1 00:00:00,480 --> 00:00:03,480 All right, so let's talk about MSK lower extremities. If you've listened to 2 00:00:03,520 --> 00:00:06,839 any of my podcasts, you know I don't go over every single boring detail. 3 00:00:06,839 --> 00:00:09,240 I'm going to focus on the things that always come up on the exams, 4 00:00:09,240 --> 00:00:11,599 the things you really need to know, the high old stuff. So 5 00:00:11,640 --> 00:00:14,599 I may not go over every single condition for lower extremity, but I will 6 00:00:14,599 --> 00:00:17,239 focus on the ones that seem to come up on exams. So let's ahead 7 00:00:17,239 --> 00:00:20,120 and get started with MSK lower extremity. As always, thank you so much 8 00:00:20,160 --> 00:00:23,280 for the really nice comments to support. I really do appreciate it, so 9 00:00:23,359 --> 00:00:26,000 thank you. Let's go ahead and get started. We'll start with the hip 10 00:00:26,039 --> 00:00:30,160 and then we'll work our way on down. So hip fracture mechanism of injury 11 00:00:30,800 --> 00:00:34,039 young patients, this is going to be major trauma, So motor vehicle collisions. 12 00:00:34,640 --> 00:00:38,719 Hip fractures not a common occurrence in young patients unless there's a serious trauma 13 00:00:38,840 --> 00:00:42,719 or some sort of pathologic condition. So normally in younger patients you're looking for 14 00:00:42,799 --> 00:00:47,640 some kind of major trauma. Old patients osteoporosis in falls. Proximately ninety percent 15 00:00:47,640 --> 00:00:50,880 of hip fractures and older patients are going to occur just from a simple fall 16 00:00:50,920 --> 00:00:54,719 from a standing position. So in young patients think high impact injury like MBA. 17 00:00:54,840 --> 00:00:58,280 Older adults think low impact like a fall from standing position due to bone 18 00:00:58,320 --> 00:01:00,719 loss scene in this age range, particularly in women due to their higher rates 19 00:01:00,719 --> 00:01:04,280 of osteoporosis. So there's a few different types of hip fractures depending on the 20 00:01:04,280 --> 00:01:10,640 location involved. Femoral neck, introcanic fractures, trokin fractures. Really, I 21 00:01:10,640 --> 00:01:12,319 think there's only one you should commit to memory, and that's the femoral neck 22 00:01:12,359 --> 00:01:17,959 fractures because of the risks associated with this type. So formoral neck fractures a 23 00:01:18,040 --> 00:01:22,159 vascular necrosis. So if themoral neck fractures, you need to know this type 24 00:01:23,319 --> 00:01:26,040 is associated with one of the highest risks of a vascular necrosis. The blood 25 00:01:26,079 --> 00:01:30,519 supply to the femoral neck is pretty poor. It's similar to the scafhoid bone 26 00:01:30,560 --> 00:01:34,760 that we'll talk about in the risk So any trauma to this area like a 27 00:01:34,840 --> 00:01:38,480 fracture, can lead to a disruption in the tenuous blood blood supply and can 28 00:01:38,560 --> 00:01:42,359 lead to complications like a vascular necrosis, which is just death of the tissue 29 00:01:42,400 --> 00:01:47,439 the bone due to insufficient blood supply. So remember increased risk of a vascular 30 00:01:47,480 --> 00:01:51,120 necrosis with formoral neck fractures compared to other type of hip fractures. Now, 31 00:01:51,120 --> 00:01:53,319 in physical exam, this is important. You're going to see a shortened, 32 00:01:53,560 --> 00:01:59,959 externally rotated lower extremity, so most hip fractures will prevent present with the lay 33 00:02:00,159 --> 00:02:05,760 being externally rotated and shortened. This is important because with a hip dislocation it's 34 00:02:05,799 --> 00:02:07,960 usually going to be the opposite. So most cases with hip dislocations, you'll 35 00:02:07,960 --> 00:02:14,879 see internal rotation and external rotation with the fracture, so internal with dislocation most 36 00:02:14,879 --> 00:02:17,039 of the time, and external with a fracture. The way that you can 37 00:02:17,080 --> 00:02:23,080 remember that is because fracture very conveniently has an E in it but not an 38 00:02:23,120 --> 00:02:27,000 eye, and then dislocation has an eye in it but not an E. 39 00:02:27,240 --> 00:02:30,240 So remember internal rotation for dislocation because that as an eye in the word, 40 00:02:30,719 --> 00:02:34,759 external rotation for fracture because it has an E in the word but not I. 41 00:02:35,240 --> 00:02:37,759 And these little things will help you get the answer right in vignette, 42 00:02:37,759 --> 00:02:40,520 so sometimes you'll look in just for those little details. Treatment is surgical in 43 00:02:40,599 --> 00:02:46,439 most cases, or IF, which stands for open reduction with internal fixation versuing 44 00:02:46,479 --> 00:02:50,159 another versus another option, which would be Arthur PLASTI don't focus too much on 45 00:02:50,199 --> 00:02:53,439 treatment. It's not gonna it's not really high yield with most of the MSK 46 00:02:53,879 --> 00:02:55,400 likely not going to be what your tests it on. So talking about hip 47 00:02:55,439 --> 00:03:00,560 dislocations, really three things you need to focus on for dislocations. So first, 48 00:03:00,680 --> 00:03:02,599 large forced trauma is going to be the most common cause. So large 49 00:03:02,639 --> 00:03:07,080 force trauma, motor vehicle accidents, pedestrians struck by automobiles, they're going to 50 00:03:07,080 --> 00:03:12,319 be your most common causes of hip dislocations can also be associated with high energy 51 00:03:12,360 --> 00:03:15,560 impact sports American football, rugby, skiing, snowboarding, gymnastics, But focus 52 00:03:15,599 --> 00:03:21,520 on your large force trauma like an MVA. Posterior dislocation is going to be 53 00:03:21,560 --> 00:03:25,560 your most common almost always posterior eighty to ninety percent, so you have posterior 54 00:03:25,599 --> 00:03:30,360 anterior dislocation. Posterior is way more common. That's the one you need to 55 00:03:30,400 --> 00:03:32,639 memorize. Ninety percent of the cases are going to be a posterior dislocation. 56 00:03:32,960 --> 00:03:36,199 AKA that's what you're going to be tested on. So that's what you need 57 00:03:36,240 --> 00:03:39,879 to know. Now for the physical exam, shortened internally rotated lower extremity like 58 00:03:39,879 --> 00:03:44,759 I talked about before, So majority of time patients will present with a shortened 59 00:03:45,080 --> 00:03:50,319 internally rotated lower extremity. That's because this is the classic presentation of a posterior 60 00:03:50,319 --> 00:03:53,120 dislocation, which we know by far is the most common type ninety percent of 61 00:03:53,159 --> 00:03:57,520 the time. So this will be the presentation you're going to see shortened internally 62 00:03:57,639 --> 00:04:01,159 rotated. Anterior dislocations will have exterior rotation, but who cares. Don't memorize 63 00:04:01,199 --> 00:04:05,000 that that's very rare. If you see a hypt dislocation, be thinking internal 64 00:04:05,080 --> 00:04:09,560 rotation again. The way you remember that is because dislocation has an eye, 65 00:04:09,599 --> 00:04:13,319 not an e, so internal rotation. Fracture has an e not an eye, 66 00:04:13,400 --> 00:04:17,600 so external rotation. Remember that treatment again not high yield, pretty straightforward 67 00:04:17,639 --> 00:04:21,519 reduced the dislocation. This can be done either closed under sedation or open with 68 00:04:21,560 --> 00:04:26,600 surgical reduction. And again, this is something that needs to be done or 69 00:04:26,600 --> 00:04:28,759 I guess I didn't mention it, but it needs to be done urgently because 70 00:04:28,800 --> 00:04:32,560 the longer the dislocation proceeds without intervention, the higher the risk of complications that 71 00:04:32,560 --> 00:04:38,160 can happen with dislocations, like a vascular necrosis. Moving on to slipped capital 72 00:04:38,199 --> 00:04:42,600 flemoral epiphysis. So this is a weakness in the proximal flemoral growth plate that 73 00:04:42,680 --> 00:04:46,079 leads to displacement of the capital fmoral epiphysis. So to put this simply, 74 00:04:46,079 --> 00:04:50,000 the fmoral head is slipping off of the flemoral neck. Sometimes it's described as 75 00:04:50,040 --> 00:04:53,600 ice cream falling off of a cone, because if you look at an X 76 00:04:53,680 --> 00:04:56,360 ray, that's actually what it looks like. Risk factors A few things that 77 00:04:56,399 --> 00:04:59,319 you need to know. Obesity, this is the single grace risk factor. 78 00:04:59,600 --> 00:05:02,600 More than sixty percent of patients with this condition measured greater than or equal to 79 00:05:02,680 --> 00:05:08,360 the ninetieth percentile in weight. Males are much more prevalent in mail is proximately 80 00:05:08,399 --> 00:05:12,839 a one point five to one male to female ratio. The age range you're 81 00:05:12,879 --> 00:05:15,959 going to see this in twelve years and girls thirteen point five years. In 82 00:05:15,040 --> 00:05:18,199 boys, that's going to be the peak age. So the mean age of 83 00:05:18,199 --> 00:05:23,000 presentation twelve years and girls thirteen point five years and boys, and this is 84 00:05:23,040 --> 00:05:26,800 because this is when they're experiencing a peak in growth related to puberty. So 85 00:05:26,839 --> 00:05:30,040 these risk factors are going to give you a really good idea of what type 86 00:05:30,040 --> 00:05:31,720 of patient you're going to be looking for in the vignette, so they're always 87 00:05:31,720 --> 00:05:34,879 going to give you the most common patient demographic, So they're not going to 88 00:05:34,959 --> 00:05:38,680 give you a seven year old, skinny female. The patient the vignette for 89 00:05:38,680 --> 00:05:41,199 slip cap is going to be a male. It's going to be obese, 90 00:05:41,240 --> 00:05:44,120 and he's going to be in the age range around twelve to thirteen years old. 91 00:05:44,120 --> 00:05:46,839 Remember these little details, they're going to help you in the vignettes. 92 00:05:46,160 --> 00:05:51,240 Clinical manifestations painful limp, So the two most common manifestations to see in patients 93 00:05:51,240 --> 00:05:55,600 are going to be pain and altered gait, so a painful limp. The 94 00:05:55,720 --> 00:05:59,360 classic complaint will be a child complaining of dole aching pain and the hip growing 95 00:06:00,000 --> 00:06:04,480 possible even in the knee with no preceding trauma. So be careful because fifteen 96 00:06:04,600 --> 00:06:08,720 round fifteen percent of patients, the only complaint they're going to have is isolated 97 00:06:08,759 --> 00:06:13,040 thigh or knee pain and not necessarily the hip. And that's because the involvement 98 00:06:13,079 --> 00:06:15,879 of the medial optat or nerve which runs along the medial thigh from the knee 99 00:06:15,959 --> 00:06:18,319 up through the hip. So they may just have a knee pain, so 100 00:06:18,600 --> 00:06:21,000 be aware of that too. This is a condition of the hip, but 101 00:06:21,079 --> 00:06:27,040 they may present with knee pain diagnosis X ray. The diagnosis of slipcap is 102 00:06:27,120 --> 00:06:30,959 usually made just with Plaine radiographs. Classic appearance will reveal a posterior displacement of 103 00:06:30,959 --> 00:06:33,839 the flemoral epiphysis. If they give you a picture on the X ray, 104 00:06:33,839 --> 00:06:38,079 it's going to look like ice cream slipping off of a cone. Remember that 105 00:06:38,079 --> 00:06:41,519 that's the classic way to describe this on X ray, ice cream slipping off 106 00:06:41,519 --> 00:06:44,160 of a cone, the flemoral heads sliding off of the neck. They're not 107 00:06:44,199 --> 00:06:46,600 going to say ice cream slipping off of a cone, but you need to 108 00:06:46,680 --> 00:06:48,319 create that visual so if you see it, you'll know what it is. 109 00:06:49,000 --> 00:06:55,160 Treatment. This is going to be operative stabilization pinning, so these patients need 110 00:06:55,199 --> 00:06:58,639 to be non weight bearing referred to an orthopedic surgeon where the treatment is going 111 00:06:58,680 --> 00:07:01,199 to be surgical pinning. So that's gold standard for slip cap. A single 112 00:07:01,240 --> 00:07:05,240 cannulated screw place in the center of the epiphosis to keep the ice cream from 113 00:07:05,240 --> 00:07:10,600 falling off of the cone. All right. Moving on to a similar disease 114 00:07:10,639 --> 00:07:15,000 that can always be very confusing to get these two mixed up. Leg calvay 115 00:07:15,160 --> 00:07:19,240 perthes disease. So this is idiopathic osteo necrosis or a vascular necrosis of the 116 00:07:19,319 --> 00:07:23,680 hip, so the blood supply to the head of the femur gets disrupted and 117 00:07:23,720 --> 00:07:27,920 this can lead to death or necrosis of the tissue. There's some theories proposed 118 00:07:27,959 --> 00:07:31,600 mechanisms, but normally we don't know why this happens five to eight years old, 119 00:07:31,639 --> 00:07:34,519 so it can be seen in children between the ages of three to twelve, 120 00:07:34,560 --> 00:07:38,319 but the peak incidence is going to be between five and eight, so 121 00:07:38,399 --> 00:07:41,680 look for that age rangel on your vignette. More common in males, even 122 00:07:41,720 --> 00:07:45,720 more so than when we talked about in slip cap so one to four male 123 00:07:45,720 --> 00:07:49,920 to female ratio, so very high incidents in males. Clinical manifestations painless LIMP. 124 00:07:50,360 --> 00:07:54,800 This is something a little bit of a little controversial, so painless limp. 125 00:07:54,879 --> 00:07:59,079 So they absolutely may have pain in this condition, but I'm generalizing this 126 00:07:59,160 --> 00:08:01,199 for the sake of the ex am and in saying painless limp, it's not 127 00:08:01,199 --> 00:08:05,959 so clear cut in real life. But normally this disease has this insidious onset, 128 00:08:05,240 --> 00:08:09,079 may start with little to no pain, oftentimes just hip stiffness. Loss 129 00:08:09,079 --> 00:08:13,120 of internal rotation. Eventually does progress and they'll develop some discomfort, usually after 130 00:08:13,160 --> 00:08:18,120 activity, but the pain, if it's present, is usually mild. It 131 00:08:18,160 --> 00:08:22,360 can also also be referred to the thigh or knee. Most exam questions are 132 00:08:22,360 --> 00:08:24,319 going to present this to you as a painless limp or maybe a limp with 133 00:08:24,439 --> 00:08:28,319 mild pain. This is what helps differentiate it from slip cap, which normally 134 00:08:28,360 --> 00:08:33,799 almost always has a painful limp. So again, this isn't one hundred percent 135 00:08:33,919 --> 00:08:37,519 nothing is in medicine. Lake Calvey can be painful, slip cap can be 136 00:08:37,559 --> 00:08:41,480 pain less. But for the exam it's best to remember Lake Calve as pain 137 00:08:41,600 --> 00:08:45,799 less and slipped cap as painful. And if you ever forget which one has 138 00:08:45,799 --> 00:08:50,639 a painful limp, which one has a painless limp? Painless, pain less 139 00:08:50,679 --> 00:08:54,519 with an L, painful with an F, remember pain less with an L 140 00:08:54,639 --> 00:09:01,000 only Lake Calve prothest disease has an L anywhere in the beginning of leg I'm 141 00:09:01,039 --> 00:09:03,639 talking about the first letters, but it doesn't have an F in any of 142 00:09:03,679 --> 00:09:07,240 the first letters, So painless with an L remember Lake Calvey and the first 143 00:09:07,320 --> 00:09:09,919 letters has an L in it, but it doesn't have in the first letters. 144 00:09:11,639 --> 00:09:15,840 Painful with an F only slip Capital for moral epiphysis has an F. 145 00:09:16,080 --> 00:09:18,159 In the first letters of the words, so that helps you remember. For 146 00:09:18,279 --> 00:09:24,039 moral epiphysis slip cap. For moorl epiphysis is painful, doesn't have an L 147 00:09:24,080 --> 00:09:26,759 anywhere in the first letters. Hopefully that wasn't too confusing, and hopefully I 148 00:09:26,799 --> 00:09:28,279 explain that right. But that's how I used to remember it. If I 149 00:09:28,320 --> 00:09:31,600 ever forgot which had the painless, which had the painful, that's how I 150 00:09:31,600 --> 00:09:35,080 remember. Look at the first letters. Is there an L, then it's 151 00:09:35,080 --> 00:09:39,000 painless. If there's an F, it's painful. Treatment observation. In most 152 00:09:39,039 --> 00:09:43,000 cases, the treatment for Lake Helve prothestases is conservative non weight bearing physical therapy. 153 00:09:43,279 --> 00:09:48,519 Around sixty to seventy percent of hips effected are going to heal spontaneously without 154 00:09:48,559 --> 00:09:52,480 any functional impairment. So surgery is an option, but it's not as common 155 00:09:52,519 --> 00:09:56,159 and it's mostly reserved for older children, generally over eight, whereas your younger 156 00:09:56,200 --> 00:10:00,679 patients typically won't benefit from surgery. So Lake Calves slip Cap, they have 157 00:10:00,679 --> 00:10:03,559 a lot of similarities, and sometimes it's hard to differentiate the two on an 158 00:10:03,559 --> 00:10:05,879 exam question. And you will get a question probably about one of these on 159 00:10:05,919 --> 00:10:09,240 your exams. So let's go again over the key differences. So slip cap 160 00:10:09,519 --> 00:10:13,120 generally going to be older children like twelve to thirteen years old, lake calve 161 00:10:13,399 --> 00:10:18,399 younger children around five to eight slipcap generally painfull lake calva for the sake of 162 00:10:18,440 --> 00:10:22,159 the exam, remember it it's pain lisp. And then finally, slip cap 163 00:10:22,519 --> 00:10:26,279 surgery will commonly be the treatment of choice, where lake calve will more commonly 164 00:10:26,600 --> 00:10:31,200 just be observation. So those two remember, don't get those mixed up, 165 00:10:31,240 --> 00:10:33,879 because that can be an easy question. You can get right if you can 166 00:10:33,919 --> 00:10:37,080 remember the little differences between the two. Okay osgod Schlaughter disease. This is 167 00:10:37,120 --> 00:10:41,840 an injury caused by repetitive strain and chronic evulsion of the pophesis of the tibial 168 00:10:41,919 --> 00:10:46,720 tubercle. So in younger children, the tibial tuberosity where the boteler tendant attaches 169 00:10:46,720 --> 00:10:50,440 to it hasn't ossified yet, which basically just means it hasn't completely turned a 170 00:10:50,480 --> 00:10:54,360 bone, so it's still contains some cartilage, so it's weaker. So when 171 00:10:54,440 --> 00:10:58,000 kids who are active play a lot of sports jumping and kicking, squatting, 172 00:10:58,399 --> 00:11:03,399 that Beateeller ligament is constantly pulling on the attachment side of the tibial tubercle, 173 00:11:03,759 --> 00:11:07,320 and eventually this causes separation of the patellar tendon from the tibial tubercle and some 174 00:11:07,480 --> 00:11:11,240 trauma and inflammation. Eventually, the area as it begins to heal, a 175 00:11:11,360 --> 00:11:18,240 callus is formed and it leads to this tibial tubercle becoming more pronounced and generally 176 00:11:18,399 --> 00:11:20,960 that's what we see on X ray role when we palpay it on our physical 177 00:11:20,000 --> 00:11:24,240 exam. This elevation of the tivial tuberosity as far as the age range thirteen 178 00:11:24,279 --> 00:11:30,039 to fourteen year old boy during a growth spurt can be seen in ages ranging 179 00:11:30,080 --> 00:11:33,159 from nine to fourteen, but it's more common in boys than the thirteen to 180 00:11:33,240 --> 00:11:35,320 fourteen year old age range, as this is a common time for a growth 181 00:11:35,399 --> 00:11:39,240 spurt. It could also be seen in girls, but it's not as common. 182 00:11:39,320 --> 00:11:41,840 So in the vignette, again, be looking for a boy in their 183 00:11:41,879 --> 00:11:46,480 early teens. On exam, you're looking for or clinical manifestations. You're looking 184 00:11:46,480 --> 00:11:50,559 for anterior knee pain which is exacerbated by activity, so kneeling, running, 185 00:11:50,679 --> 00:11:54,240 jumping, squatting. I think basketball, as most vignettes are going to mention 186 00:11:54,320 --> 00:11:58,919 a young male playing basketball that presents with anterior knee pain on physical exam pronoun 187 00:12:01,679 --> 00:12:05,519 pronounced tender tibule, tubercle. So remember all that calous formation is causing this 188 00:12:05,600 --> 00:12:09,120 area to become more pronounced. And then as far as treatment, it's really 189 00:12:09,120 --> 00:12:13,200 just gonna be conservative. So it's typically a benign and self limited condition, 190 00:12:13,600 --> 00:12:16,559 and conservative measures are going to be the mainstay of therapy, so And says 191 00:12:16,600 --> 00:12:20,799 physical therapy self limited condition symptoms generally resolve as the growth plays ossified. It's 192 00:12:20,919 --> 00:12:24,320 rare to require surgery. Okay, so you're gonna get an exampt question. 193 00:12:24,360 --> 00:12:28,480 It's gonna be a young kid, it's gonna be hip or knee paying exacerbated 194 00:12:28,519 --> 00:12:31,399 by sports, and the answer choices you're gonna have lake Helva, slipcap, 195 00:12:31,639 --> 00:12:35,159 Osgat schlatter trust may have been there. You're gonna have no idea which one 196 00:12:35,279 --> 00:12:37,600 is, which, which one affects the hip, which one affects the knee. 197 00:12:37,240 --> 00:12:39,720 So this is the mnemonic I had, and it's it's dumb, but 198 00:12:39,840 --> 00:12:43,720 it helped me remember enough about Osgat Schlatter that I could remember the little bit 199 00:12:43,960 --> 00:12:48,240 about it that I needed to differentiate from slipcap and the other ones. So 200 00:12:48,879 --> 00:12:52,320 Ozgat Schlatter is the one that evolves the knee. It's usually worth worse with 201 00:12:52,480 --> 00:12:56,080 squatting, So I used to remember instead of osgod schlatter disease, You're gonna 202 00:12:56,120 --> 00:13:01,879 remember Osgood's squatter denise. So squatter because the pain is usually worth worse with 203 00:13:01,039 --> 00:13:05,919 like squatting, kneeling sometimes jumping, and denise because it's a condition of the 204 00:13:05,000 --> 00:13:09,039 knee, the potellar ligament, and the tibial tubercle. These dumb things are 205 00:13:09,039 --> 00:13:15,679 gonna help Sabi on an examp. So remember Osgod osgod schlaughter disease. Remember 206 00:13:15,679 --> 00:13:18,840 Osgod's squattered in knees. All right, so let's talk about some more nice 207 00:13:18,879 --> 00:13:24,080 stuff. Of all of the Loric's extremity MSK questions, the majority are going 208 00:13:24,120 --> 00:13:26,799 to be about the knee. So let's start with one of the biggest ones 209 00:13:26,840 --> 00:13:31,559 in that's interior cruciate ligament injury. So the ACL is the most commonly injured 210 00:13:31,639 --> 00:13:35,039 knee ligament, and the majority of a CL tears are going to occur from 211 00:13:35,080 --> 00:13:39,000 athletic injury. So the type of injury you're looking for is a non contact 212 00:13:39,080 --> 00:13:43,279 pivoting injury most common cause. So the typical mechanism for an ACL injury involves 213 00:13:43,720 --> 00:13:48,720 running or jumping athlete who suddenly stops and changes directions like they're cutting. They 214 00:13:48,840 --> 00:13:52,120 pivot or the land in a way which involves rotation and valgus stress of the 215 00:13:52,200 --> 00:13:56,799 knee and the tibia slides anteriorly on the femur and pop goes the a CL 216 00:13:58,360 --> 00:14:01,960 history, pop and swell. So the way this will be described on a 217 00:14:01,000 --> 00:14:03,720 vignette, of course, in real life, is the patient felt a pop 218 00:14:03,799 --> 00:14:07,200 in their knee at the time of the injury and then had a cute swelling 219 00:14:07,240 --> 00:14:11,440 after which is hemarthrosis which led to the swelling. Up to seventy seven percent 220 00:14:11,720 --> 00:14:16,240 of patients presenting with a cute traumatic knee hemarthrosis will have an ACL injury. 221 00:14:16,320 --> 00:14:20,279 So remember pop, then sudden swelling, pop and swell for the ACL. 222 00:14:20,399 --> 00:14:24,759 That little rhyme there, pop and swell for the ACL physical exam Lockman test 223 00:14:24,840 --> 00:14:26,720 the most sensitive exam test. Therefore, this is the one you should commit 224 00:14:26,799 --> 00:14:30,639 to memory. You do this test with the knee and thirty degrees reflection, 225 00:14:30,759 --> 00:14:35,840 stabilize the distal femur with one hand while pulling the proximal tibia anteriorly towards you 226 00:14:35,919 --> 00:14:37,919 with the other hand, and attacked. ACL is going to limit the anterior 227 00:14:39,000 --> 00:14:41,480 translation how far the tibia will go. If this isn't the case, there's 228 00:14:41,559 --> 00:14:46,240 increased anterior translation compared to the unaffected knee, patient likely has an ACL tear. 229 00:14:46,559 --> 00:14:50,399 The way that you're going to remember Lachman is the most sensitive exam test 230 00:14:50,440 --> 00:14:54,759 for an ACL tear is that the first three letters in Lockman are ACL rearranged, 231 00:14:54,840 --> 00:15:01,320 So Lackman Lockman LAC is ACL rearrange. So you'll always know if you 232 00:15:01,399 --> 00:15:05,360 see a Lockman test, look at those first three letters ACL rearranged. This 233 00:15:05,480 --> 00:15:09,120 is your most sensitive exam test for AL tears. Of course, imaging, 234 00:15:09,200 --> 00:15:11,279 I'm not going to really go into this for most of these because it's going 235 00:15:11,320 --> 00:15:15,600 to be repetitive, But like most extremity injuries, you start with an X 236 00:15:15,679 --> 00:15:18,000 ray to rule upon the abnormalities, do an MRI to make the actual diagnosis 237 00:15:18,080 --> 00:15:22,200 of the tear. Treatment is going to be individualized to each patient. Most 238 00:15:22,240 --> 00:15:26,159 active, younger patients and athletes are going to opt for surgical reconstruction. Older 239 00:15:26,200 --> 00:15:30,679 patients may go the conservative route with physical therapy, so conservative or surgical repair. 240 00:15:31,039 --> 00:15:33,679 Two things that memorize for an ACL tear the pop and swell. For 241 00:15:33,759 --> 00:15:37,279 the ACL, that pop felt in the knee, followed by him arthrosis causing 242 00:15:37,320 --> 00:15:41,519 the swelling. And remember your Lockman tests best physical exam test Lockman LAC. 243 00:15:41,720 --> 00:15:46,159 First three letters are ACL rearranged. Moving on to post tior cruciate ligament injury. 244 00:15:46,519 --> 00:15:48,840 Very little to know here. This isn't a very high y old topic. 245 00:15:50,480 --> 00:15:54,279 It's rare to see this as an isolated injury. Isolated PCL injuries, 246 00:15:54,320 --> 00:15:58,240 they're just very uncommon. It's usually going to be in combination with other multiligament 247 00:15:58,320 --> 00:16:00,679 trauma to the knee, so the mechanism is usually going to be a direct 248 00:16:00,759 --> 00:16:06,200 blow to the proximal tibia with a flex knee like a dashboard injury. So 249 00:16:06,320 --> 00:16:08,759 the main cause of a PCL injury is a high energy trauma, most often 250 00:16:08,960 --> 00:16:14,879 involving motor vehicle collisions. Second most common would be sporting related activities, but 251 00:16:15,279 --> 00:16:18,399 focus on your motor vehicle accident direct blow to the proximal tibia with a flex 252 00:16:18,519 --> 00:16:22,919 knee when it hits the dashboard. As far as the test, posterior drawer 253 00:16:22,039 --> 00:16:26,360 tests. So there's a few different physical exam maneuvers for a PCL tear, 254 00:16:26,480 --> 00:16:30,320 but posterior drawer tests is generally considered the most accurate maneuver for diagnosing PCL and 255 00:16:32,080 --> 00:16:34,120 injury. AKA, that's the one you should know. So knee at ninety 256 00:16:34,159 --> 00:16:40,279 degrees of flexion, Wrap both hands around the patient's proximal tibia normally sitting on 257 00:16:40,320 --> 00:16:44,120 the foot to keep the leg fixated. Then apply a posteriorly directed force to 258 00:16:44,200 --> 00:16:48,000 the proximal tibia so you push back on the tibia with the knee flexed. 259 00:16:48,279 --> 00:16:53,600 Increased posterioria displacement compared with the uninvolved leg suggest tear of the PCL m riot 260 00:16:53,639 --> 00:16:59,200 A confirm of course, treatment's going to be conservative or surgical, conservative like 261 00:16:59,279 --> 00:17:03,440 rest ice itself. Nothing specific to know here, and it's really surprising how 262 00:17:03,519 --> 00:17:07,440 well some individuals can do with this type of injury. They did a study 263 00:17:07,519 --> 00:17:11,680 and two percent of all college football players presenting for the exam prior to the 264 00:17:11,799 --> 00:17:15,480 NFL Draft had an asymptomatic PCL terror, So they were playing football with this 265 00:17:15,599 --> 00:17:21,119 terror. They had no idea, So conservative verse surgical, depending on the 266 00:17:21,240 --> 00:17:23,839 patient. Nothing high yield to memorize there, all right, moving on to 267 00:17:25,039 --> 00:17:29,160 medial collateral ligament injury. Just a couple of things to commit to memory for 268 00:17:29,319 --> 00:17:34,920 MCL and LCL injuries will go over both of those. So medial collateral ligament 269 00:17:36,000 --> 00:17:38,640 injuries are caused by a valgus force to the lateral aspect of the knee. 270 00:17:40,039 --> 00:17:42,720 So really two mechanisms of injury will see with an MCL injury, either from 271 00:17:42,759 --> 00:17:47,160 direct valgus stress from a blow to the lateral aspect of the knee, or 272 00:17:47,279 --> 00:17:49,200 via an indirect stress like if the foot gets caught on the floor when the 273 00:17:49,240 --> 00:17:55,000 athletes trying to change direction quickly. The key is the valgus stress. Whatever 274 00:17:55,039 --> 00:17:57,640 the cause, something caused the need to be pushed inward valgus stress. That's 275 00:17:57,640 --> 00:18:02,680 what you need to remember. How positive valgus stress test. The diagnosis of 276 00:18:02,759 --> 00:18:07,359 an MCL injury is often made clinically based upon the history, clinical presentation, 277 00:18:07,559 --> 00:18:10,640 and exam findings, and the physical exam tests you need to know as a 278 00:18:10,720 --> 00:18:12,960 valgus stress tests. You do this with the knee at both thirty degrees reflection 279 00:18:14,000 --> 00:18:18,359 and zero degrees of extension. You apply valgus stress and you look for laxity 280 00:18:18,400 --> 00:18:22,279 of the joint. You feel how much the medial joint line widens. Okay, 281 00:18:22,359 --> 00:18:26,200 so the only thing I would remember for your medial collateral ligament injury is 282 00:18:26,319 --> 00:18:30,359 valgus you have to remember valgus force, valgus stress. This is associated with 283 00:18:30,519 --> 00:18:33,880 MCL injuries. How do you remember what valgus is? How do you remember 284 00:18:33,920 --> 00:18:36,599 what it's associated with? So this is how you remember it. This is 285 00:18:36,599 --> 00:18:41,640 how you associated with MCL. MCL. Valgus has the word gus in it, 286 00:18:41,759 --> 00:18:44,240 So when you seek gus and valgus, I want you to think of 287 00:18:44,519 --> 00:18:48,480 Gusto as in Muccio gusto muccio, because Mucco starts with an M, so 288 00:18:48,599 --> 00:18:53,599 that helps you remember MCL and gusto from the valgus. Muccio gusto in English 289 00:18:53,680 --> 00:18:56,200 means nice to meet you, and this helps you remember the knee is being 290 00:18:56,240 --> 00:19:00,160 pushed inward from lateral force, and the knee is are getting closer together and 291 00:19:00,319 --> 00:19:03,400 meeting together. It's a ridiculous way to remember it, but I never forgot 292 00:19:03,440 --> 00:19:07,119 it. So as soon as you see valgus, think Muccio Gusto m and 293 00:19:07,200 --> 00:19:11,440 mucho Gusto helps to remember mc L injury. Nice to meet because the knees 294 00:19:11,480 --> 00:19:15,960 are being pushed in and meeting together. Treatment is going to be very low 295 00:19:17,079 --> 00:19:21,519 yield, conservative or surgical. Nothing to bother memorizing talk about lateral collateral ligament 296 00:19:21,559 --> 00:19:25,799 injury the opposite, so this occurs due to a sudden various force to the 297 00:19:25,880 --> 00:19:30,240 knee as opposed to valgus. So these are among the least common knee injuries, 298 00:19:30,279 --> 00:19:33,119 but they can occur when the knee joint is struck from the inside, 299 00:19:33,200 --> 00:19:36,880 so various stress, and it's really rare to have this as an isolated injury. 300 00:19:36,880 --> 00:19:41,519 It's much more common in combination with other other injuries, so positive varus 301 00:19:41,839 --> 00:19:45,519 stress tests. So either do this at both thirty degrees offlection and zero degrees 302 00:19:45,559 --> 00:19:52,279 a full extension while applying various stress. So remember MCL has a positive valgus 303 00:19:52,400 --> 00:19:56,240 test because muccio gusto knees are meaning together mucho gusto ns to meet you. 304 00:19:56,599 --> 00:20:00,960 And then when we have LCL injuries by method of exclusion, it's the exact 305 00:20:00,039 --> 00:20:06,400 opposite, so varus legs being pushed outward LCL positive virus stress test. I 306 00:20:06,480 --> 00:20:11,440 also used to remember that leaky pipes rust because of rust and va russ leaky 307 00:20:11,519 --> 00:20:15,720 helps me remember the l and LCL, so hopefully one of those stick, 308 00:20:15,000 --> 00:20:22,039 whether it's mucho gusto or leaky pipes rust in LCL with virus stress. So 309 00:20:22,160 --> 00:20:26,279 remember that remember your test for those. Let's move on to miniscal injury. 310 00:20:26,680 --> 00:20:30,960 So cute miniscal tears most often are going to be from twisting injury. So 311 00:20:30,759 --> 00:20:36,160 the tears typically happen when a person quickly changes direction while rotating or twisting the 312 00:20:36,200 --> 00:20:40,200 knee when the foot is planted. In older adults, we can see chronic 313 00:20:40,279 --> 00:20:44,079 degenerative tears and these can occur with minimal twisting or stress. In some cases 314 00:20:44,119 --> 00:20:47,319 no trauma at all, but in general though, be thinking some sort of 315 00:20:47,480 --> 00:20:52,480 twisting of the leg in the vignette. As far as the manifestations, I 316 00:20:52,519 --> 00:20:56,759 want you to remember pop lock and drop like poplock and drop it, So 317 00:20:56,279 --> 00:21:00,799 when you think of miniscal tears, remember pop lock and drop as the most 318 00:21:00,839 --> 00:21:04,839 common clinical manifestation. So patients with untreated miniscal tears are going to complain of 319 00:21:04,880 --> 00:21:08,559 the knee popping locking where they can't fully extend the knee, and then sometimes 320 00:21:08,599 --> 00:21:11,359 the knee will even give out where they drop because the knee just gave way. 321 00:21:11,400 --> 00:21:15,240 So remember miniscal tears pop lock and drop it. They're also going to 322 00:21:15,279 --> 00:21:18,559 have joint line tenderness on the exam, So on exam, joint line tenderness 323 00:21:18,680 --> 00:21:23,359 is really the most sensitive physical exam finding. It's nonspecific though, so the 324 00:21:23,440 --> 00:21:26,839 physical exam test you should know about as it's the most commonly tested on is 325 00:21:26,960 --> 00:21:30,960 known as the McMurray test. So the McMurray test is a test of repeated 326 00:21:32,039 --> 00:21:36,039 passive flection and extension of the knee. Place your fingers at the joint line 327 00:21:36,200 --> 00:21:38,359 while you're performing the test, and you're feeling for a painful pop or click 328 00:21:38,400 --> 00:21:44,640 in the knee indicating a likely miniscal tear. Just an fyi in case you 329 00:21:44,720 --> 00:21:48,240 don't know that. I do have a YouTube channel where I have like pictures 330 00:21:48,279 --> 00:21:51,200 of all these things and it's a lot easier to go along with the explanations 331 00:21:51,519 --> 00:21:52,440 if you have time to look at the videos, just to get a better 332 00:21:52,480 --> 00:21:56,759 idea, because it's hard to explain these physical exam tests. There is other 333 00:21:56,839 --> 00:22:00,640 tests with this type of injury. There's the apple, the thessaly, they're 334 00:22:00,640 --> 00:22:03,519 not as commonly used or tested on. I'd focus on the McMurray tests as 335 00:22:03,599 --> 00:22:06,839 that's the one you need to do, you'll likely need to do in an 336 00:22:06,960 --> 00:22:10,359 osci and the one you'll get tested on this is you can remember McMurray test 337 00:22:10,480 --> 00:22:14,759 is associated with meniscal tears, So Murray is obviously a man's name, and 338 00:22:14,920 --> 00:22:18,519 meniscle when you broke, when you break down the words a miniscle as men 339 00:22:18,880 --> 00:22:23,519 is called, so menace call men is called, and men is called murray. 340 00:22:23,759 --> 00:22:26,599 So as soon as you see miniscal tear and a question, hopefully your 341 00:22:26,640 --> 00:22:30,119 head thinks men is called? What are men called? They're called murray. 342 00:22:30,400 --> 00:22:34,359 That helps you remember the McMurray tests. So men is called murray as a 343 00:22:34,400 --> 00:22:37,599 miniscal tear as you use the McMurray test. All right, Moving on to 344 00:22:37,880 --> 00:22:44,480 the tibiofamoral dislocation, the knee dislocation. This is a potentially limb threatening injury. 345 00:22:44,920 --> 00:22:48,720 Dislocations of the tibiophomoral joint of the knee are true surgical emergencies. They 346 00:22:48,759 --> 00:22:52,519 have a high rate of neurovascular injury. And if there's a populateal artery injury 347 00:22:52,599 --> 00:22:56,559 caused from the dislocation that goes unrecognized about eight hours after the majority of patients 348 00:22:56,599 --> 00:23:00,519 are going to require amputation of the leg. So this is a really serious 349 00:23:00,640 --> 00:23:04,680 injury. It's normally going to occur from high energy trauma, so relatively rare 350 00:23:04,759 --> 00:23:07,359 injury, but when it does takes place, it's certainly going to be a 351 00:23:07,480 --> 00:23:11,559 serious high energy trauma like a motor vehicle accident, fall from very high up 352 00:23:12,160 --> 00:23:15,880 complications. These are the main things that you need to know about tibio from 353 00:23:15,920 --> 00:23:19,720 oral dislocations. First one poplteal artery. This is the most dangerous complication following 354 00:23:19,759 --> 00:23:25,119 a tibial from oral dislocation. Delaying diagnosis and repair can lead to amputation like 355 00:23:25,160 --> 00:23:29,279 I talked about before, So what we do to avoid missing this diagnosis is 356 00:23:29,319 --> 00:23:33,880 after the dislocation is reduced, we assess the distal and the poplteeal pulses. 357 00:23:33,920 --> 00:23:37,319 This can be done with an echo break index of betside ultrasound if available. 358 00:23:37,960 --> 00:23:41,799 Also of course palpating. If there's signs of vascular compromise, these patients need 359 00:23:41,839 --> 00:23:45,519 emergency surgery console to keep them from losing the leg. And then also you 360 00:23:45,839 --> 00:23:49,200 may have an injury of the pernial nerves. So focus on the poploteal artery, 361 00:23:49,400 --> 00:23:52,319 but also be aware that the proneal nerve is injured in about twenty three 362 00:23:52,359 --> 00:23:56,759 percent of patients with need dislocations. Main takeaway with need dislocations, assess for 363 00:23:56,880 --> 00:24:02,720 vascular compromise, don't miss a popliteal arter injury. Moving on to Patello famral 364 00:24:02,839 --> 00:24:07,079 syndrome antior knee pain. This is what you're looking for in the vignette, 365 00:24:07,079 --> 00:24:11,359 antior knee pain with Patelo famorl syndrome. So it's an overuse disorder that involves 366 00:24:11,400 --> 00:24:15,640 the Patelo for moral region and it will present as antiior knee pain around or 367 00:24:15,720 --> 00:24:18,519 behind the patello. Who you're looking for in the vignette is going to be 368 00:24:18,680 --> 00:24:22,880 runners and women in the vignette. It will be a female runner. That's 369 00:24:22,920 --> 00:24:25,599 your demographic. That's who's going to be in the vignette. That's who this 370 00:24:25,680 --> 00:24:29,720 is seen most commonly. And sometimes this is even called runners knee I used 371 00:24:29,759 --> 00:24:33,839 to remember this because the name instead of being Patello for moral syndrome, I 372 00:24:33,920 --> 00:24:37,519 remembered it as Patello female run syndrome. So just help me remember. If 373 00:24:37,559 --> 00:24:40,599 I see a vignette it's a female and she's a runner, I should be 374 00:24:40,680 --> 00:24:45,079 thinking of Patello from female run syndrome aka Patello for Moorl syndrome. So remember 375 00:24:45,160 --> 00:24:49,519 Patelo female run syndrome. You'll remember female runner. That's who's likely going to 376 00:24:49,599 --> 00:24:55,200 be in the vignette. Treatment is conservative and says rest et cetera. Takeaway, 377 00:24:55,359 --> 00:24:56,960 female runner antior knee pain. That's what you need to know for this 378 00:24:57,559 --> 00:25:02,640 now, eliot tibial band syndrome. This is going to sound very similar to 379 00:25:02,759 --> 00:25:06,960 Patello fhamoral syndrome. The main difference is the location of the pain and this 380 00:25:07,119 --> 00:25:10,799 is the second most common cause of knee pain due to overuse, patelophamoral being 381 00:25:10,920 --> 00:25:15,839 the first lateral knee pain in this case instead of anterior, so overuse injury 382 00:25:15,880 --> 00:25:19,400 of the lateral knee. The pain develops where the iliotibial band runs a clock 383 00:25:19,480 --> 00:25:23,319 across the lateral famoral epicondo runners, you're going to see the sin so again 384 00:25:23,400 --> 00:25:29,000 primarily seen in runners, can also be seen in cyclists basically any athlete undergoing 385 00:25:29,039 --> 00:25:33,759 exercises with repetitive knee flection and extension. But primarily runners will be what you're 386 00:25:33,759 --> 00:25:37,039 looking from the vignette. Not so much of a predilection though for females as 387 00:25:37,079 --> 00:25:41,920 we saw in patelo femoral syndrome aka patello female run syndrome. Remember it that 388 00:25:41,000 --> 00:25:45,480 way. Treatment conservative and SAIDs, rests, etc. There's some physical exam 389 00:25:45,599 --> 00:25:48,480 tests for this. The noble the overtest i don't think they're worth the time 390 00:25:48,519 --> 00:25:52,680 memorizing. Way more high yield things for you to focus on. For msk 391 00:25:52,240 --> 00:25:57,440 SO Patelo famoral syndrome, iliotibial band syndrome, very similar treatment similar usually the 392 00:25:57,519 --> 00:26:00,160 vinet vinet, they're going to be a runner. Main thing to focus on 393 00:26:00,279 --> 00:26:04,599 to differentiate is where the pain is. Patelo formoral syndrome, antior pain. 394 00:26:06,359 --> 00:26:10,720 Remember that's where the patela is. So do you remember it's patela patelo, 395 00:26:10,839 --> 00:26:12,599 So you remember it's the patella. Patella is obviously in the anterior side of 396 00:26:12,599 --> 00:26:15,640 the name. That's where the pain is. And then iliotibial band syndrome pain 397 00:26:15,759 --> 00:26:18,960 is going to be lateral. That's the main takeaway to differentiate these two. 398 00:26:19,240 --> 00:26:22,880 Otherwise it's very little to no moving on to an ankle sprain, So, 399 00:26:23,079 --> 00:26:27,640 lateral ankle sprains are going to be your most common inversion of the plantar flexed 400 00:26:27,920 --> 00:26:32,119 foot. That's going to be the most common mechanism of injury in an ankle 401 00:26:32,240 --> 00:26:36,079 sprain. Medial ankle sprains are actually very rare. They're not going to give 402 00:26:36,079 --> 00:26:37,920 you that. Remember, they're going to give you the common stuff. That's 403 00:26:37,920 --> 00:26:40,519 where you're going to be tested on. So it's going to be a lateral 404 00:26:40,599 --> 00:26:45,519 ankle sprain that's involved in seventy to ninety percent of all sports related ankle sprains. 405 00:26:45,519 --> 00:26:49,000 And the ligament that's most commonly going to be injured in the vignette is 406 00:26:49,039 --> 00:26:53,079 going to be the anterior talo fibular ligament. This is the injury the ligament 407 00:26:53,400 --> 00:26:57,119 injuring the majority of ankle sprains, seventy three percent of ankle sprains. No, 408 00:26:57,319 --> 00:27:00,039 this one. There's obviously other ggaments that can be injured, but this 409 00:27:00,160 --> 00:27:03,359 is the one you need to commit to memory. It's the one that I 410 00:27:03,519 --> 00:27:04,440 was asked. This is the one that you're going to be asked, and 411 00:27:04,559 --> 00:27:10,119 remember. The way that you can remember this is anterior taalofibular ligament is sometimes 412 00:27:10,200 --> 00:27:14,200 referred to as the ATF ligament, and ATF in your mind is going to 413 00:27:14,279 --> 00:27:18,440 stand for always tears first, because it's the most likely ligament to tear in 414 00:27:18,519 --> 00:27:23,319 an ankle sprains. Remember anterior taalofibular ligament aka the ATF ligament, always tears 415 00:27:23,440 --> 00:27:27,640 first. Let's talk about the Ottawa Ankle rules. So the Ottawa Ankle Rules, 416 00:27:27,640 --> 00:27:32,480 they're very sensitive for excluding ankle fractures and determining whether or not you need 417 00:27:32,680 --> 00:27:37,119 X rays of the ankle or the midfoot ninety six to ninety nine sensitive. 418 00:27:37,559 --> 00:27:40,880 They're really just very common sense. Basically, it states if you can walk 419 00:27:41,400 --> 00:27:47,400 after the injury or you're basically, if you can walk after the injury and 420 00:27:47,519 --> 00:27:51,400 you're not tender in the ankle or the midfoot, it's probably a sprain and 421 00:27:51,440 --> 00:27:53,640 you don't need X rays. The specific guidelines are as followed. So if 422 00:27:53,640 --> 00:27:57,640 you're unable to bear weight both immediately after the injury and for four steps in 423 00:27:57,720 --> 00:28:03,200 the office or the ear plus you have tenderness at the posterior edge or the 424 00:28:03,319 --> 00:28:06,880 tip of the lateral or medial malleolis, you need an ankle X ray. 425 00:28:07,440 --> 00:28:10,720 And then the other one is if you're unable to bear weight both immediately after 426 00:28:10,799 --> 00:28:12,839 the injury and for four steps in the office or the er plus you have 427 00:28:12,920 --> 00:28:17,279 tenderness at the base of the fifth metatarsal or the navicular, you need a 428 00:28:17,319 --> 00:28:19,200 foot X ray. If you don't present with those things, you probably don't 429 00:28:19,200 --> 00:28:22,119 need an X ray and it's a sprain. Nothing to know for the treatment 430 00:28:22,160 --> 00:28:26,640 of a sprain, it's just ice elevation end sets ankle X rays. If 431 00:28:26,680 --> 00:28:29,359 you get a question, it's likely going to be about the interior tail of 432 00:28:29,400 --> 00:28:33,160 fib ligament. So remember only one thing about ankle sprains. Remember atf ligament 433 00:28:33,240 --> 00:28:38,400 always tears. First, let's talk about ankle achilles tendin rupture. Two things 434 00:28:38,440 --> 00:28:45,759 that I would know for achilles tendin rupture risk factors floral quinolans SOW. Fluoroquinolones 435 00:28:45,759 --> 00:28:49,640 can put patients at an increased risk for tendin rupture. Is it common? 436 00:28:51,000 --> 00:28:53,119 No? In Actually a large case study was only seen in twelve patients per 437 00:28:53,160 --> 00:28:57,799 one hundred thousand. But just because something isn't common in real life doesn't mean 438 00:28:57,880 --> 00:29:00,559 it's not a common exam question. And this one's one of the favorites for 439 00:29:00,640 --> 00:29:04,400 examp questions. So I would just know that another common cause is going to 440 00:29:04,480 --> 00:29:10,240 be a sports related injury. Over eighty percent of ruptures occurred during recreational sports, 441 00:29:10,319 --> 00:29:14,400 particularly stopping ghost sports as like tennis, basketball, softball. But for 442 00:29:14,440 --> 00:29:18,480 the exam focus on some history of fluoroquinolone use. No needs to focus on 443 00:29:18,480 --> 00:29:21,599 the clinical menifestations. They're pretty common sense. Basically, they're gonna have a 444 00:29:21,720 --> 00:29:26,160 pop in some severe pain in the posterior ankle. What you should know though, 445 00:29:26,240 --> 00:29:29,119 is the Thompson tests, so definitely be familiar with the Thompson tests. 446 00:29:29,400 --> 00:29:32,319 To do this, the patient lies prone with their feet dangling off the table. 447 00:29:32,680 --> 00:29:36,519 You squeeze the calf the gastro acnemius muscle, and then you watch for 448 00:29:36,559 --> 00:29:40,200 a plant our flection of the foot. The absence of plant our flection is 449 00:29:40,240 --> 00:29:42,400 going to mark a positive test and it will be indicative of a rupture. 450 00:29:42,839 --> 00:29:47,920 This is an important test because other indicators of an Achille tendon rupture they're not 451 00:29:47,960 --> 00:29:51,480 always accurate. For instance, asking somebody just to plant our flex the foot, 452 00:29:51,519 --> 00:29:55,720 it's not always accurate to assist and diagnosis because you can actually plant our 453 00:29:55,720 --> 00:30:00,240 flex your foot using accessory muscles like the tibialis posterior. So always from the 454 00:30:00,279 --> 00:30:03,440 Thompson tests and a suspect Achilles tendon rupture, squeeze the calf, that's what 455 00:30:03,519 --> 00:30:07,680 you're going to be asked. Diagnosis of a rupture can be made solely by 456 00:30:07,680 --> 00:30:10,920 the clinical exam. You can get an MRI or even an ultrasound to confirm, 457 00:30:11,200 --> 00:30:14,960 but the treatment can range from splinting all the way to surgical repair. 458 00:30:15,119 --> 00:30:18,960 It's not important know the two things Chilles tend in rupture, remember your fluoroquinolone 459 00:30:18,039 --> 00:30:22,559 use and know the Thompson test. Plant or fasciitis. Very little to know 460 00:30:22,720 --> 00:30:26,200 here, So this is chronic overuse that leads to micro tears and inflammation in 461 00:30:26,279 --> 00:30:30,839 the origin of the plant or fascia. So they're gonna have heal pain that's 462 00:30:30,880 --> 00:30:33,119 worse with their first few steps in the morning or after a period of inactivity. 463 00:30:33,480 --> 00:30:36,599 This is what you're looking for in the vignette. They'll have some heal 464 00:30:36,640 --> 00:30:38,039 pain when they first wake up in the morning. It's normally how it's going 465 00:30:38,079 --> 00:30:41,960 to be presented. This is mainly a clinical diagnosis. X rays would really 466 00:30:42,039 --> 00:30:45,880 just to be able to rule out some differentials like maybe a calcaneal stress fracture, 467 00:30:47,200 --> 00:30:49,880 but nothing really to know for imaging or lab tests. Treatment is conservative 468 00:30:49,960 --> 00:30:55,599 stretching exercises for the plant or fascia, calf muscle, silicone heelshoe inserts and 469 00:30:55,759 --> 00:30:59,799 sets. You can even use corticosteroid injections. Very little to know there. 470 00:31:00,559 --> 00:31:06,599 Interdigital Morton's neuroma. This is a compressive neuropathy of the interdigital nerve that leads 471 00:31:06,599 --> 00:31:11,200 to plantar four foot pain. So basically something is squeezing on the foot, 472 00:31:11,519 --> 00:31:15,240 causing the metatarsos to squeeze together and put pressure on the nerve between the two 473 00:31:15,279 --> 00:31:18,480 structures, which leads to proliferation and a benign growth of the nerve tissue. 474 00:31:18,759 --> 00:31:22,559 This can lead to numbness, burning, et cetera on the foot like those 475 00:31:22,640 --> 00:31:26,920 parascesaes. Who you're looking for in the vignette, women with tight fitting shoes, 476 00:31:26,000 --> 00:31:30,519 women wearing high heels in the vignette. This will absolutely be a female 477 00:31:30,559 --> 00:31:34,880 as they're approximately five times more likely than males to develop more neuroma. They 478 00:31:34,960 --> 00:31:38,240 may mention something about wearing shoes that are too tight, wearing high heels. 479 00:31:38,960 --> 00:31:45,039 High heels cause overpronation of the foot, and that's one of the risk factors. 480 00:31:45,079 --> 00:31:48,319 And then tight shoes are also associated with this condition. While you're looking 481 00:31:48,400 --> 00:31:52,599 for in the description of the pain is burning pain most common in the third 482 00:31:52,799 --> 00:31:56,839 inner metatarso space. So patient with the neuroma will most commonly be complaining of 483 00:31:56,920 --> 00:32:00,680 this burning pain in the third inner metatarso space between the third and the fourth 484 00:32:00,799 --> 00:32:04,160 distal metatarsals. It's a clinical diagnosis. For the most part. You can 485 00:32:04,279 --> 00:32:07,440 use ultrasound actually visualize the neuroma, but it's usually not necessary and nothing really 486 00:32:07,480 --> 00:32:10,799 to know if for a treatment, it's mainly conservative metatarsal support, padded shoe, 487 00:32:10,839 --> 00:32:16,240 insert specialized orthopedic shoes. So two things that I would focus on to 488 00:32:16,359 --> 00:32:20,240 identify it in the vignette. It's going to be a woman in the vignette, 489 00:32:20,279 --> 00:32:22,839 and the pain will likely be in the third in a metatarsal space. 490 00:32:22,240 --> 00:32:25,359 I used to remember this because the M in Morton, Sonoma, if you 491 00:32:25,400 --> 00:32:29,839 turn if you turn an M to the side, it's a three and then 492 00:32:29,880 --> 00:32:32,319 helps remember the third intermetatarsal space will be the most common area for the burning 493 00:32:32,359 --> 00:32:37,079 pain. If you turn an M upside down, that's a W and it 494 00:32:37,160 --> 00:32:38,880 helps you remember this is most common in women. The other thing that I 495 00:32:39,000 --> 00:32:42,200 used to remember too is if you turn it. If you turn an M 496 00:32:42,319 --> 00:32:45,160 upside down, it kind of looks like the heels in high heels. I 497 00:32:45,200 --> 00:32:47,319 don't know, Maybe that one makes no sense to you better with the visuals 498 00:32:47,359 --> 00:32:51,680 on YouTube, but that's the main things that I that I remember so more 499 00:32:51,720 --> 00:32:53,240 in Sonoma. Turn that M to the side, it's a three. Third 500 00:32:53,279 --> 00:32:57,880 intermetatarsal space most common. Turn the M upside down, that's a W. 501 00:32:58,319 --> 00:33:00,960 Remember it's most common in women. Moving on to Jones fracture. Jones fracture 502 00:33:01,039 --> 00:33:07,160 is a fracture of the fifth metatarso specifically, a fracture of the proximal diaphysis 503 00:33:07,240 --> 00:33:13,319 at the junction of the metaphysis and diaphysis. You can remember Jones fracture is 504 00:33:13,319 --> 00:33:16,039 a fracture of the fifth metatarsal because Jones has five letters. And then there's 505 00:33:16,079 --> 00:33:20,359 something called pseudo Jones fracture, so you may hear of this. Pseudo Jones 506 00:33:20,400 --> 00:33:23,039 fracture terminology isn't being used as often, but if you hear it, it's 507 00:33:23,079 --> 00:33:25,759 the same thing. It's a fracture of the fifth metatarsal, but it's just 508 00:33:25,839 --> 00:33:29,680 a little bit more proximal. In this case, it's the fracture of the 509 00:33:29,839 --> 00:33:32,759 base or the tuberocity of the fifth metatarsal. I used to remember that because 510 00:33:32,759 --> 00:33:37,640 I would remember Jones is a fracture of the fifth metatarsal. Pseudo Jones adds 511 00:33:37,680 --> 00:33:39,920 a p there and just helps him remember. It's a little bit more proximal 512 00:33:40,359 --> 00:33:45,640 at the base of the tuberocity the base or the tuberosity of the fifth metatarsal. 513 00:33:45,640 --> 00:33:47,480 So that's Jones fracture. Not too much to know there either. And 514 00:33:47,559 --> 00:33:52,920 then Finally moving on to Liz Franc or a Tarso metatarsal injury. This is 515 00:33:52,920 --> 00:33:58,160 an injury in which the metatarsal bones are displaced from the tarsis. So the 516 00:33:58,279 --> 00:34:02,319 Liz Franc ligament consists of religaments that run from the second metatarsal to the medial 517 00:34:02,359 --> 00:34:07,199 cuneiform. So when you have a Tarso metatarsal fracture or other trauma in this 518 00:34:07,320 --> 00:34:12,239 area, it can lead to a disruption between the medial cuneiform and the base 519 00:34:12,320 --> 00:34:15,000 of the second metatarsal, which can lead to widening between the first and the 520 00:34:15,039 --> 00:34:20,679 second metatarsal basis. Because when because the second metatarsal, when it fractures, 521 00:34:20,800 --> 00:34:22,400 it loses its anchor that holds it in a place, which is the List 522 00:34:22,440 --> 00:34:27,599 Franc ligaments what spreads apart, look for something called a flex sign. This 523 00:34:27,760 --> 00:34:30,480 is pathnemonic for a Liz Franc injury. So a flex sign is when there's 524 00:34:30,760 --> 00:34:37,079 an evulsion fracture at the origin or the insertion point of the List Franc ligament, 525 00:34:37,159 --> 00:34:40,039 So either at the medial cuneiform or the base of the second metatarsal, 526 00:34:40,119 --> 00:34:45,440 or the List Franc ligament transverses. Oftentimes you'll see a bony fragment in this 527 00:34:45,920 --> 00:34:51,199 first intermetatarsal space or this finding path indemonic for list Franc injury because you know 528 00:34:51,280 --> 00:34:53,599 the anchor of the liszt Franc ligament has been fractured off, so either at 529 00:34:53,639 --> 00:34:59,320 the origin or the insertion point of the ligament surgical intervention. So these can 530 00:34:59,360 --> 00:35:02,599 be treated concern patively with a cast and immobilization. But the problem is even 531 00:35:02,679 --> 00:35:07,679 relatively minor injuries to the tarso metatarsal joint can lead to severe disability. So 532 00:35:08,320 --> 00:35:13,320 whereas some of their other injuries can be treated with supportive measures, Lizz Frank 533 00:35:13,400 --> 00:35:16,119 injury, more often than not it's going to be surgical repair because if it's 534 00:35:16,159 --> 00:35:21,679 not treated properly, diagnosis his mystic can lead to osteoarthritis and long term disability. 535 00:35:22,119 --> 00:35:22,800 All right, So those are the main things that I think you need 536 00:35:22,840 --> 00:35:25,800 to know for the lower extremities. Let's move on to five quick questions and 537 00:35:25,880 --> 00:35:30,480 we will wrap it up. Question one, twenty seven year old Mail presents 538 00:35:30,480 --> 00:35:34,079 to the office with pain and swelling of his left knee. He was playing 539 00:35:34,119 --> 00:35:37,039 soccer with friends and he was running. He stopped short to change directions and 540 00:35:37,119 --> 00:35:40,639 felt a pop in his left knee, followed by pain and swelling. A 541 00:35:40,719 --> 00:35:46,239 Lockman test is performed, which demonstrates increased anterior translation of the tibia compared to 542 00:35:46,280 --> 00:35:51,159 the uninjured leg with no distinct endpoint. What type of injury to this patient 543 00:35:51,280 --> 00:35:54,079 likely sustained? You should know this one. That's your anterior cruciate ligament. 544 00:35:54,159 --> 00:35:58,639 So first the history of a pop in the knee followed by immediate swelling. 545 00:35:58,840 --> 00:36:02,280 That hemarthrosis a common presentation for an ACL tear. Up to seventy seven percent 546 00:36:02,360 --> 00:36:06,679 of patients with humor throsis after an injury of the knee have an a CL 547 00:36:06,760 --> 00:36:08,519 tear. When you have that positive Lockman test as well, we know that's 548 00:36:08,559 --> 00:36:13,039 a sensitive test for an ACL tear. Remember that because the first three letters 549 00:36:13,039 --> 00:36:15,400 of Lackman or a CL rearrange all signs point to an ACL tear. We 550 00:36:15,480 --> 00:36:20,079 have the pop and swell, and then we also have the Lockman test ACL 551 00:36:20,119 --> 00:36:22,599 first three letters. We know this is an interior cruciate ligament injury. Question 552 00:36:22,679 --> 00:36:27,239 two. A fourteen year old boy presents the office complaining of interior knee pain. 553 00:36:27,599 --> 00:36:30,800 He says the pain is most severe when he plays basketball or squats down 554 00:36:30,199 --> 00:36:34,960 on exam. You know to pronounced tender tabule tubercle. What is the main 555 00:36:35,039 --> 00:36:37,760 state treatment for the likely diagnosis in this patient? So that is going to 556 00:36:37,840 --> 00:36:43,440 be conservative and says ice rest elevation. So this is og Schlatter disease. 557 00:36:43,480 --> 00:36:46,159 We have a fourteen year old boy fits the demographics already as an osgit Schlatter's 558 00:36:46,199 --> 00:36:51,280 most common in males nine to fourteen years of age range, peak incidence in 559 00:36:51,320 --> 00:36:54,360 boys thirteen to fourteen years when they're going through the growth spurt, paying exacerbated 560 00:36:54,400 --> 00:36:58,159 by squatting, jumping, et cetera, when he's playing sports. All very 561 00:36:58,199 --> 00:37:01,800 typical. And then an exam the announced tender tibio tubercle seals of the deal. 562 00:37:01,880 --> 00:37:06,320 As we know this is an injury caused by repetitive strain and chronic revulsion 563 00:37:06,679 --> 00:37:10,159 of the hypothesis of the tibio tubercle. Mainstay of treatment for osgod Schlatter disease 564 00:37:10,280 --> 00:37:15,639 is conservative with n sets, etc. Surgical repair is rare. Remember osgod 565 00:37:15,679 --> 00:37:22,440 schlaughter disease remember instead Osgood's squatter denees. Remember it's exacerbated by activity like squatting, 566 00:37:22,440 --> 00:37:24,440 and Denise helps you remember it's an issue of the knee. Question three, 567 00:37:24,559 --> 00:37:29,039 what is the most common ligament to injure in an ankle sprain, So 568 00:37:29,199 --> 00:37:32,039 that of course is going to be your anterior taalo fibular ligament, your atf 569 00:37:32,239 --> 00:37:37,360 ligament. Remember atf ligament ATF in your mind stands for always tears first, 570 00:37:37,440 --> 00:37:40,840 because this is the ligament in the ankle most likely to tear in an ankle 571 00:37:40,920 --> 00:37:45,840 sprain. Question four, which test is performed as part of the physical exam 572 00:37:45,920 --> 00:37:50,760 and is suspected Achilles tend rupture, then involves squeezing the gastro acnemius muscle and 573 00:37:50,920 --> 00:37:53,320 watching for plant our flection of the foot. That is going to be your 574 00:37:53,360 --> 00:37:57,639 Thompson test. So squeeze the calf and look to see if the foot plant 575 00:37:57,679 --> 00:38:02,079 reflection plant or flexes. If not, this is a positive test indicating a 576 00:38:02,239 --> 00:38:07,679 likely Achilles ten rupture. Question five last question. A thirty one year old 577 00:38:07,719 --> 00:38:10,360 Mail was playing football with friends when one of his friends landed on the lateral 578 00:38:10,400 --> 00:38:15,239 aspect of his right knee in an attempt to tackle him. Immediately felt a 579 00:38:15,360 --> 00:38:19,800 tearing sensation, which was followed by severe pain. A Valgus stress test is 580 00:38:19,800 --> 00:38:24,320 performed, which displays pain and laxity at approximately thirty degrees offlection. What structure 581 00:38:24,360 --> 00:38:28,559 of the need, did this patient likely injured? So that is going to 582 00:38:28,639 --> 00:38:31,679 be the medial collateral ligament. So we have a patient with lateral trauma to 583 00:38:31,760 --> 00:38:37,440 the knee and a positive Valgus stress test, So an MCL injury would be 584 00:38:37,559 --> 00:38:39,679 the most common structure to be injured in the setting of this type of trauma 585 00:38:40,000 --> 00:38:44,719 and confirmed with the positive Valgus stress test. Again, if you forget which 586 00:38:44,800 --> 00:38:49,840 test is positive with which ligament, remember MCL is tested with the Valgus stress 587 00:38:49,920 --> 00:38:52,400 test valgus. Think of mucho gusto. Mucho starts with an M. That 588 00:38:52,400 --> 00:38:58,199 helps you remember MCL Gusto for valgus, And remember mucho gusto means nice to 589 00:38:58,239 --> 00:39:00,559 meet you. And that's because the Valgus force from these is being pushed inward, 590 00:39:00,960 --> 00:39:04,639 meeting at the middle. All right, So that is everything that I 591 00:39:04,679 --> 00:39:07,760 think you need to know if your lower extremities. Thank you so much for 592 00:39:07,840 --> 00:39:09,480 listening, and good luck on your pants, your pantry, your ears, 593 00:39:09,599 --> 00:39:10,920 and good luck in PA school.