WEBVTT 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.