I'm going to take a back for a larger question. So I think what we've seen with all of these is that they're incredibly difficult to see on plain radiographs and frequently missed, right? And so my question for you guys is what are you doing to optimize your intraoperative visualization of these fractures with fluoroscopy, right? I know a lot of it's a direct reduction of the fracture. Any tips for the audience about imaging besides take your time and get a lot of images? I mean, is there anything you're doing with positioning for these patients? Anything you're doing with your fluoroscopy or it's just kind of different every time? I like to use big fluoroscopy, no mini fluoroscopy, mostly because it's very hard to get a reduction and then move something off the table and then do it where I like to keep what you're working on in position and the CRM can move around you. You can also tend to see better. And then using the articular visualizations that we kind of learn as junior residents, Broden views and other things I think are really helpful. I think especially the other thing that you can see in Dr. Given's talk is that that posterior approach is often hard to understand exactly where the joint is because it slopes down and it's not a true lateral of the joint. So you just have to be very confident in your direct visualization before you do it and lots of distraction. Yeah, and the other thing I would add to it is just because the patient's prone, that doesn't mean you can't put a bump under one hip or the other. So when they're prone, you still want to position them as if their foot is kind of straight up and down because you'll see a lot of times people put someone prone, they won't put a bump under the foot, right? It's not in the correct angle. The toes are pointing to the outside portion of the table, the heels in, you're trying to do a posterior approach. So you put a bump under the contralateral side of the patient, it gets the foot lined up in line with the floor. And then to get your mortise view, you have to tilt the C-arm towards the patient's head so that it's coming down in line with the joint. If you shoot straight down to the floor, you won't see the joint. So you just have to think about the orientation of the joint surface you're seeing as you're working. All right. Let's see if we have any other topics for discussion here. So I think we have a few minutes. And so, first of all, Mike, I think that point about bumping the contralateral hip when you're prone is absolutely a very important point. It brings your foot into a neutral position. I think you will find yourself struggling because they always want to externally rotate through their hip on the side when you place them prone, when they're extended like that. And so I agree with that wholeheartedly. It's always easier for us to work in orthogonal planes and a very easy way to do that is bumping your opposite side. Okay, well, so do you guys have any other comments for our audience here? Because otherwise I'm going to throw up a couple of cases just real quick, just to get some rapid fire kind of thoughts and see what we got here. All right. I'm just going to jump in real quick and near Jeff and Mike as well, but try the distract, try some kind of a small distractor if you haven't, because it's incredibly helpful really with all this stuff, lateral process, posterior process talus. I use it, I use it a cuboid. I use it all the time. And it's really, I think if you use it for a plateau, you know, I've heard people say, you know, I use it for a plateau and I'd never do it any other way. And I think once you, you know, it takes a few minutes to apply, but take that few minutes because it saves you so much time and your visualization is much, much better. Could not agree more. All right. Okay. All right. So we've got a few minutes. I've told, I've told we got 15 minutes to burn here. So we'll, we'll, we'll try this here. So I'm sharing my screen. Let's do this here. Okay. So I think we're going to skip the cuboid, but I am not a cuboid nihilist. I want that out there. Okay. All right. So this is a nice case. And this is, this is, this lady's still in the hospital right now, actually, but all right, let's skip through. Okay. All right. So we're skipping this right now. May come back to it. Okay. So, so this is a woman involved in a motor vehicle collision, high speed, multiple injuries. So, so this is our initial imaging here. Okay. And so mortise and lateral, multiple lines there, you know, not high quality imaging, but you can definitely tell something's going on, right? So I've got a comminuted tailor neck fracture. I think that that part is obvious, but this is our CAT scan. And so, you know, this is, and obviously I'd want to hear from you guys about what you see here. I'm sorry, I can only give you a few select cuts. It's a pretty interesting pattern, right? I mean, as you can see, there's just profound comminution of the neck laterally, which you don't typically see, I think. And then the fracture extends almost into the tailor head. Then the tailor head doesn't look like it's quite lined up with the navicular. And then the tailor head is also diving into that sustentacular fracture there. So first of all, you know, let's say this is a perfect, we're isolated. It's a closed injury, right? Isolated injury. Soft tissues aren't too bad. X-Fix, fix it all. Take one part down, come back for another. What do you guys think? So just based on the limited views, like when I look at that, I almost look at it more as, I mean, as the tail is fractured, but this is really a calcaneus fracture dislocation where the calcaneus is, the body of the calcaneus is dislocated up through the talus and superior. And so I don't think that you can do anything until you bring the calcaneus out from inside the talus and put it back underneath. And then I would get a full set of imaging to figure out what's next. Okay. Any other same opinion? I think as with any other fracture we treat, getting things close to the native anatomy, any subluxations or dislocations reduced and holding it temporarily, whether that's with pins or an external fixator and getting new imaging is incredibly helpful. Okay. So that's two votes for some form of provisional reduction, improved reduction of the subtalar joint, getting the calcaneus underneath the talus and then repeating the imaging with things in better alignment. So staged approach. Lori. Yeah, I don't know. I'd have to see more imaging to know. I mean, ideally you would like to get that subtalar joint reduced and not let that sit for very long. That may or may not be an easy thing to do. Sometimes, I mean, honestly, sometimes you can do it in the ER. I think it's always worth an attempt because if you can get that subtalar joint reduced in the ER that makes your life a whole lot easier. You can get new imaging then and you can plan a bit better. But I don't know, I'd have to look. I'd have to look at more imaging to give you, I'm hedging here. I'm gonna hedge, sorry. All right, so you've got, I feel like a few hedges there. All right, so let's say you get it reduced, you're provisionally held it, it's time for definitive fixation. I'm sorry, guys, this is all you're getting. So these are your images because I didn't hedge on this one. So questions I have, right, for fixing this sustentacular fracture, first of all, does it need to be fixed? I mean, can we just reduce the talus and kind of move on fairly small piece? And then if we're gonna fix the sustentaculum, are you doing a single approach? Does that require a separate approach to address both the talus and the calcaneus? What do you guys think? Oh, Laura, you're muted. All right, for me, when I fix the sustentaculum, like that incision has to be where I want that incision to be. Like I can't, I would have a really, I have a really hard time fixing a sustentaculum through an incision that I'm also going to address a tailor neck. So I think like Mike said, I mean, I think I would, I think I would probably fix this sustentaculum through a more planter approach. And then I would cheat my approach to the neck and head a little bit more dorsal and try to get as big a skin bridge as you can between the two of those. Okay. I think your chance of getting the neck aligned well is probably on the medial side because you've got no kind of read on the lateral side. So I'd want to make sure I can get a really good look at that medial side. Okay. Then I had another question in there somewhere. Oh, order. Where do you start? Talus first, calcaneus first? I would prioritize reconstruction and fixation of the talus because if you can get the talus back together you have an attempt and a reasonable chance of salvaging the ankle, subcutaneous joint and show part. If you don't get the talus right, none of them are right. And, you know, seeing someone afterwards that has a tailor neck malunion, or in this case, neck plus head, that's an incredibly difficult thing to salvage. So as I plan and map this out, my priority would be fixation of the talus then figure out how to treat the other things based on the limited imaging I have. All right, Jeff. I agree with that. In this case, I may try to do the sussetaculum first just because I might be able to see it a little better and then provide a stable platform onto which to fix the talus. Again, I think this is going to be two separate approaches because you need to see the head and the TN joint and that medial reed. So I may do that first, but it's probably fine either way. Okay. So I'll just, I'll show you guys what I did. And obviously this is unfair because you don't have, I mean, this is something where I was staring at this CAT scan for an hour at least, just kind of going back and forth through all the options. So I kind of thought like Jeff here. So first of all, this woman actually had multiple injuries, but shockingly, she was safe to go to the operating room. Shockingly, this wasn't massively swollen actually. Their soft tissue was relatively appropriate. And so I went ahead and took this on. I always thought that I was going to take her splint off and be spanning this and reducing the subtalar joint and coming back another day. And it actually turned out that we had operating room time. It was earlier in the day. And so it's just kind of the sun was shining upon us. So I followed Jeff's kind of line of logic here that I just didn't think I could get the talus right until I had a platform to put it on basically. And it would keep falling into that defect or the subtalar joint would just keep falling out from underneath it, kind of how Mike talked about it, how the talus or the calcaneus wants to keep going laterally. And I didn't think I could get the talus right until I had the calcaneus right. So I just started there. And this was actually through a single incision. So I did cheat it more inferiorly. And I will grant you, I raised more of a flap than I really felt comfortable with to get to see both of those things. But that's the same approach that you saw really nicely displayed in Dr. Swords' talk, which was working in the interval between the posterior tibial tendon and the FDL. And I was able to lift the FDL up, found the tibial nerve and carefully got that out of the way and retracted the FDL. And you're staring at this really nice key to reduction with an apex, with a shearing type injury that needs basically a buttress plate. You have a partial articular fracture that needs just a plate in the right position to resist the temptation for it to shear. And so I think obviously the challenges here, again, is that you're trying to use a single incision for two separate articular fractures, and it's not ideal, but that's what I thought was great about this here. I don't know. What do you guys think? Should I have gotten more fixation into the sustentaculum? Is it gonna fall apart? She caught on fire already. Usually you don't need a ton of fixation. I mean, you just need to hold the piece back. I think that looks great. Yeah. Yeah. And again, I mean, this was also, like I said, I mean, this is an unfair, this is the world's thinnest woman who is actually healthy, who in a bad accident, it's unfortunate. I mean, it's like, again, like she's a non-smoker, non-obese, might actually listen. You know, I mean, like it's just, it's, and so this is the rest of it here. So we got it through two incisions with the planter, with the medial incision cheated a little bit more planterly. And I will grant you, I mean, the lateral side of the talus was annihilated. It was exceptionally difficult to just contain that and make sure you had it in the right area. So. Okay. That's great. Thank you. I hope it stays that way. That's awesome. All right. That's that. I'll stop sharing here. I don't think there's any more questions. Okay. All right. Well, I want to thank the panelists because that was fantastic. Again, I'm sorry, Dr. Givens couldn't be here because I'm sure it would have added a lot to our conversation, but this for me was ideal. I mean, these are all people that I would want to hear a talk from and I want to learn from about how to fix these things. So thanks guys for being here and thanks to everyone for coming out tonight on St. Patrick's Day to learn about obscure foot fractures. So. Thanks everybody. Thanks, Brian. Yeah. Thanks everybody. I was muted. Okay. We got it.

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forgotten fractures

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navicular fractures

peripheral calcaneal fractures

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