Good evening, everybody. I'm Lauren Gainey coming to you from the University of Connecticut. And I want to introduce you to our first of hopefully a few webinars talking about the basics of foot and ankle care. We have a really great group today and we're gonna be focusing today on trauma. So with me, I have Dr. Hauk who's one of our physical therapists. And with the foot and ankle interest group and physical therapy, they've been really helpful in helping us coordinate all these. So I want to introduce Jeff as well and he will be starting us out with our first speaker. Hi, so I'm introducing Tracy Herrig has spent the last six years working as a nurse practitioner in private foot and ankle orthopedics practice in Reno, Nevada. She is currently pursuing her doctorate of nursing practice from the University of Reno, Nevada. And she'd rather be skiing and mountain biking. Oh, but not right now. Thank you. Let's see if I can figure this out. All right. Can you guys see me okay? Yeah, and you can hear me okay? All right, I see a bunch of nodding. Well, thank you. Thank you for joining. I'm Tracy Herrig, nurse practitioner with foot and ankle service and in private practice in Reno, Nevada. This presentation is on fifth metatarsal fractures. I have no disclosures. For one little bone, there are four distinct fracture types with different mechanisms of injury and different treatment approaches. There are bulging fractures or proximal fifth metatarsal fractures. There are two different types of Jones fractures and distal metatarsal fractures. I added a bit about the proximal apophysis of the fifth found in kiddos and something called Islin disease because they often get mistaken for fractures. And we'll start off with, oh, no, we won't. There we go. We'll start off with anatomy because it really does have everything to do with why different mechanisms contribute to different fracture patterns and why our treatment approaches can be really different even though we're talking about millimeters here. First of all, the attachment points. So the calcaneus attaches to the lateral base of the fifth via the plantar aponeurosis which is really just a fancier term saying plantar fascia. The peroneus tertius tendon attaches to the metaphysis. The peroneus brevis tendon attaches to the tuberosity. And then there are multiple ligaments. There's the capsular ligaments, the fourth, fifth and then the cuboid in the fifth. Next is the vascularity. You'll hear the term watershed and a watershed infarct is when an ischemic lesion and if you will, this is a fracture for us occurs at the junction between two main arterial territories. So the blood supply comes in from each end of the bone and terminates in this narrow area which leaves it less perfused. If a fracture happens here, it's harder, it has a harder time healing because it's just not the best for perfusion. And then we'll touch on mechanism of injury and we're going to need a little bit more depth later but I think, so we'll touch on inversion plantar flexion. So I think dancing or touching a football in the air and landing hard are most commonly in my world and missing a step or curb. That seems to be just the number one complaint for all these guys for me. Also your foot shape sets you up for some of these problems. So a cavovarous foot alignment or a metatarsus adductus with a prominent fifth. The classification of Jones fractures is a bit confusing, I think because our understanding of the fracture patterns and how we treat them has changed over time. The most commonly used classification now is the 1993 Lawrence and Bott, and I'm sorry, Dr. Bott, if I'm botching your name wrong but the classification you described is the zones one, two, and three but now we consider a real Jones fracture is just happening in that zone two or three. So we've sort of dropped that Jones zone one fracture. It can be kind of confusing. So that zone one is the avulsion fracture and because it's typically got a great blood supply there is typically predictable outcome and that's not considered a real Jones fracture. It involves a proximal tuberosity starting from the lateral cortex where there were that articular involvement of that metatarsal cuboid joint. Historically displaced Jones one fractures have been managed operatively but many published reviews support non-operative management and for years now, at least in our practice these do really well. We all have stories about them going on to non-union. In fact, this last month, I just saw a post-op for someone who went on to non-union and I was like, oh, I just made a PowerPoint which says these always heal and she kind of like got a good chuckle out of that. And that can be kind of frustrating but they typically do just fine. The protocol for our practice is that they can go into a boot or a shoe. For us, we typically will put them in a boot for two to three weeks. This helps to stabilize the musculature we think and it provides good pain control. And then when we see him back at around three weeks we'll transition them to one of those post-op shoes mostly because they're so bitter about being in the boot or maybe a carbon fiber plate until the pain resolves. And this can take up to 12 weeks for these fractures. They tend to be a bit slow to heal in my experience. So, oh gosh, hang on. Sorry guys. So zone two is the real Jones is standing up. So I call it the trickster because it looks so small and wimpy but they just don't heal well. It also gets a little tricky sometimes trying to figure out if it's really in this zone when it's right on that border. So this is the one where our urgent care will call us a lot. Is this a Jones or is this not a Jones? And sometimes they present as an avulsion fracture and then you see him back at six weeks. And lo and behold, there's also that zone two fracture that you just didn't see initially. These involve the distal tuberosity and metametaphyseal-diaphyseal junction extending to the fourth, fifth intermetatarsal articulation without involvement of the TNT joint. So that's gonna be a horizontal fracture pattern that you're gonna be seeing. The slide here is to convince you that surgery will give you a more predictable outcome. Thank you, Dr. Bob Anderson for this great bottom line. Your non-op risk is 30% of non-union and a 50% refracture rate. So these just do better if you fix them. But I think it's important to remember though, it's not a 100% non-union rate. This is not a trimal angle fracture that will be catastrophic if you just let fly. So if you have a little old lady who's a terrible surgical candidate or someone who just is not in a place to have surgery because of money or whatever, it's just not going to kill them to try non-operative management. In this case, you do everything you can to get it to heal. So non-weight bearing, bone stimulators, hope and pray, whatever. Just be upfront with the risks and document your conversation. I have a couple over the years that have healed on their own, usually because they were missed initially and just took a really long time for symptoms to resolve. We're getting there. Oh, did I miss this slide? Oh yeah. Jones zone three is the stress fracture. So this involves the proximal 1.5 centimeters of the diaphysis distal to the fourth, fifth intermetatarsal articulation. This is a little bit further down the road. Majority of these fractures have a cable virus alignment is what studies have shown us. Eversion increases that torsional strain on the fifth metatarsal. And remember, these folks are overloading their lateral column. So it will have a stress fracture story. I just stood up from my lawn chair and felt a pop. This was, oh no, don't fail me now. There we go. I don't know why it has a bit of a lag. I'm sorry. This is one of our patients. You can see the fracture on the right with that classic cable virus alignment. And man, did he get the works. Had no idea it was coming at him. Let's see. This is a cable virus alignment where we had not only placed that intermedial leash through and across the fifth, but realigned his foot shape to take the forces off that lateral column so that it will heal. Many surgeons would likely give these folks a chance to heal by just doing the ORF of the fifth, but they have to have that really rigid cable virus foot shape. And it was really a stress fracture situation without any trauma. There's a greater risk of non-union after the ORF. So it can be a bit of a hard sell because it's a wicked hard recovery, but ultimately these guys do well and they have a nice predictable outcome. So zones two and three, a return to activity following ORF. NFL and NBA players get back pretty quickly with a lot of fancy stuff we found. So bone stimulators, custom orthotics, a lot of bougie therapy. Traditionally, a lot of the research has been on these folks, but a recent great study show that the rest of us also get back to our return to activities, including I impacted about 13 weeks postoperatively with no bone stimulators or custom orthotics. So if you do a good job of fixing them, they just, they get back at it. The most widely published post-op protocols that I could find was like two weeks in a splint and then three to six weeks weight bearing in a boot or a shoe. We put these folks in a tall fracture boot and then weight bear is tolerated right off the bat and they seem to do just fine. But I'll let that be controversial for everyone else. Let's see. Here we are, we're gonna get past that. All right, so these are the distal metatarsal fractures. So the distal diaphysis, they called these dancers fractures because it's typically a spiral fracture occurring from a rotational force to the axially loaded plantar flex foot. Historically associated with athletes or dancers, current literature is suggesting that the increased incidence of women over 40, which is super young by the way, is suggested of a fragility fracture and that we should be thinking about doing maybe an osteoporosis workup with these. And I'll say in my practice, I don't overwhelmingly get a ton of dancers. It's mostly the ladies over 40 that just step awkwardly off of something. This can be a head and neck fracture, either intra or extra articular. This injury comes from a direct force on the plantar dorsal or lateral foot. So this is like I smacked the bedpost or my dog stepped on my foot. These also do really well managed nonoperatively for the most part. I remember when we first started, we were fixing a lot of these and then lo and behold, I think we just had a run of people who were like, I don't know if I wanna have surgery. And it was like, okay. And then they ended up in my clinic and they all did pretty well. And so we tend to manage these mostly nonoperatively. There's a great study that shows there's a high level of return to activity in about 8.3 weeks. And that's what I found as well, instead of saying, oh, you're gonna do great at six weeks, this is just a little bit longer at eight weeks. So I would be lying if I said I had this conversation with every single fracture patient, but with this metatarsals, I really do try to remember the importance of making sure the patient is modifying everything that they can to increase the rate of union. So that's, you know, have you been diagnosed with osteoporosis? Are you working with your primary on that? What's your, you know, vitamin D situation? Are you, could you just put down a couple of the cigarettes and a little bit of the alcohol while you're trying to heal this and optimize that diabetes and try to get some good nutrition during this time. Apophysis of the proximal fist. This develops around the age of, I think I've got some pictures. There we go. It develops around the ages of eight and 12. It takes a couple of years to fuse. It's often mistaken as a fracture. So sometimes they can get a fracture near the apophysis, which is where this little top picture is. But usually it's this little jagged line that looks like a little growth plate. It's nice if you get bilateral standing views, because you can see them on both sides. They can injure them with trauma. It's not technically a salterhairs, but it sure does act like one if they've smacked it. They can be really tender here. And if you just treat it like a little salterhairs, it will just get better. So cast them or boot them. I let them run in the cast. They do fine. You can also get this thing called Island disease. Never once said that in practice, but that is what it's called. It's apophysitis of that proximal fist, and it acts a lot like severs. So the little kiddo that was most memorable for me was a little girl who was competitive in skate skiing. And it's this very like lateral force on the foot with boots that aren't very supportive. And so she was doing that like six days a week. It really irritated that brevis insertion. And the treatment for that is just like what you would do with severs. You shut them down if they're super duper painful in a boot or even a cast, and you try to get them to lay off of activity for a couple of weeks. And they do better. In this little girl's case, I don't think she wanted to do any of that, and she probably just did better anyways. But it can be really frustrating for these little kids when that happens, just like it does with severs. So hopefully I wasn't talking too, too fast. There's all my references. And I think I had a couple of more. Yeah, there you go, photo credits. And that's it. Thank you so much. That's it. Thank you, Tracy. So a couple of housekeeping things that I forgot to say at the beginning, but what we'll be doing is at the end of this, we will be having a Q&A session as well as some cases if time allows. So please feel free to enter any questions into the Q&A section, even as you think of them, if you want to put them into the Q&A, we'll be able to answer those at the end of the session. You will also be getting a link at the end for a survey, and that'll be really helpful for us in order to determine where to focus our upcoming webinars, if there's things of interest to you guys. So please fill those out and give us ideas for what you're interested in. And with that, I'm going to introduce Dr. Lorraine Boakye. She is currently a fellow at Brigham and Women's Hospital. And excitingly, she will be heading to UPenn next year to join as faculty. I'm interested in clinical research and mentorship and trained previously at UPMC and is a Yale undergrad alum. So we are really excited to hear about Liz Frank injuries. Thank you, Lorraine. Thank you. Thank you guys all for joining us tonight. So we'll get into it. I'm talking about Liz Frank injuries. Nothing to disclose and hopefully something soon. So overall goals for the talk are to identify pertinent history associated with Liz Frank injury, become familiar with the imaging parameters, be able to appropriately triage the injury and counsel the patients, and then sort of understand the outcomes of the injury complex. So getting into background and anatomy, the term is kind of a catch-all for a range of injuries from a subtle mid-foot sprain to Frank dislocation of the TMT joint. It was initially coined by Jacques Liz Frank de Saint-Martin in 1824. It's a pretty rare injury complex. It's really about 0.2% of all fractures. But it's interesting because they found that as high as 20% of these are missed on initial imaging. So in terms of anatomy, the TMT joints are stabilized by dorsal and plantar ligaments. Dorsal ligaments are weaker than the plantar ones. And so bony displacement is usually more likely with dorsal injury. The other interesting thing is that there's no intermenotarsal ligament between the bases of one and two, but there is a ligamentous connection between the bases of two through five. And in general, we like to think about the Liz Frank ligament as an interosseous ligament that runs from the plantar surface of the medial cuneiform to the plantar surface of the base of the second metatarsal. And it's super important in terms of stability because it's a keystone architecture. And studies have shown that the second metatarsal base is recessed an average of eight millimeters relative, or sorry, eight and four relative to the medial and lateral cuneiforms respectively. And then kind of thinking of this in terms of columns of the midfoot, the medial column, that's the first TMT navicular with the medial cuneiform reticulation. The middle column, the second and third TMT joint with those joints of the navicular middle and lateral cuneiform. And then the lateral column is the fourth and fifth TMT joints in the cuboid. So Liz Frank again, ligamentous conduit between, you can think of it as the medial middle columns. Overall, the kind of sagittal plane motion is 10 to 20 degrees. And that occurs at the fourth and fifth, and there's usually less motion as you go kind of medial. So for the second and third TMT joints, a study shown that it's 0.6 and 1.6 respectively in terms of sagittal plane motion. And then as we come towards kind of where the Liz Frank is, it's way, way less. And essentially that kind of imparts some of the injury with when there's too much motion. So thinking about clinical pearls, these are classically axial load on a plantar flexed foot. The axial load is applied with the plantar flexion, usually at the MTP joints. And that causes the ligamentous complex at the TMT joints to fail dorsally. There can also be rotational forces applied to the midfoot, which could cause additional subflexation or dislocation. And some other kind of types have been due to dorsal flexion, AB duction or adduction of the midfoot. They're often high energy injuries. We think of fall from height, crest injuries, MVC, but they're also kind of a low injury variant, which is usually athletic injuries or gun level falls. Again, these are subtle and often missed. A review of over 2000 cases in the literature saw essentially this distribution of injury pattern. And so you can see that only 10% were from sporting injuries, but I imagine that's kind of what you guys would be seeing and interacting with the most. So rare, but a lot of times it sees us and we don't see it. And again, as many as 4% of that initial 0.2% occurs in NFL players, which is kind of an interesting pearl. In terms of physical exam, these patients usually have an inability to bear weight with dorsal swelling and plantar ecchymosis, midfoot pain, and any pain with passive range of motion of the forefoot. It's really important to get a good exam in terms of neurovascular status because do you imagine the dorsum of the midfoot is not very big and doesn't have a lot of space to accommodate swelling. And so there are thoughts that you could have one, myopraxia or nerve injury, especially adgenically within surgery, but also if there's too much swelling, there's also a risk of compartment syndrome. There are a few maneuvers that you can do that patients will probably hate, but are kind of clinically interesting. There's the Pichiano-Key test, and that kind of recreates instability via dorsal force on the forefoot while stabilizing at the TMT joint. Meyerson looked at doing coronal compression across the first and second metatarsals, and there's usually a click or reproducible pain. In terms of imaging, there is kind of a panoply of things that we are pimped on as residents and trainees throughout, so I'll try to go through that with you because it's helpful to kind of take a look at the x-rays in practice this way. But typically, there's an AP oblique and lateral image of the foot. Weight-bearing views are super helpful, especially in cases of subtle injuries where one's an athletic individual. Comparison films are helpful because they can kind of give us a sense of what that person's native relative anatomy is, and it kind of helps us figure out if this is a real injury or if this is just how they were born. Dynamic stress views are helpful again for subtle cases, and the kind of path mnemonic sign for these is the flex sign, which is the avulsion either off of the second metatarsal base or the cuneiform. So here is a view of a normal and an injured Les Frank kind of interval, and typically we think about 0.2 millimeters of diastasis as being positive, but again that's kind of all relative. So looking kind of standard radiographs at the AP view, we use that to look at the diastasis between the first and second metatarsal bases. The medial border of the second metatarsal should line up with the medial border of the middle cuneiform. They're also helpful in evaluating any displacement through the intercuneiform joint or the CN joint. It also helps identify any fractures at the metatarsal bases and also at the medial middle cuneiforms, and it helps us look at proximal extension. Here's an example. So you can kind of see relative widening here through that interval. So then oblique views. These are 30-degree internal rotation views. Here the medial border of the fourth metatarsal should line up with the medial border of the cuboid. These views are helpful in evaluating any displacement of the third, fourth, fifth metatarsal bases, lateral cuneiform, and cuboid. So here are a couple of images of patients with kind of positive findings here. So you can see on this view on the right that none of these metatarsal bases line up with the midfoot articulations as they should. Here you can see a little bit of comminution through the cuneiform and then a fracture at the base of the second. Then lateral views. We use those to look at the dorsal cortex of the first metatarsal, and that should be collinear with the medial cuneiform. Here again you can look at any dorsal planar dislocation, fracture displacement, or any flattening of the medial longitudinal arch. So here is a lateral, and you can see that does not line up. So kind of your spidey sense it should go off with that. Stress radiographs. Again, good adjunct to diagnosis. It would be very hard for some to comply with this unless dated, so a lot of times it's most kind of useful intra-op to think about your reduction, and certainly when they're asleep it's much more humane. But if you're concerned and the patient's willing, it's a good way to figure it out. So again, pronation, abduction of the forefoot while stabilizing midfoot, issues with it. There's no real standardization of how much force to impart, so kind of as much as is necessary is how it was taught. There's also potential for iatrogenic injury if you're moving way, way hard. And again, patient compliance with it. So here's a fluoro shot of a stress view, so you can see sad fingers here doing a little bit of abduction and looking at the interval widening there. And there's some instability too. So in terms of advanced imaging, it may be helpful to think about articular involvement. It may also identify non-displaced or any occult bony injury. Also super helpful for preoperative planning if you want to take a look at combination that may not be visible in x-ray. I'll play that again real fast for you, but you can see as we're coming up through this area, injury here with combination of the cuneiform and then a fracture of the second metatarsal base there. In terms of MRI, they might be helpful if you're looking for the presence or the extent of ligamentous injury. It's also helpful for early detection. The bony edema and soft tissue injury would be visible earlier. It's difficult though to know how much this aids in terms of diagnosis in a higher injury setting, but certainly for a lot of the athlete injuries, it's been a helpful tool. So treatment options. I like to think about it as acute versus chronic. Here we're really focusing on acute, but it's helpful to know that if these are misdelayed, they can basically cause a whole host of forefoot-midfoot issues, including midfoot instability, forefoot abduction deformity, collapse of the medial longitudinal arch, and post-traumatic arthritis. We actually had a patient who presented super late for many reasons. You can kind of see the intense deformity here with the abduction of her foot. It may be hard to see, but she has completely flattened through the arch there. So now back to thinking about acute injuries. Non-operative indications are essentially if the injury is super stable, no displacement on weight bearing and stress views. Here's where that's important because you really want to know that this isn't something that's going to fall apart if someone's walking on it or if there are any unforeseen issues or if the patient's unable to undergo surgery for whatever comorbid issues. So in this case, the treatment would be cast immobilization for six to eight weeks, probably longer than that in terms of non-weight bearing, but people like to kind of shut it down with a cast or a splint, or if someone's unable to tolerate that for some reason, you could kind of consider other options, but that's pretty much standard. And then you need serial radiographic monitoring to make sure that nothing's displacing. In terms of operative options, the real goal is to kind of weigh the patient demographics with your intervention. So thinking about age, extent of injury, their activity level, their desired return to sport, and then kind of consider that in terms of timing, which is kind of balancing soft tissue status and hoping that it won't go into sort of more chronic injury. So indications here, any evidence of instability, malalignment, or concomitant injury. Treatment options, there are many. This is one of the kind of hotly debated things in ortho foot and ankle. So provisional fixation, delayed RAF and arthrodesis. There's a couple of studies out of where I trained that look at doing kind of provisional X-fix and then delayed fusions for some of these acute and chronic injuries, which is interesting as well. There's closed reduction percutaneous fixation, a full open reduction internal fixation, and then primary arthrodesis of the midfoot. Either way, all these people, again, get immobilized for a very long time, at least six weeks. And then I know kind of there are a lot of ranges of when people start to feel comfortable letting patients wait their posts operatively, but typically it's around 12 weeks. So it's really a long haul for these folks. So looking at the options, essentially surgical management is either joint sacrificing or joint preserving. When to actually use fusion versus RAF versus closed reduction percutaneous pinning, again, is super controversial. Many, many fixation contracts, including wires, screws, solid and cannulated, plates either used in bridge or compression, staples, tight ropes, suture buttons. So this is kind of a choose your own adventure thing for surgeons, which is really nice, but ultimately patients know that they will be getting some combination of hardware and not be walking for a long time. So looking at fusion versus fixation, these are just example radiographs to kind of get a sense of the constructs there. So here's one where we did a closed reduction percutaneous pinning and basically stabilized with a lift string screw and then an intercuneiform screw to keep that stable as well. And then here's one where she was acutely fused. We used staples across the first TMT, staples across the second, or one staple across the second, and then a plate across the third. So complications. Post-traumatic arthritis is the most common. Removal of hardware, theoretically a complication, but really kind of another step in the treatment algorithm, depending on how you look at things. It's reported as both in the literature, which is sort of interesting. Infection, male union, non-union, plaintive experiment, and neuroma. So removal of hardware, I'm highlighting just because for a patient's life overall, it's important to kind of think about this in the context of their treatment timeline. So studies have shown, again, the rates of removal are higher for RAF versus fusion. Essentially, the thought is to remove electively, so to speak, at a certain time interval that no one has really chosen a consensus for. So really anywhere from three to six months post-operatively. Three to six months post-operatively. Thinking about when is important, but also if a patient is kind of amenable to a second surgical intervention, it kind of sway you one way or the other. So another thing to bear in mind is that people are often then required an additional period of non-late bearing or limited activity after the elective hardware removal. So I think overall it's kind of difficult to assess outcomes holistically for these injuries because it's such a varied injury complex. But really the crucial part is early diagnosis, and hopefully some of the things that I went over here will help that. Return to support usually happens when patients are able to bear weight without pain. That is super subjective, but that's probably the closest I got to sort of a consensus answer in talking to my attendings and looking at the literature. There was no real consensus again for when to start sports-specific training in full play, so I think we kind of play it by ear. So overall, take-home points for y'all. There's a lot of debate regarding the optimal treatment of these injuries. Essentially you should have a very high index of suspicion when evaluating patients with mid-foot pain and a couple of the other kind of classic signs. Their evaluation of the x-rays is helpful, again because as high as 20% of these are missed on initial radiographs. And ultimately when thinking about how to talk to patients about it, these are super painful, potentially career-threatening, or essentially really changing your level of activity if you're a weekend warrior or sort of a layman's athlete. But these really take up to a year for you to start to feel normal and get back to where you were previously, and that in and of itself may not be realistic expectation. So a bunch of references for y'all, but thank you guys so much for coming. Thank you. Thank you, Dr. Boakye. That was a great review of a complex injury. Now moving up the extremity to the ankle, we have Mr. Thomas Hunt, who's going to be talking about ankle fractures deciding who should be operated on and who should not be, and going over the evaluation. So Mr. Hunt is a certified physician assistant in the Orthopedic Foot and Ankle Center in Columbus, Ohio. Also serves as a clinical associate professor at Ohio Dominican University since 2012. So take it away. Thank you very much for the introduction, and thank you to AOF for having me speak tonight. I'm happy to speak about this subject matter. I drew the short straw drawing 10 minutes for all of ankle fractures, but I'll do my very best to cover the most pertinent aspects of this. As far as it is related to this talk, I have no pertinent disclosures. The objectives of this is to really just try to evaluate the fracture types of the ankle, determining the specific criteria for when we can treat these non-operatively versus when they would require surgical management. I'm not going to spend a lot of time with the anatomy review. Pretty much everyone that's logged into this webinar has a good sense of anatomy here, but what I do want to take note of is the deltoid ligament is going to be very important when we're looking at bimalleolar fractures, and particularly trying to isolate out what we believe or perceive to be a Weber fracture that is actually a bimalleolar equivalent that's going to have a lot of significance as it comes down to the medial ankle anatomy, in particular the deltoid ligament. Lateral ankle ligaments as well are important, but typically when you're dealing with fractures, it's the bone that has been compromised. In a lot of those situations, the ligament was not the stress point because it was the bone that gave way rather than the ligament tearing. When it comes to fractures, ligamentous anatomy laterally doesn't always play a role until you start getting into, again, bimalleolar equivalent fractures where you're looking at syndesmotic disruptions and those type of ligament compromises that will help us try to make a determination on whether or not we need to look at surgical intervention. When we look at fractures, we want to look at a basic fracture principle, and when we're going through an algorithm to try to determine who would need to have surgery, the first thing to ask is, is the fracture open or closed? Obviously, open fractures would require immediate surgical intervention, whether it be an external fixator or internal fixator, that decision we can decide based off of gross contamination, and we'll get into that a little bit later in the discussion. Displaced and nondisplaced obviously also plays a role. As a surgical practice, we're not expediting recovery by providing surgery. We are providing a more anatomic alignment. If the fracture is nondisplaced, depending on the type of fracture, more often than not, we can treat those nonoperatively, but displaced fractures oftentimes would need to be typically addressed surgically. Also, things to consider when considering surgical intervention is if there's any type of neurologic or neurovascular compromise, or if there's any soft tissue and ligamentous injuries that may hinder the overall recovery of them nonoperatively. Again, when you look at operative versus nonoperative, you have to determine what the type of fracture is, and then what are the patient's overall healing potential? Do they smoke or use tobacco products? What is their overall bone quality? What is their diabetic state? What medications could hinder their healing, particularly some of the rheumatoid patients with a lot of their steroids, wound issues that could come into play with some of the biologics, and then also the patient's compliance. Obviously, compliance could lead you to surgery that you otherwise wouldn't really consider if it was a nonoperative setting, but also compliance may lead you to treat it more nonoperatively, even if it's an operating patient, just because you're not certain that they're going to comply with the surgical recovery. Radiographically, we typically will look at an apilateral and oblique fuse. In some regards, if we're looking at bimalaral or equivalence, we'll do an external rotation stress, much like Dr. Baiochi mentioned with Liz Franks, how well they can tolerate a stress examination can be difficult. You may have to do it intraoperatively or under some sort of anesthetic to try to get a true sense. Then obviously, with x-rays of the ankle and particularly fractures, you always want to take a proximal x-ray just to roll up the mesonear or the proximal fibular fractures that may be associated with synesthematic disruptions. We'll go through each individual fracture types now. These are the fracture types that I'm looking to highlight in this discussion is the isolated medial malleolar fracture and then the Weber fracture classification. We'll touch upon bimalleolar and bimalleolar equivalent, posterior malleolar fractures, and then fracture dislocations and open fractures fairly quick because almost always that's going to require surgical intervention. As I talk, deciding the indications for surgery, those are almost always indicated for surgery. When we're dealing with the isolated medial malleolus fracture, location is going to play a role in whether or not it's displaced or non-displaced. Most of these fractures are going to be closed fractures for the most part, particularly if they're non-displaced. Evulsion fractures rarely would require any type of surgical intervention unless you're going to go in to stabilize the deltoid, but typically you're going to provide them a period of time to see if they can heal that before looking at surgery. That's going to be really more for a chronic unstable patient that has healed the fracture but didn't necessarily hear the deltoid complex. When you look at operative, if it's an open fracture, obviously we're going to be looking at operative management and then if the fracture segment is displaced or if there's any degree of tailored tilt. The only caveat to that would be your vertical shear fractures of the medial malleolus. Sometimes even if those aren't displaced due to the shear force of them, they often require some sort of plating. Usually two screw fixations won't be sufficient with vertical shear fractures. When turning our attention to lateral malleolus, we have to look at the Weber classification and determine its overall location. Weber A is below the joint line where Weber B is at the level of the joint line or trans-endosmotic and then Weber C is typically proximal to the joint line. Weber A's oftentimes can we treat these conservatively, particularly if they're non-displaced, if less than three millimeters of shift and there's no tailored tilt. This is certainly in this picture here, reasonable fracture to treat non-operatively. As long as there's no medial clear space widening or shift and it remains non-displaced, then typically we can have an indication for non-operative management with this patient. Once we start getting into operative management, you're typically looking at displaced Weber A's or Weber B and C fractures that tend to disrupt the syndesmonic and deltoid ligaments or have a degree of fibular shortening. The deltoid pain in this x-ray, it's clear that there's medial clear space widening. So from a surgical standpoint, this would be a patient where we would opt in and indicate for operative management. But if they don't see a medial clear space widening, that could certainly be a bimalleolar equivalent. If they have a significant amount of pain over their deltoid, you'd be surprised at how many times surgically we would take that patient to the operating room. We always open Weber B and C fractures medially with a medial arthrotomy and a good majority of them do have a deltoid tear. There's certainly some reports in the literature where you could leave that. A lot of traumatologists will leave the deltoid alone, but in a foot and ankle specific practice, we almost always go over and assess the deltoid operatively. Bimalleolar fractures are the more obvious of it. I put equivalent on this stage as well when they're not that obvious, but typically bimalleolar fractures are fractures that involve both the lateral and the medial malleolus. There's usually a displacement and even if there is not a significant amount of displacement, these fractures inherently are unstable. So if the patient's healthy enough and it seems to be appropriate, then surgical management would be much better suited for bimalleolar fractures. Non-operative, really the only patient population that we would not consider bimalleolar or AF on non-operatively would be if there's something in their concomitant health history that would prevent them for any type of surgical management. But typically this requires an open reduction internal fixation. You usually have to stabilize the fibula fracture first, plus or minus the syndesmotic ligament. And then, like I said, we always make an approach immediately for the deltoid, whether they had an actual medial malleolus fracture or not. But if the medial malleolus is fractured as well, then that would also require surgical stabilization. Here's a before and after picture of a bimalleolar fracture. You can clearly see the medial clear space widening with the displacement of the medial malleolus, and that required a fibula plate, which reduced the mortise and then malleolar screw fixation. Again, another one which clearly shows subluxation medially, and then we would have to really make sure that in assessment of this patient that we're assessing their neurovascular status. This clearly had syndesmotic disruption, so this one required a tightrope fixation or screw fixation across to also stabilize the syndesmosis. Stereo malleolar fractures, if they quickly result in less than 25% of the articular surface, then we can treat these non-operatively. A CT scan is much better at determining the amount of articular surface that may be involved. Also, if there's any type of step-off, two millimeters or greater in the articular surface, again, CT's a little bit better at picking that up. This is a fracture on the right that we would clearly be able to treat non-operatively, but we would still likely CT that just to make sure there was no step-off, although in the plain radiographs, it does not appear to. Operative management is obviously for articular surfaces that are greater than 25% or have a step-off. Clearly, you can see on this x-ray that that involves approximately 50% of the articular surface, so this would be one that, even though it's not displaced, would require surgical intervention because of their high degree of post-traumatic arthritis down the road if you were to leave that inter-articular surface mile wide. And then here's, arguably, maybe between the 25 and 50% of the articular surface, but clearly has the two millimeter articular step-off at the joint level. Fracture dislocations, there's obviously a lot of different types and mechanisms, but most, if not all, fracture dislocations would be surgically indicated here. So the decisions for surgery and fracture dislocations, there's just really no non-operative management that would be able to be used in this setting. Open fractures, obviously, would require surgical intervention. You're not really making a decision at that point whether or not an open fracture requires surgery. It's just a matter of how you're going to proceed with that surgical intervention. Are you going to do a primary debridement if the wound is grossly contaminated? And can you do a primary open reduction internal fixation if it's a healthy patient that's low energy without any real significant contaminants? And you could perhaps do it in one setting. But a lot of these are high energy type fractures, usually have gross contamination of the wounds, your motor vehicle crashes, your motorcycle crashes. So oftentimes you're going to start with external fixation to be able to settle the soft tissues down and reduce it without further contaminating your internal fixation from an infection standpoint. Thank you. That was terrific. Thank you very much, Tom Hunt. And then now we're going to go to Ashley Waite to do some talk about rehab. So Ashley Waite is a board certified orthopedic clinical specialist and doctor of physical therapy. She presently works for the Department of Orthopedics at University of Rochester Medical Center. She is actively involved in the foot and ankle, knee and running teams, as well as the orthopedic residency program within the sports and spine rehabilitation department at URMC. Her post-professional special interests and continuing education endeavors have been focused on clinical examination of runners, clinical gait analysis, as well as strength and power development for endurance athletes. Take it away, Ashley. Thank you, Jeff, for the introduction. I'm excited to be back to talk to you guys about ankle fractures, both post-injury and post-operatively and how we're going to manage these individuals in a rehab setting. I have no disclosures. So my objectives for today are going to be to discuss considerations for conservative, as well as preoperative physical therapy interventions as they relate to the management of patients with ankle fractures. And then I want to dive deep into it and outline some of the interventions and considerations that we should take into account in the acute, subacute, and also the long-term management of these individuals. So the initial interventions really for these patients with ankle fractures are going to occur as soon as the ankle injury is identified, whether it's by a PT, athletic trainer, coach on field. What we're going to look at first is the Ottawa ankle rules. If we have a positive Ottawa ankle rule finding, we're going to educate the patient on appropriate management, as well as follow-up. So we're sending this person out to urgent care for imaging to rule out a fracture before continuing with our intervention. If we don't have any positive findings on these Ottawa ankle rules, we need to make sure that we're also looking proximally, making sure that we're not missing any other injuries that may have initially been missed. So especially if these are patients of advanced age or a patient who has suffered from an ankle fracture or ankle injury, I guess I should say, from fall. The sooner you can implement patient education related to price principles, appropriate assistive device use, the better. And then eligible clinicians, those of us who can practice under direct access, if we decide that it would be appropriate, we could continue to treat these patients under direct access for 10 visits or 30 days without a physician's referral, given that we're not suspecting that there's a fracture present. So I'm gonna go over this relatively quickly, but the location and the severity of the fracture is gonna contribute, of course, to how successful conservative approach may be for the individual suffering from a fracture. And I usually educate patients that if we're looking at the ankle as a ring of supporting structures around the talus, it can really help us appreciate how instability may become a chronic concern if that ring is broken in more than one spot. So again, depending on the stability of the fracture, it's gonna determine what the optimal plan of care is gonna be. And the malleolar fractures are gonna make up the majority of ankle fractures, and that's gonna be the focus of my following slides. And then the principles related to exercise progression discussed in those slides, it can be implemented in a non-op patient case scenario, it just sort of depends on where that individual is with their weight-bearing status. So this systematic review with meta-analysis looked at the prognosis of physical function following ankle fracture. And what they found is that whether conservative or surgical intervention was implemented, the fastest gains in function for these folks is gonna occur in the first three months, and 80% of the total gains are gonna be in the first six months. Unfortunately, the progress slows and kind of gets to a ceiling effect around that six months. And then there are some functional limitations reported even two years post-injury for these individuals. And in my experience as a PT, oftentimes the referral is placed well into the acute phase of recovery for these patients. And I really think that patients could benefit from PT intervention as soon as possible following an injury, as long as there's appropriate restrictions stated in the referral. But I think that we can potentially help close the gap and bring these patients a little bit closer to 100% recovery by the time that that natural healing process is going to slow down. So the acute phase of recovery can be broken up into maximum protection, moderate, and minimum protection phases. Post-operatively, a patient will remain usually non-weight-bearing with a cast or a splint until the follow-up with the doctor at two weeks post-op for a reassessment. Traditionally at this point, patients are gonna be non-weight-bearing precautions until their follow-up with the doctor, then again at six weeks post-operatively. In the meantime, there's encouragement provided to continue with all of the price protocols, protection, rest, ice, compression, elevation, appropriate use of assistive devices for safety, and also starting to perform some toe exercises, just getting them moving to minimize the risks of DVT. And the one area that again, I think we can really approve upon as PTs is just getting these patients into an outpatient setting to review appropriate exercises in general for their health and wellness. That still might be indicated despite having a post-op status. And setting up a relationship with patients early on can set the stage moving forward for a timeline transition to routine PT intervention when that's deemed appropriate by the ordering physician. So related to PT intervention early on, this prospective randomized control trial was conducted to assess the effect of overall health status with weight-bearing at two and six weeks post-op and ankle ORIF. What they found is that weight-bearing had a statistically significant benefit in patient-based general health status. Looking at five different aspects of the patient's health quality at six weeks post-operatively. And these improved scores did not come at the cost of any adverse events in terms of wound problems or loss of fixation. And then some other benefits to consider with early weight-bearing would be to improve your muscle strength, increase your ankle range of motion sooner on, decrease osteoporotic changes, and decrease the demand that an individual is gonna have on their upper extremities, especially if they have an issue going on in their upper connect chain. All right, so traditionally, the outpatient PT starts during the moderate phase of protection, somewhere around six to eight weeks. With a patient coming into the clinic and saying weight-bearing is tolerated, I've just started walking, just put my foot down on the ground. So I included the timeframe here of two to eight weeks just because the research is pointing towards potential earlier weight-bearing recommendations. However, more studies are being conducted to analyze this recommendation. So at this point, methodology of therapy is gonna include facilitating the reduction in swelling with progressive loading if that's indicated. I typically recommend that patients buy compression socks if they don't already wear them just to ensure that we're keeping the expected amount of swelling under control. From here, we're initiating range of motion exercises to restore motion, specifically dorsiflexion. And then we can consider using graded mobilizations for desensitization, edema management, and pain relief. Muscle inhibitory techniques, isometrics, also including some balance and proprioception activities as indicated. And also I think it's important to be mindful of incorporating the uninvolved lower extremity into your balance and proprioceptive training, even if there are weight restrictions on the involved side, just because that will help optimize the benefits of cross-education principles. And at this point in their plan of care, ideally we'd be seeing these patients once a week for PT guidance. So between weeks eight and 12, we're entering the minimum protection phase of recovery. We're emphasizing light intensity activities. It'd be beneficial at this point to obtain a baseline foot and ankle ability measure if you haven't already, just so you can monitor their functional progress. Here, we're going to facilitate more mobility, strengthening more so into the end range of motion, gastric strengthening as appropriate, proximal strengthening based on what the patient's goals and expectations are, gonna progress their stability, their neuromuscular control activities with bilateral balance activities, proprioception challenges, starting bilateral, progressing to unilateral. We can also manipulate the visual system and also challenge them by having them stand on different compliance surfaces. And then we can take them from static balance challenges to progressively harder dynamic challenges. Also incorporating some unanticipated balance drills once they get closer to that return to sport phase to help facilitate control around their daily environments. So as we enter more of the subacute recovery phase around 12 weeks post-op, at this time we can unfortunately expect gains and function to slow. However, we still have three more months left to expect gains upwards of 80% of their prior level of function. So at this point, we're trying to incorporate more work hardening tasks and functional strengthening, provided that their foundational range of motion has been achieved, as well as general base of stability, their pain levels are under control. And at this point, recovery is gonna continue for two years post-operatively. So depending on who the individual is in front of us, we might be working on like plyometric activities to return to run progression. We may consider decreasing PT frequency to every other week if we haven't already, just provided that our patients are compliant with their program. Okay, so at URMC we use a return to run criteria that we put all of our patients through. So essentially we're having them go through these testing in this order. So a closed chain dorsiflexion test or a knee to wall test, we're assessing their single leg heel raise. We are looking at a frontal plane or a lateral step down. Y balance test, we are asking them to hop some maximally vertically on one foot, and then we're also watching them jog. So in order for us to clear them to return to run, we're looking for at least 85% limb symmetry between they're involved and they're uninvolved in order to return to a walk run progression. And if the patient doesn't pass on their first test, which is usually the case, usually they have to go through this a couple of times. We plan on reassessing them again every two to four weeks until they do pass it. At this point, when they pass their return to run, we like to have them running for two weeks prior to progressing them to anything more formal, like sport specific as an agility and plyometrics. So for individuals that have lower level expectations, you know, we don't necessarily need to put them through this. We'll just continue with the functional strengthening if they're not looking to get back into some of these higher level activities, some of our older patients. Okay, so once our patients at the six month mark postoperatively, we're starting to consider the return to sport or full return to work in those individuals who have a physically demanding occupation. So like I said, at this point, our athletes have been provided with the return to run progression and they've been working on progressive strength training and plyometric progressions between that return to run test and this point. So that gives you about two to three months worth of activities just to allow for, you know, appropriate periodization and to avoid an overtraining syndrome. And then with our return to, excuse me, return to sport testing, we're gonna be looking at these different components. So a single leg crossover hop for time, single leg figure of eight hopping test, single leg frontal plane or lateral hopping over a 30 centimeter mark, single leg square hopping, and then we're going to put them in a fatigue state. So we'll have them do single leg heel rise to fatigue, which isn't necessarily graded at this point because they should have already theoretically passed this for the return to run. And then we look at that single leg crossover hop for time again to see what their form and their tolerance is once they're in a fatigue state. And with this, we're asking for a little more, we're looking for 90% limb symmetry on all of the criteria in order to pass. And we're also taking into consideration their foot and ankle measurement scale, their score on that outcome measure should be greater than a 29. So, you know, what's our canary in the coal mine? How do we avoid overtraining syndromes? So, you know, we're keeping an eye on our pain, we're keeping an eye on swelling. I'm instructing patients that if they have a little pain and swelling, of course, that's normal, but if it doesn't resolve within 48 hours, if it's, you know, causing a disruption in sleep, you're noticing that you're limping, your range of motion is regressing, specifically closed chain dorsiflexion. We are pulling the plug or we're backing off a little bit on wherever they're at in their exercise progression. And then of course, any neurovascular symptoms is a cause for concern. And, you know, we want to, again, try to avoid that overtraining status by keeping an eye on these factors. So in summary, earlier is better. The sooner we can get these patients in for PT, the better. You really can't underestimate the value of patient education and just simple reassurance that can be provided in the very early phases of recovery. Regardless of the time from injury you're seeing a patient, you want to make sure that you're following basic principles. So don't forget the basics. You want to make sure you're implementing appropriate strategies to optimize the lower kinetic chain biomechanics before even thinking about getting back to running or getting back to sports, regardless of whether or not they've, you know, been at six months post-op or not. So this is really going to be imperative for the longevity of the joint. And in the later phases of rehab, when all the basics have been checked off, an individualized PT plan of care really needs to be implemented to ensure that you're providing the patients with optimal stimulus to achieve demands of their specific activities of daily living and their personal goals. Thanks, Ashley, that was great. Yeah, so I think we've finished with all the speakers and now we're ready for questions and discussion. And I think we have one in the chat, but if anybody else had a question or something that you heard that you want to answer to, now's the time to put it in the chat and we can put it in front of the speakers. I see the first one here, I see one that's about the Liz Frank fracture. Do you want to start with that, I think? So this says, can you read it? I don't think that the audience can read it. I think this is just going to us, so yeah. Maybe I'll read it out loud and then we can kind of answer it. So what is consensus of Liz Frank weight-bearing post-ORIF and then parentheses bridge for young athletes before hardware removal? Is there a difference between eight and 12 weeks considering osteopenia with waiting the full 12 weeks versus earlier weight-bearing if asymptomatic? So that's a good question. I think, honestly, there have been a couple of studies looking at early return to weight-bearing and return to sport with these lower energy ones, especially if they're fixed with a closure reduction part pending. I've seen as early as eight weeks for those and somewhere between six to eight for weight-bearing and then initiation of sport. But typically, if it's any higher injury or more involved in terms of open reduction, functional fixation or fusion, the delay for weight-bearing, at least in the places I've practiced, has been closer to 12. We kind of anticipate that there would be just due to osteopenia, but sorry to our PT friends, but it's usually a really long time. And I think if there are more studies that can be kind of done looking at the impact of early weight-bearing, certainly we welcome them, but that's kind of the practice paradigms that I've seen. Yeah, I mean, the way that I, obviously we worry about everything breaking before the ligaments yield. What I tend to do is I let them start weight-bearing at six weeks, but they have to do it in a protected state. So I don't let them walk outside the boot, thinking that at least it'll allow them some mobility, some avoidance of that disuse osteopenia, but putting less strain on the joint. So I don't let them really train, I let them do range of motion strengthening, but no real weight-bearing without the boot until the hardware comes out. I think for me, it's a little different whether it's a dorsal plate versus a transjoint screw, because if a plate breaks, while obviously I don't want it to break too early, I worry less about destruction of the joint versus a screw that goes through the lisfranc joint or through the intercuneiform joint. But I agree with fusion, I take a little bit longer to let them walk. So walk at six weeks. So, hey, I had a follow-up question just to keep it on lisfranc for a minute. You know, you were talking about return to play criteria for lisfranc, and Ashley presented one for ankle fractures and running. Would some of that apply to the return to play for the lisfranc injuries? Yeah, that's a great question. As she was kind of going through it, I was thinking, I wish we had that protocol. It's a really neat way to kind of think about how people can functionally participate in their desired sport, and that's a good test, essentially, of what they'll kind of endure as they are in their actual setting. So I think it's interesting because kind of our paradigm has been you can walk and run when it doesn't hurt. And again, that's been super subjective. I haven't had kind of strict criteria for it, but I think I will probably adopt some of those in order to kind of hone in kind of a better time point for when people can start getting their lives back. Now, and what's interesting about the lisfranc is that, you know, when you look at and we actually, unfortunately, I don't have the name of the study, but we just reviewed this in our sports journal club that ORIFs actually take longer to get back to sport than fusion because you're going through two recoveries. So we just said, you know, well, technically, the longer you keep the hardware in the better, you know, if you can keep it in for three, four months, but then you're not really rehabbing them until four months, and then you just reopen their incision, took all their hardware out, and you're kind of restarting back over. Whereas fusions, interestingly, because you're not taking hardware out, actually, you return to play sooner, which is a little bit counterintuitive, I think. So we fell out of love with just doing ORIFs a while ago and switched to doing fusions on most of our patients, even the younger ones, even the lower injury ones, because we were letting them wait there at six weeks and protected. So we'd keep them in the boot for 12 weeks or 10 to 12 weeks, but we would let them walk on it at six weeks and then get them into PT as quickly as possible, even in the boot. And we just found that these people did better and we had less, we must've had a run of, it's been a few years, we had a run of just failures and screw breaking and plate breaking. We would try the different techniques as they came out and the fusion folks just did the best. And we found that functionally that it wasn't as worth it to spare the joint as it was to just get them back to life quicker. And ultimately they've done better. And so I know it seems a little like heresy, but that's what we've been doing in our practice for quite some time now. And I'm interested, Dr. Wade or Dr. Hauk, what do you guys see, we talk about it that you fuse a joint and obviously you fuse an ankle or sub-tailor joint, that's a big deal. And then when, at least I have the discussion with patients, especially the middle-aged people are really concerned about fusing a second TMT joint. I think of it as not a big deal, but when you're rehabbing them, do you see changes in mechanics with these midfoot fusions? Ashley, you want to go first? Sure, I'll jump in. I think a lot of what I see is the weight bearing restrictions that they're on are obviously very warranted when it's in the midfoot, but there's so much fear and apprehension going into it that I think a lot of what I see and I struggle with initially is getting that neuromuscular control back, regardless of whether it's a fusion or an RAF. So that's why I'm plugging for getting them in sooner because just having them even put their foot on the ground, just to feel the ground and get that sensory awareness, I think is a huge benefit to these folks, provided that you're going to trust them, of course, that they're not going to, you give an inch and they take a mile. But I think just waking up those sensory receptors and getting them moving in directions and planes that are safe is a good way to encourage them to get as much out of it as they can without putting the risk of the hardware in jeopardy. And that's a great answer. And I just, in addition to that, I think when they get rigid in the midfoot, you've just got to make sure they have motion at the other joints, like subtalar joint and ankle joint, they have to have sufficient compensatory motion basically to make it a non-issue. And I think I just get really aware of all of that. Well, and I think what we found is that after an injury, even with an ORAF, their joints aren't great long-term anyways. And so we were getting quite a bit of, you know, post-traumatic arthritis in these folks or stiffness, maybe subacute arthritis. And so it wasn't like we were keeping these virgin joints, right? I mean, that's what happened. That's what we just found is that they would show up with like the stiffness and the sort of post-traumatic arthritis. And so it was like, well, are we really saving? We're working really hard to save these joints. We're keeping them non-weight. We used to keep them non-weight-bearing for 10 weeks. And then lo and behold, they don't have great joints anyways through the midfoot. And so that's why we went to fusing. And I don't know. I don't know what the great answer is. So we have another left turn here and discussion. And the chat, so, and this is, and I love this question because I think it's, it comes up all the time. It's like a mason new fractures, like when you're kind of staring down at the ankle, and then all of a sudden you've got something up at the knee. So somebody said, I was asked a direct question about the, you know, amazing new fracture, you know, maybe what is it? How do you figure out what's going on? And when should you be suspicious of it? Yeah. So as a new fractures, you know, it's obviously a little bit different from a traumatic setting versus, you know, orthopedic setting, you know, any patient with any ankle injury or any injury of any sorts, you know, emergency room, urgent care trauma centers are asked to x-ray the joint above and below. Sometimes in orthopedics, we don't always get that. We should already have that as they come to us. But as a new fracture is a type of fibular fracture or bimalleolar fracture, but basically it can be a fibular fracture in and of itself or bimalleolar equivalent. But what's happening is as the force of the fracture migrates up the syndesmosis, that force has to exit out somewhere. And that will either go across the articular surface exiting out the deltoid ligament or in mezzanine fractures, they will travel proximally up the syndesmosis and the force will exit out either in the mid shaft of the fibula or even all the way up to the proximal aspect of the fibula. They're rarely displaced. Mid shaft fractures are a little bit more displaced than the proximal fractures of the mezzanine, but oftentimes we don't have to fix the proximal aspect. Even if it's mid shaft fibula and it is displaced, it's not the weight bearing portion of the ankle kinematics. So oftentimes we don't have to do an overinduction internal fixation of the mezzanine component. But for any ankle fracture or bimalleolar equivalent, it's always important for the examiner to evaluate the proximal aspects of the leg, evaluate the knee, particularly the lateral fibula. There have been some reports in the literature of some displaced proximal mezzanine fractures that were missed and then have common perineal nerve injuries associated with them. The common fibular nerve exit just adjacent posteriorly to the fibular head. So you do have to watch for it. It'll see you probably more than you will see it. But I didn't spend a lot of time on it because from a surgical indication standpoint, it's very similar to a bimalleolar equivalent or bimalleolar fracture. But it just implies that there's a symptomatic disruption associated with the fracture segment. Yeah. One thing I always teach my residents is that if you ever see an isolated medial malfracture or posterior malfracture, be very suspicious of something more proximal because that's unusual to see. So that's, you know, as we went through the Weber classification, you know, the Lady Hansen classification, it always involves the fibula. So when you don't see a fibula in your ankle x-rays, look higher and make sure that you're not missing something. But we have a question about fixation of the syndesmosis using two screws versus one. I guess you could also extend that to using, you know, a suture device versus, you know, more rigid fixation. I don't know if Tom, if you want to. Yeah, sure. And I'd love to hear the panel's thoughts too. I mean, from our practice, you know, I work in a, you know, subspecialty of just foot and ankle. So our whole group is foot and ankle. And we have, you know, six different partners that fix it six different ways. So the literature is convincing in either way. The advantages to the two screw fixation is it's a more rigid construct. So it will provide a little bit more stability long term if you're fearful that the syndesmosis may stretch back out over time. But you have to keep in mind that the syndesmotic joint does have some motion to it. So that's where the, you know, rope type fixation comes in or more flexible type fixation with the idea that you can get the more natural anatomic and kinematic movement that the syndesmosis in itself wants to apply. We have one physician that actually does one screw and one rope. And he'll come back in 12 weeks or so and take the screw out. But he's had a couple of occasions where that has shifted on him again. And then they had to go back in and redo it. So I think there's probably more anecdotal evidence on what the surgeon preference is more. So there's obviously lots of literature on it. But I think the people that are making the decisions on what type of fixation they have, it's based off of their own experiences and what they've had success with. But the downside to the hardware is because it's a flexible joint and will move with time, those screws almost invariably will break every time. Yeah. The thing I'll say about mesenov in particular, just like you spoke about, we're not usually fixing proximally. So something you have to consider is the pistoning effect that it can shorten, right, which is different than in an ankle fracture when you're fixing a Weber B or Weber C and you can bring it out to length. And so also when you have a distal fracture, you only have so much real estate. So it's usually hard to get two devices across if you're also dealing with a distal fracture. So I would encourage, I think too is important if you're not fixing the fibula because otherwise it's going to tend to piston. I tend, if I feel a fibula short, I'll use screws because I feel like I can pull the fibula down and hold it there. But I'll always take them out because I think people are more comfortable when they come out. I prefer the flexible device for almost every other indication. And you try to diverge them a little bit to try to keep that fibula stable in the incisora. But I think the important thing is getting your fibula out to length and however you can hold that, whether it's with solid or flexible device and they all certainly have their benefits to them. What have you been using, Dr. Boisje? So it's fascinating. In fellowship, there's kind of a split between solid screws and tight ropes. And when I trained in residency, my trauma attendings pretty much standardly did solid screws because that was kind of working within their wheelhouse and the foot and ankle sporty type folks would do tight ropes. So I think in future for me, kind of similar to what you said, Dr. Gainey, I'll probably do tight ropes for most people. But if there is proximal extension or a bunch of shortening that was really hard to get out to length, I'd consider solid screws. I think kind of similar to Lisfranc, you've got to think about the hardware removal aspect of it because these folks will come back kind of at a standard set time to get them taken out. Or if you're comfortable with it breaking and knowing that it's broken and that's in literature been shown to be okay, there's that option as well. But certainly another thing I thought about kind of in terms of implant choice is cost. The tight ropes are obviously way more expensive. And so if you kind of weigh the cost between tight rope at day zero versus implanting screws and then having a return trip to the OR, it's kind of hard to know what actually in the long run is worse in terms of overall cost. But there have been some good biomechanical studies that have tried to kind of say which is the best, but I don't know that they really reached a consensus. I'm moving on. I had a question for Ashley. So I started to move patients like you discussed to weight bearing early. My challenge is getting them to rehab because a lot of times they're right foot and they can't drive or they have a hard time. We have studies showing that reaction time really after ankle fractures is somewhere around six weeks. So that's been a challenge getting them into formal PT early, even though I'm having them walk. So I guess, are there resources that you suggest patients go to or just easy exercise they can do on their own early on before they can physically get to a physical therapy office? I don't have any resources that are out there per se, but I would think about like the patient in front of you and what their physical fitness level is already. And just, I think from a physician standpoint, I mean, there's always going to be an accessibility issue, I guess I should say that. So what we've done here at the U of R is we've put together like preoperative appointments. Now, obviously that's not always applicable in the trauma situation, but we do have like packets that we put together for patients, just covering the very basics, like, you know, make sure you're moving your toes, you know, you can do straight leg raises, side-lying leg lifts, things to get the rest of your body moving. Because oftentimes when patients get the, you know, don't weight bear, don't move, just rest, they take that very literally. So I think sometimes having, you know, active recovery, something to do that, you know, keeps your body moving as much as possible can be really helpful. So depending on what their expectations are, if they have a preexisting exercise or fitness regimen, maybe just, you know, open-end question, what have you been doing? And then giving them some suggestions as far as what is still safe to be doing, because oftentimes these patients just get really spooked and they don't want to do anything until they get the green light. When oftentimes there's a lot that they potentially could be doing to keep themselves in their best health and mindset before they can either get into us because of an accessibility issue or scheduling, or like I said, just the referral being placed at the time. I think that's a great point, too, so, you know, the percent of people who actually go to PT that could benefit is really low, right? And so, us as PTs would do a good job, like, having, like, a McDonald's version, right, of PT that just kind of serves, you know, French fries and the, you know, the Big Mac. I think what that's evolving right now in terms of the COVID kind of effect and also something that's already been in place to try to provide, like, something that's just like what, you know, Ashley just talked about, something just transitional or that just gets people moving instead of this kind of full-on elite, you know, kind of, you know, service. So, we have a question from the audience asking, when a patient only has so many PT sessions due to insurance constraints, at what point do you recommend the patient, quote, cash those in? Yeah, that's a really good question. I would say that, you know, earlier is better. So, once they have the clearance to be, I would say this, I would want to use maybe one or two as soon as possible, even if they were very limited, just for the patient education side of things. Make sure they're using their assistive device and doing everything that they can do safely. And then I would say the most important would be when they are allowed to start doing weight bearing to make sure that that's facilitated in a smooth manner, because oftentimes these individuals will get a lot of anterior ankle impingement, especially with the malleolar RAFs, and really ensuring that they're doing their dorsiflexion stretches correctly, that they're, you know, pushing hard enough, but not pushing too hard and knowing what they should feel. I think that that is absolutely key for these individuals to do well. So, I would say using it in that first three-month window when you're going to have the fastest gains is the most important. And hopefully getting one or two in right away, like I said, just for the patient education standpoint. I think I'd try to spread them apart across the whole six months. I would, I'd spread them out, I'd get them in and find out what their goals are and talk to them and then see how much they're independent. If they really want to do, you know, stuff on their own, I'd have them buy a slant board. They're only like, you know, 30 bucks, right. And have them do their own home gym, you know, but I think there's ways to take like six visits and spread them across a long period of time. Okay. So, since we haven't touched on fifth metatarsal fractures, Tracy, you're up. So, I have found that these zone one fractures, even though I agree I am a non-op person on these, they take forever to heal on x-ray, which you alluded to a little bit. So, you know, I tend to just go clinical exam, but at what point do you get concerned about, you know, not seeing healing and, you know, what's your discussion with patients about expectations with that? We definitely, especially if there's some displacement happening. I mean, and I tell them like, listen, what is your, I mean, we love to do surgery, but most of the time they will heal fine. And so I'm really upfront with them. This is going to take a while. And at the end of the day, every now and then some of them don't heal and we end up going in and doing something, whether it's shelling out a piece or putting a screw through, or we've done different things over the years, but for the most part, they heal. I did have a, like this 14 year old kid who went on to not heal and the mom, you know, was pretty bitter about it. And then, I mean like what 14 year old kid doesn't heal if it's metatarsal fracture, but he didn't. And then a year later, his sister came in with the exact same fracture. And I was like, I know, but like these heal. And she was like, not buying it. Of course, the kid went on to non-union. Of course they got surgery. I mean, every now and then they don't heal. And so I would say, I mean, I always give, you know, six weeks is like, you should be turning the corner. Like the light at the end of the tunnel should be happening. I always see him at six weeks and it's usually like, yeah, I'm a bit better. I'm getting better. It's still really slow. If they're super anxious to get back to work, it's a carbon fiber plate can be really helpful because everyone's over the immobilization at that point. So then it's usually, I'm like problem-solving shoe stuff. And then I would say most of the time at eight weeks, they're turning the corner. Like they're, they're fine. But it's at that like eight week time that they're usually calling back and they're like, I'm no fricking better. And they hate you and you hate yourself. Anyways, let me fix them. Do you send, tend to send these patients to physical therapy? Yeah, I send everyone to physical therapy. I'm a big physical therapy fan. And I let that sort itself out. I have some, a couple of really enthusiastic physical therapists in town that do well, you know, that really like foot and ankle and they're into it. I would say most patients don't take me up on it though, for the fifth met, you know, mostly because it takes so long for them to get better. They're in some sort of immobilization, whether it's that postoperative sandal or boot or whatever. And so like, God, their foot might be better, but like their hips all jacked and their backs hurting. I mean, they're just really worn down. And so honestly that probably gets them to physical therapy more than their foot. That's a great point. So I guess to that question for, for our PTs here, you know, you're right. I mean, I get a lot of, I offer them the even up on the other side, but are there any other tips you guys have as far as avoiding the back hip knee pain from wearing the boot or the sandal? Find an alternative. No, no, I mean, I'm not kidding. We do have, we are testing a brace right now, but that is less asymmetrical when you use it. But yeah, I mean, I, while you're using it, I don't know, exercise evening out the limbs. I I'm, I'm at a loss for how to make their hips fine, except for doing hip and knee exercises and you know, adjusting the gait. But I mean, Ashley, what do you have? I, you know, I'm in the same boat. I think I, I encourage everybody to get the two things, a compression sock when they're very swollen, cause that's always an issue. And then I'm using the even up can be, can be greatly beneficial too. So that, and just making sure that if they don't have the easy up, they have appropriate shoe wear. So, you know, making sure that you're not wearing a sandal on one side. I mean, it seems kind of obvious, but you'd be surprised that sometimes not. So I think that that's just helpful to go over appropriate shoe wear for what you're wearing on the side. That's not immobilized. I have a question for you guys on the fifth met. We used to surgically, we used to do RAF for, for those distal metatarsal fractures that were the long shaft fractures. I remember when I first started the surgeon I worked for would say, you know, we call these I'm in Reno. So everything's gambling associated here, but like we call these dealers choice, you know, like if you're ready, if you just want a predictable outcome and you want to get back to your life in six weeks, we'll just do an RAF right off the bat. And if not, you know, we can do non-operative management, but they're not as predictable. And, and somewhere along the way, we ended up like people do fine. And so we don't do as many, we just did one last month, but we don't do as many as we used to. And just, I wanted to ask if you guys, what you guys do with those as well. I have never fixed one. I've never had one not heal. Cause I mean, to me, unlike the proximal, like a Jones fracture, like it changes my recovery. Right. I put a screw in there and it's remarkable. And I'm, I'm not, I'm very conservative, I think, but it's a 12 minute surgery and they're healed on x-ray by eight weeks and asymptomatic versus you put them in a cast and there are six weeks on weight bearing, you have a bone stem and maybe it's healing, maybe it's not, and you're sweating. And, you know, that to me is a game changer for a distal fracture where the bone, where the blood flow is so good. And then you have a prominent plate on the lateral foot and a big open incision. There's still six weeks, non-weight bearing. And before you're allowing them to walk, now you're making them non-weight bearing. Like for me, you know, maybe I've just gotten lucky, but as I've had some that are five, six millimeters displaced and they've all healed. But it sounds like, yeah, I mean, that's how I trained that we just didn't fix them. And I haven't been burned yet. We've had, I mean, I think we're more in line with your line of thinking as well. We've started to push the envelope a little bit more on the ones that are displaced significantly, just because we have had some issues come back with, you know, Taylor's bunions or, you know, deformities, you know, more malunions. I agree with you, they do heal, but we've had some malunions come back, you know, rubbing in their shoes or, you know, those kinds of things. So we've, we've actually pushed our threshold a little bit more to fix the real significant, you know, five millimeter displaced ones, just for those reasons, because that's where we have been burned, not that the fracture didn't heal. We've been burned functionally down the road. Have you seen that in your practice as well? I haven't, but I always worry about the shortening because they definitely shorten, you know, and if I think if you can get away with it, because it's the fifth, if it was, you know, second, third or fourth, you know, second is the bane of my existence. So I think if it's another one that shortened that much, I'd be more worried. But I haven't yet, but it may just be my, you know, that I just haven't had as many. Sure. I had one other question. I know we're getting running out of time, but then this always comes up. So I thought maybe this would be a way to end maybe, but the Liz Frank diagnosis, you're always here that it gets missed. And then when you present the criteria, it doesn't, it seems like it shouldn't be missed. So, I mean, what's, what's, what do you think about all that? So, yeah, no, that's a good question. I think ultimately it is because a lot of the radiographic findings are maybe subtle, but can also be a little bit confusing if you're not used to looking at the kind of normal architecture of the midfoot. Oftentimes, like people can kind of see fractures and that something is broken or it's horribly displaced and it just isn't where it should be. But some of the finer points of the midfoot connections, especially on the oblique, I remember going through this as a lower level resident and just being like, what is this supposed to look like? And so I think, you know, if ortho trained folks who theoretically start to see this more and more can miss it, it's certainly going to be missed by other ancillary staff or people at urgent care or ER. It's just a matter of sort of pattern recognition. So kind of getting down, you know, the way that I was taught to read a chest x-ray, which I have not done in many years, but thinking about it kind of systematically and going through all of the kind of medial column theory sort of aspects of it, or just thinking about the relationships between the architecture of the bones. A lot of times people kind of have diffuse pain and it doesn't really correspond to the kind of frank like, okay, we've got dorsal swelling, plantar ecchymosis. Those are kind of the hallmarks, but not every patient will have those. And so a lot of these folks, it'll be sort of a mysterious, I don't know what happened. My foot kind of turned, it feels funny. And so it's a lot less of the kind of classic tip-offs, but hopefully those as sort of an amalgam will kind of have you guys have your spidey senses go off when you have any number of those things. Yeah. I think the other thing is sometimes they're only obvious on weight-bearing x-rays early on, which you don't have the ability to do in urgent care and the ED. And so, you know, you have to have a clinical suspicion. And if you're not seeing these regularly, I think it can be hard. You know, sometimes they've just shifted, you know, with time and by the time they get to you, they've switched, or we just have the ability to do weight-bearing. But even then sometimes, you know, it's hard, you know, and then I'll go to an MRI or a CT just to make sure I'm not missing something because they're painful there. And so I think those subtle ones are the hard ones to, because even with an MRI, well, then the dorsal is stretched and the interosseous is sprained and one of the three is torn. So you still don't know if it's stable or not. So some of these are, are tricky. I think it's also challenging because a lot of times in an ER urgent care, when the x-rays are normal from their perspective, you know, which it is an on weight-bearing x-ray. So you're not going to see that subtle displacement, even if there isn't, you know, in a grade two or grade three, let's say. You know, the grade ones are the ones that, you know, tend to come back with continued pain, but a lot of times the ER urgent care is recommending they follow up their primary care if they're not better in a couple of weeks. And, you know, then the primary care is looking at another x-ray that they perceive as normal. So you just perpetuate this, you know, algorithm that I think it makes it more prone to be missed. And, and that's where you start running into the ortho practice getting involved three or four months later. And now you start looking more at fusion because, you know, it's too late. The joints are already starting to see those, those malignant forces. I mean, Chris Cozier, you know, did tons of research on this and talked about primary fusions, which we touched upon earlier. And, you know, but, you know, listening to him and his talks, a lot of ones he gives at AOFAS, you know, even he's questioning, do you want to do a primary fusion on a 20 year old NFL player? You know, so it's tough, but, you know, the problem is when they're missed, that's where you're going because MRIF is really out the window at that point. So it's unfortunate, but I think it is the fact that the weight-bearing x-ray and follow-up being to primary care rather than ortho. I always get Larry of the midfoot sprain. If I see midfoot sprain from the ER, it's a Liz Frank until proven otherwise. Tom, at what point do your guys not do an ORF? Like, is there a time limit where they'll say that, you know, it has to be fusion is, you know, I've heard kind of different things, curious what you guys do. Yeah, I think, I think we're, our group's starting to get more of a consensus. You know, I work primarily with Dr. Burlett. So, you know, he's pretty hard, fast rule, 12 weeks. So anything, you know, after 12 weeks he's, he's fusing. Now again, he'll, just like Chris Coetzee, he'll go off of that, right? I mean, you'll, you'll, it's hard to not look at the patient, you know, and you're looking at a 19, 20 year old and you think, do I really want to fuse this? So I certainly think that he's went away from that on occasions just because he just can't, in good faith, even though the research says that's the right call. There's just something about that 18, 19, 20 year old active patient that we just say, I don't know, let's, let's just take a chance at ORF and see what we get. So I would like to say our group is pretty consistent with 12 weeks, but I can think on a number of occasions where we have gone away from that and still took a chance. So the answer is probably no. You know, it's interesting. And I always tell the residents this when they're taking their OITE or their boards, like there's actually no indication where ORF is the right answer based on the research, right? It's crazy that there is not a single study that says ORF is the better option. Yeah, I totally agree. I mean, you just like, you hesitate and makes you nauseous to think about doing it in these young people, but it is interesting that the data really doesn't support it. They do fine. They do fine. Yeah, they do fine. I mean, they do well. I mean, I don't think that fusion is a bad answer at all, but it's, I don't know. It's just hard to look. I mean, we, we would put a lapidus on a patient that's 20 year old bunion and not think twice about. Right. That's where this came from. That's where the conversation came from. Yeah. We do it all the time. I mean, especially if there's any medial column instability or hypermobility at that first ray, you know, we're, we're going to offer a lapidus procedure versus a, you know, extra articular osteotomy any day of the week. Uh, so I, I, I don't disagree that Liz Franks, you know, acute or chronic will do well with a fusion, but I still think that there's, there's more research that needs to be done to your point. We talk about this all the time. This is like the biggest controversy in our clinic. So I'm not like saying this, like, Oh, this is a hard and fast rule. Everyone has a hard time with it, but it's just interesting that we can't get that research. You think it would be easy to, to, to be reliable and validate, but, um, it just that the research doesn't, uh, maybe someone who's going to UPenn next year can, can take that charge as the research doc. I'm ready. You're coming to the end. So I don't want to hold people, but last question to everyone on this topic. You tell me if you get it, Liz Frank, what are you doing? Fusion or RAF? I'm going fusion. That is so hard. I want to say fusion. Cause I know it's right, but I would probably say a closed reduction pert pin and take my screws out. Interesting. We're going for a home run. Jeff and Ashley, what are you doing? Uh, whatever you say, we'll pick it up. You just pitch it to us. We'll pick it up. It's hard to disagree with Chris Cotier. Chris Cotier is the world leader here. So all right. Thank you guys. That was a great, great group of talks and, uh, very comprehensive and on time, which was even, even better. So thank you all for taking the time to do this and please fill out your evaluation. So we, we know where else to, to start talking for our next symposium. I think we're thinking July for the next one. So if you're a foot and ankle special interest group member, just, you know, shoot the, the hierarchy, whatever you're interested in and we'll put it in, uh, to the group. So hopefully get some topics everybody benefits from. Yeah. Great. Thank you. Great. Thank you all. Thank you.

ankle fractures

management

treatment

Ottawa ankle rules

conservative management

surgery

physical therapy

rehabilitation process

function gains

limitations

early intervention

foot and ankle injuries

patient education