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[1/14] Xrays (like hips) don’t lie: a thread. Look at these X-rays before going onto the polls in the next tweets and decide how you’d treat. This medial mal is isolated (nothing higher up, no fibula fracture) in a middle aged patient.
![[1/14] Xrays (like hips) don’t lie: a thread. Look at these X-rays before going onto the polls in the next tweets and decide how you’d treat. This medial mal is isolated (nothing higher up, no fibula fracture) in a middle aged patient.](https://pbs.twimg.com/media/Eb2GwdpWAAETHTv.jpg "[1/14] Xrays (like hips) don’t lie: a thread. Look at these X-rays before going onto the polls in the next tweets and decide how you’d treat. This medial mal is isolated (nothing higher up, no fibula fracture) in a middle aged patient.")
![[1/14] Xrays (like hips) don’t lie: a thread. Look at these X-rays before going onto the polls in the next tweets and decide how you’d treat. This medial mal is isolated (nothing higher up, no fibula fracture) in a middle aged patient.](https://pbs.twimg.com/media/Eb2GwdoXgAEdqBf.jpg "[1/14] Xrays (like hips) don’t lie: a thread. Look at these X-rays before going onto the polls in the next tweets and decide how you’d treat. This medial mal is isolated (nothing higher up, no fibula fracture) in a middle aged patient.")
[2/14] Without looking further, and from these xrays alone, how would you treat this isolated medial malleolus?
[3/14] For those who chose nonop, why?
[4/14] For those who chose operative, why?
[5/14] And finally, for those who chose operative management with open (non-perc) reduction, why?
[6/14] First, to nonop. Reasonable in even displaced medial mals, plenty of data, like this, showing nonunions usually not a problem ( https://pubmed.ncbi.nlm.nih.gov/30879641/ ). You could also argue this fracture sits below plafond and therefore not important for wt bearing. Classic paper next...
[7/14] Here is a free pdf of the classic Herscovici paper with impressive Xrays. Keep in mind he had strict criteria for what these needed to look like to be nonop. But our fracture doesn’t look like the one below from his paper, does it?... https://pdfs.semanticscholar.org/e024/7b9898658dce4dd24a036189d01a412d24ae.pdf?_ga=2.100162910.1135659166.1593608847-1307081376.1593608847
![[7/14] Here is a free pdf of the classic Herscovici paper with impressive Xrays. Keep in mind he had strict criteria for what these needed to look like to be nonop. But our fracture doesn’t look like the one below from his paper, does it?... https://pdfs.semanticscholar.org/e024/7b9898658dce4dd24a036189d01a412d24ae.pdf?_ga=2.100162910.1135659166.1593608847-1307081376.1593608847](https://pbs.twimg.com/media/Eb2GxfeXYAEfUN8.jpg "[7/14] Here is a free pdf of the classic Herscovici paper with impressive Xrays. Keep in mind he had strict criteria for what these needed to look like to be nonop. But our fracture doesn’t look like the one below from his paper, does it?... https://pdfs.semanticscholar.org/e024/7b9898658dce4dd24a036189d01a412d24ae.pdf?_ga=2.100162910.1135659166.1593608847-1307081376.1593608847")
[8/14] In fact even without CT, careful assessment of X-rays tells you something is odd. The shape of this is weird, curve is wrong. It looks flat (green). Fracture looks wider than its bed (red). And also, additional piece (blue) that makes me wonder about PT tendon sheath.
![[8/14] In fact even without CT, careful assessment of X-rays tells you something is odd. The shape of this is weird, curve is wrong. It looks flat (green). Fracture looks wider than its bed (red). And also, additional piece (blue) that makes me wonder about PT tendon sheath.](https://pbs.twimg.com/media/Eb2GxwNWoAIXdla.jpg "[8/14] In fact even without CT, careful assessment of X-rays tells you something is odd. The shape of this is weird, curve is wrong. It looks flat (green). Fracture looks wider than its bed (red). And also, additional piece (blue) that makes me wonder about PT tendon sheath.")
![[8/14] In fact even without CT, careful assessment of X-rays tells you something is odd. The shape of this is weird, curve is wrong. It looks flat (green). Fracture looks wider than its bed (red). And also, additional piece (blue) that makes me wonder about PT tendon sheath.](https://pbs.twimg.com/media/Eb2Gxw9XgAA_By2.jpg "[8/14] In fact even without CT, careful assessment of X-rays tells you something is odd. The shape of this is weird, curve is wrong. It looks flat (green). Fracture looks wider than its bed (red). And also, additional piece (blue) that makes me wonder about PT tendon sheath.")
[9/14] Now to lateral. The normal shape of medial mal has curved colliculi (purple) reaching back to overlap fibula. Here, even though not perfect lateral (talar domes, red), the shape looks flat and never reaches fibula. Even if you “build back” small fragment, still not right.
![[9/14] Now to lateral. The normal shape of medial mal has curved colliculi (purple) reaching back to overlap fibula. Here, even though not perfect lateral (talar domes, red), the shape looks flat and never reaches fibula. Even if you “build back” small fragment, still not right.](https://pbs.twimg.com/media/Eb2GySqXQAAzj5q.jpg "[9/14] Now to lateral. The normal shape of medial mal has curved colliculi (purple) reaching back to overlap fibula. Here, even though not perfect lateral (talar domes, red), the shape looks flat and never reaches fibula. Even if you “build back” small fragment, still not right.")
![[9/14] Now to lateral. The normal shape of medial mal has curved colliculi (purple) reaching back to overlap fibula. Here, even though not perfect lateral (talar domes, red), the shape looks flat and never reaches fibula. Even if you “build back” small fragment, still not right.](https://pbs.twimg.com/media/Eb2GySoX0AA94hU.jpg "[9/14] Now to lateral. The normal shape of medial mal has curved colliculi (purple) reaching back to overlap fibula. Here, even though not perfect lateral (talar domes, red), the shape looks flat and never reaches fibula. Even if you “build back” small fragment, still not right.")
![[9/14] Now to lateral. The normal shape of medial mal has curved colliculi (purple) reaching back to overlap fibula. Here, even though not perfect lateral (talar domes, red), the shape looks flat and never reaches fibula. Even if you “build back” small fragment, still not right.](https://pbs.twimg.com/media/Eb2GyTiX0AAo0VT.jpg "[9/14] Now to lateral. The normal shape of medial mal has curved colliculi (purple) reaching back to overlap fibula. Here, even though not perfect lateral (talar domes, red), the shape looks flat and never reaches fibula. Even if you “build back” small fragment, still not right.")
[10/14] I skipped CT, X-rays gave me enough to operate. I nearly always open mine for perfect reduction. And here when I opened I was staring at cartilage (blue, pencil in sawbone). The medial mal had rotated 180° from P to A, leaving PT tendon (yellow) behind, with torn sheath.
![[10/14] I skipped CT, X-rays gave me enough to operate. I nearly always open mine for perfect reduction. And here when I opened I was staring at cartilage (blue, pencil in sawbone). The medial mal had rotated 180° from P to A, leaving PT tendon (yellow) behind, with torn sheath.](https://pbs.twimg.com/media/Eb2Gy7UXgAAYaW9.jpg "[10/14] I skipped CT, X-rays gave me enough to operate. I nearly always open mine for perfect reduction. And here when I opened I was staring at cartilage (blue, pencil in sawbone). The medial mal had rotated 180° from P to A, leaving PT tendon (yellow) behind, with torn sheath.")
![[10/14] I skipped CT, X-rays gave me enough to operate. I nearly always open mine for perfect reduction. And here when I opened I was staring at cartilage (blue, pencil in sawbone). The medial mal had rotated 180° from P to A, leaving PT tendon (yellow) behind, with torn sheath.](https://pbs.twimg.com/media/Eb2Gy7xX0AAkS7u.jpg "[10/14] I skipped CT, X-rays gave me enough to operate. I nearly always open mine for perfect reduction. And here when I opened I was staring at cartilage (blue, pencil in sawbone). The medial mal had rotated 180° from P to A, leaving PT tendon (yellow) behind, with torn sheath.")
[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.
![[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.](https://pbs.twimg.com/media/Eb2GzUYXkAAQTgf.jpg "[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.")
![[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.](https://pbs.twimg.com/media/Eb2GzUiXYAAnlcw.jpg "[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.")
![[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.](https://pbs.twimg.com/media/Eb2GzUwWAAcpzVc.jpg "[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.")
![[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.](https://pbs.twimg.com/media/Eb2GzVVXgAEMV8t.jpg "[11/14] I shoved piece back behind tendon so it lay in its bony bed, being careful not to nab anything else (bundle). Held with K-wires & separate visualization wire (purple) like you’d do in acetabulum so could see reduction. To keep drill from slipping, used drill guide on tip.")
[12/14] Added second bicortical screw posteriorly for compression (countersunk, otherwise was rubbing tendon), then fixed sheath and separate deltoid avulsion with suture anchor. Then did a perc cotton stress to make sure force didn’t propagate beyond medial mal (it didn’t).
![[12/14] Added second bicortical screw posteriorly for compression (countersunk, otherwise was rubbing tendon), then fixed sheath and separate deltoid avulsion with suture anchor. Then did a perc cotton stress to make sure force didn’t propagate beyond medial mal (it didn’t).](https://pbs.twimg.com/media/Eb2GzpTWAAEgoeY.jpg "[12/14] Added second bicortical screw posteriorly for compression (countersunk, otherwise was rubbing tendon), then fixed sheath and separate deltoid avulsion with suture anchor. Then did a perc cotton stress to make sure force didn’t propagate beyond medial mal (it didn’t).")
[13/14] Final images, and clinical image after sutures from anchor oversewing the busted soft tissues. Tendon didn’t subluxate on testing. Closed and nwb x 6 weeks.
![[13/14] Final images, and clinical image after sutures from anchor oversewing the busted soft tissues. Tendon didn’t subluxate on testing. Closed and nwb x 6 weeks.](https://pbs.twimg.com/media/Eb2Gz0qXkAYTIUv.jpg "[13/14] Final images, and clinical image after sutures from anchor oversewing the busted soft tissues. Tendon didn’t subluxate on testing. Closed and nwb x 6 weeks.")
![[13/14] Final images, and clinical image after sutures from anchor oversewing the busted soft tissues. Tendon didn’t subluxate on testing. Closed and nwb x 6 weeks.](https://pbs.twimg.com/media/Eb2Gz0zWkAEPjlG.jpg "[13/14] Final images, and clinical image after sutures from anchor oversewing the busted soft tissues. Tendon didn’t subluxate on testing. Closed and nwb x 6 weeks.")
![[13/14] Final images, and clinical image after sutures from anchor oversewing the busted soft tissues. Tendon didn’t subluxate on testing. Closed and nwb x 6 weeks.](https://pbs.twimg.com/media/Eb2Gz1vWsAAH_gO.jpg "[13/14] Final images, and clinical image after sutures from anchor oversewing the busted soft tissues. Tendon didn’t subluxate on testing. Closed and nwb x 6 weeks.")
[14/14] I combed literature for similar cases, this was closest. This isn’t even that kind of case, because in mine it was bone that was “dislocated” not tendon. https://pubmed.ncbi.nlm.nih.gov/24026087/ But at least this article warns you to expect the unexpected. And of course, respect Xrays! :)
