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We're gonna move on now

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and discuss ankle injuries, which are very, very frequent,

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not just in the United States, but worldwide.

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This gives you an idea of the number

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of ankle injuries that occur each year.

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Okay? The major mechanism that is involved

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with these injuries is low energy trauma,

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especially in older persons, more frequently in a woman.

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And typically, as shown in this particular picture,

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we're dealing with supination

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or inversion, often associated with external rotation.

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We're gonna talk about these mechanisms in more detail. Now.

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One of the interesting things, at least to me

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for years has been, can you judge the severity of an injury

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to the joint by the presence or absence of a joint effusion?

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So let's think about that for the ankle joint.

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Remember, we have capsular ligaments.

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So I always wondered if you have a severe injury

1:07

of a capsular ligament,

1:09

wouldn't you disrupt the joint capsule?

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And wouldn't that decrease the likelihood of seeing

1:16

a significant effusion?

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And the same thinking could occur in other joints,

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but we're dealing today with the ankle joint.

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And I wondered about that.

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And then there was a recent article that came along

1:29

and looked at that particular situation.

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And what they found,

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and here are the conclusions of the article, is

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that if you see a significant ankle effusion,

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there's a higher likelihood you're dealing

1:44

with a severe injury.

1:47

The presence of an effusion associated

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with an increased risk of severe ligament injury,

1:52

including the anterior talo fibrile ligament,

1:55

which is a capsular ligament.

1:57

They also found that the presence of an effusion

2:01

in the ankle, or even in the post, uh,

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posterior subtalar joint as shown here, is associated

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with an increased risk for severe talo Taylor

2:12

osteochondral involvement.

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So effusions apparently

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are a bad prognostic sign in the ankle

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and possibly in the posterior subtalar joint,

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follow an injury to the ankle.

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Well, let's look now in more detail at the pathogenesis

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of ankle uh, injuries.

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We're gonna start by showing you the general concept here

2:36

of the greater ring, the greater ring of the ankle.

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So if we look at this particular coronal section, we can see

2:45

and create a greater ring.

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The tuss is normally surrounded by a bone

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and soft tissue, osseous, ligamentous ring

2:56

that renders its stable

2:58

Through the tibial bone,

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through the syndesmotic ligaments, the lateral maus,

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the lateral ligaments that tailors the medial ligaments

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and the medial maus.

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So the general thing

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to remember is a single break in this ring, we'll call it a

3:16

unipolar injury,

3:18

generally does not produce ankle instability.

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The tailless cannot be displaced.

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That single injury could be a male fracture,

3:28

a tibial fracture, or a single ligament, this injury.

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Therefore, when you deal with two

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or more breaks in the ring, let's call it a bilar

3:39

or even multipolar injury, generally you are dealing

3:44

with ankle uh, instability.

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And here I show you breaks, two breaks, one medially,

3:50

and one mat laterally.

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When you see this sort of situation in the greater ring,

3:56

more likely you're dealing with ankle instability

4:00

and possible displacement of the Alis.

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The second concept is the pattern that tissues fail.

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Bones may fail through compression, evulsion

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or torsion ligaments fail through avulsion

4:15

or rarely through compression.

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So when I look at fractures about the ankle,

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I look at their orientation.

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If I deal with obli

4:25

or particularly steep o blight fractures,

4:28

typically these are compression fractures.

4:32

They tell you the observer,

4:33

something about the mechanism of injury.

4:37

When we deal with transverse fracture lines, particularly

4:41

as we get toward the end of the bone, we're dealing

4:45

with avulsion fractures.

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So that is a second important general concept.

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The third concept that I would emphasize is related

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to a lesser ring.

4:58

When you look at the connection of the tibia

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and fibula here in a transverse drawing section,

5:06

you can see a lesser ring, okay, right here,

5:11

they're bound together, lesser ring related to bone

5:16

and ligaments, and it's that lesser ring

5:19

that indeed provides stability.

5:22

There's a further connection here in the middle of the ring,

5:27

which is the interosseous ligament I talked about earlier.

5:31

There is a final connection,

5:33

the inferior transverse ligament, which serves

5:36

as a hinge toward the posterior aspect of the lesser ring.

5:42

So this is the lesser ring connecting the tibia

5:46

and fibula with a central connection and a posterior hinge.

5:52

The general way that we get failure

5:54

of the syndesmotic ligaments

5:56

Is an open book pattern of injury

6:00

where the anterior aspect opens up first

6:03

and then the, the uh, opening

6:07

proceeds in an abnormal fashion toward the posterior aspect

6:11

of the syndesmotic ligaments.

6:13

So the typical injury sequence, there are exceptions,

6:17

is tearing of the anterior tibial, uh,

6:21

tibial fibular ligament, generally with some of the fibers

6:25

of the interosseous ligament,

6:27

and then further tearing of the interosseous ligament,

6:31

then the posterior tibial fibular ligament.

6:33

And finally, that hinge, the inferior transverse ligament.

6:38

That's the classic sequence of events.

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Now, the failure may not be within the ligament itself,

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it may be in the form of evulsion fractures.

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And these can involve a variety of sites, some

6:52

of which have names.

6:54

This is the OT cubicle involving the anterolateral aspect

6:59

of the distal tibia.

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This is the wag staff, or LeFort cubicle.

7:04

And then this is called a Mann fragment.

7:08

I'm gonna show you several examples of it here.

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I show you two examples involving the postal lateral portion

7:17

of the distal tibia.