S1E44 MSK Lower Extremity

All right, so let's talk about MSK lower extremities. If you've listened to
any of my podcasts, you know I don't go over every single boring detail.
I'm going to focus on the things that always come up on the exams,
the things you really need to know, the high old stuff. So
I may not go over every single condition for lower extremity, but I will
focus on the ones that seem to come up on exams. So let's ahead
and get started with MSK lower extremity. As always, thank you so much
for the really nice comments to support. I really do appreciate it, so
thank you. Let's go ahead and get started. We'll start with the hip
and then we'll work our way on down. So hip fracture mechanism of injury
young patients, this is going to be major trauma, So motor vehicle collisions.
Hip fractures not a common occurrence in young patients unless there's a serious trauma
or some sort of pathologic condition. So normally in younger patients you're looking for
some kind of major trauma. Old patients osteoporosis in falls. Proximately ninety percent
of hip fractures and older patients are going to occur just from a simple fall
from a standing position. So in young patients think high impact injury like MBA.
Older adults think low impact like a fall from standing position due to bone
loss scene in this age range, particularly in women due to their higher rates
of osteoporosis. So there's a few different types of hip fractures depending on the
location involved. Femoral neck, introcanic fractures, trokin fractures. Really, I
think there's only one you should commit to memory, and that's the femoral neck
fractures because of the risks associated with this type. So formoral neck fractures a
vascular necrosis. So if themoral neck fractures, you need to know this type
is associated with one of the highest risks of a vascular necrosis. The blood
supply to the femoral neck is pretty poor. It's similar to the scafhoid bone
that we'll talk about in the risk So any trauma to this area like a
fracture, can lead to a disruption in the tenuous blood blood supply and can
lead to complications like a vascular necrosis, which is just death of the tissue
the bone due to insufficient blood supply. So remember increased risk of a vascular
necrosis with formoral neck fractures compared to other type of hip fractures. Now,
in physical exam, this is important. You're going to see a shortened,
externally rotated lower extremity, so most hip fractures will prevent present with the lay
being externally rotated and shortened. This is important because with a hip dislocation it's
usually going to be the opposite. So most cases with hip dislocations, you'll
see internal rotation and external rotation with the fracture, so internal with dislocation most
of the time, and external with a fracture. The way that you can
remember that is because fracture very conveniently has an E in it but not an
eye, and then dislocation has an eye in it but not an E.
So remember internal rotation for dislocation because that as an eye in the word,
external rotation for fracture because it has an E in the word but not I.
And these little things will help you get the answer right in vignette,
so sometimes you'll look in just for those little details. Treatment is surgical in
most cases, or IF, which stands for open reduction with internal fixation versuing
another versus another option, which would be Arthur PLASTI don't focus too much on
treatment. It's not gonna it's not really high yield with most of the MSK
likely not going to be what your tests it on. So talking about hip
dislocations, really three things you need to focus on for dislocations. So first,
large forced trauma is going to be the most common cause. So large
force trauma, motor vehicle accidents, pedestrians struck by automobiles, they're going to
be your most common causes of hip dislocations can also be associated with high energy
impact sports American football, rugby, skiing, snowboarding, gymnastics, But focus
on your large force trauma like an MVA. Posterior dislocation is going to be
your most common almost always posterior eighty to ninety percent, so you have posterior
anterior dislocation. Posterior is way more common. That's the one you need to
memorize. Ninety percent of the cases are going to be a posterior dislocation.
AKA that's what you're going to be tested on. So that's what you need
to know. Now for the physical exam, shortened internally rotated lower extremity like
I talked about before, So majority of time patients will present with a shortened
internally rotated lower extremity. That's because this is the classic presentation of a posterior
dislocation, which we know by far is the most common type ninety percent of
the time. So this will be the presentation you're going to see shortened internally
rotated. Anterior dislocations will have exterior rotation, but who cares. Don't memorize
that that's very rare. If you see a hypt dislocation, be thinking internal
rotation again. The way you remember that is because dislocation has an eye,
not an e, so internal rotation. Fracture has an e not an eye,
so external rotation. Remember that treatment again not high yield, pretty straightforward
reduced the dislocation. This can be done either closed under sedation or open with
surgical reduction. And again, this is something that needs to be done or
I guess I didn't mention it, but it needs to be done urgently because
the longer the dislocation proceeds without intervention, the higher the risk of complications that
can happen with dislocations, like a vascular necrosis. Moving on to slipped capital
flemoral epiphysis. So this is a weakness in the proximal flemoral growth plate that
leads to displacement of the capital fmoral epiphysis. So to put this simply,
the fmoral head is slipping off of the flemoral neck. Sometimes it's described as
ice cream falling off of a cone, because if you look at an X
ray, that's actually what it looks like. Risk factors A few things that
you need to know. Obesity, this is the single grace risk factor.
More than sixty percent of patients with this condition measured greater than or equal to
the ninetieth percentile in weight. Males are much more prevalent in mail is proximately
a one point five to one male to female ratio. The age range you're
going to see this in twelve years and girls thirteen point five years. In
boys, that's going to be the peak age. So the mean age of
presentation twelve years and girls thirteen point five years and boys, and this is
because this is when they're experiencing a peak in growth related to puberty. So
these risk factors are going to give you a really good idea of what type
of patient you're going to be looking for in the vignette, so they're always
going to give you the most common patient demographic, So they're not going to
give you a seven year old, skinny female. The patient the vignette for
slip cap is going to be a male. It's going to be obese,
and he's going to be in the age range around twelve to thirteen years old.
Remember these little details, they're going to help you in the vignettes.
Clinical manifestations painful limp, So the two most common manifestations to see in patients
are going to be pain and altered gait, so a painful limp. The
classic complaint will be a child complaining of dole aching pain and the hip growing
possible even in the knee with no preceding trauma. So be careful because fifteen
round fifteen percent of patients, the only complaint they're going to have is isolated
thigh or knee pain and not necessarily the hip. And that's because the involvement
of the medial optat or nerve which runs along the medial thigh from the knee
up through the hip. So they may just have a knee pain, so
be aware of that too. This is a condition of the hip, but
they may present with knee pain diagnosis X ray. The diagnosis of slipcap is
usually made just with Plaine radiographs. Classic appearance will reveal a posterior displacement of
the flemoral epiphysis. If they give you a picture on the X ray,
it's going to look like ice cream slipping off of a cone. Remember that
that's the classic way to describe this on X ray, ice cream slipping off
of a cone, the flemoral heads sliding off of the neck. They're not
going to say ice cream slipping off of a cone, but you need to
create that visual so if you see it, you'll know what it is.
Treatment. This is going to be operative stabilization pinning, so these patients need
to be non weight bearing referred to an orthopedic surgeon where the treatment is going
to be surgical pinning. So that's gold standard for slip cap. A single
cannulated screw place in the center of the epiphosis to keep the ice cream from
falling off of the cone. All right. Moving on to a similar disease
that can always be very confusing to get these two mixed up. Leg calvay
perthes disease. So this is idiopathic osteo necrosis or a vascular necrosis of the
hip, so the blood supply to the head of the femur gets disrupted and
this can lead to death or necrosis of the tissue. There's some theories proposed
mechanisms, but normally we don't know why this happens five to eight years old,
so it can be seen in children between the ages of three to twelve,
but the peak incidence is going to be between five and eight, so
look for that age rangel on your vignette. More common in males, even
more so than when we talked about in slip cap so one to four male
to female ratio, so very high incidents in males. Clinical manifestations painless LIMP.
This is something a little bit of a little controversial, so painless limp.
So they absolutely may have pain in this condition, but I'm generalizing this
for the sake of the ex am and in saying painless limp, it's not
so clear cut in real life. But normally this disease has this insidious onset,
may start with little to no pain, oftentimes just hip stiffness. Loss
of internal rotation. Eventually does progress and they'll develop some discomfort, usually after
activity, but the pain, if it's present, is usually mild. It
can also also be referred to the thigh or knee. Most exam questions are
going to present this to you as a painless limp or maybe a limp with
mild pain. This is what helps differentiate it from slip cap, which normally
almost always has a painful limp. So again, this isn't one hundred percent
nothing is in medicine. Lake Calvey can be painful, slip cap can be
pain less. But for the exam it's best to remember Lake Calve as pain
less and slipped cap as painful. And if you ever forget which one has
a painful limp, which one has a painless limp? Painless, pain less
with an L, painful with an F, remember pain less with an L
only Lake Calve prothest disease has an L anywhere in the beginning of leg I'm
talking about the first letters, but it doesn't have an F in any of
the first letters, So painless with an L remember Lake Calvey and the first
letters has an L in it, but it doesn't have in the first letters.
Painful with an F only slip Capital for moral epiphysis has an F.
In the first letters of the words, so that helps you remember. For
moral epiphysis slip cap. For moorl epiphysis is painful, doesn't have an L
anywhere in the first letters. Hopefully that wasn't too confusing, and hopefully I
explain that right. But that's how I used to remember it. If I
ever forgot which had the painless, which had the painful, that's how I
remember. Look at the first letters. Is there an L, then it's
painless. If there's an F, it's painful. Treatment observation. In most
cases, the treatment for Lake Helve prothestases is conservative non weight bearing physical therapy.
Around sixty to seventy percent of hips effected are going to heal spontaneously without
any functional impairment. So surgery is an option, but it's not as common
and it's mostly reserved for older children, generally over eight, whereas your younger
patients typically won't benefit from surgery. So Lake Calves slip Cap, they have
a lot of similarities, and sometimes it's hard to differentiate the two on an
exam question. And you will get a question probably about one of these on
your exams. So let's go again over the key differences. So slip cap
generally going to be older children like twelve to thirteen years old, lake calve
younger children around five to eight slipcap generally painfull lake calva for the sake of
the exam, remember it it's pain lisp. And then finally, slip cap
surgery will commonly be the treatment of choice, where lake calve will more commonly
just be observation. So those two remember, don't get those mixed up,
because that can be an easy question. You can get right if you can
remember the little differences between the two. Okay osgod Schlaughter disease. This is
an injury caused by repetitive strain and chronic evulsion of the pophesis of the tibial
tubercle. So in younger children, the tibial tuberosity where the boteler tendant attaches
to it hasn't ossified yet, which basically just means it hasn't completely turned a
bone, so it's still contains some cartilage, so it's weaker. So when
kids who are active play a lot of sports jumping and kicking, squatting,
that Beateeller ligament is constantly pulling on the attachment side of the tibial tubercle,
and eventually this causes separation of the patellar tendon from the tibial tubercle and some
trauma and inflammation. Eventually, the area as it begins to heal, a
callus is formed and it leads to this tibial tubercle becoming more pronounced and generally
that's what we see on X ray role when we palpay it on our physical
exam. This elevation of the tivial tuberosity as far as the age range thirteen
to fourteen year old boy during a growth spurt can be seen in ages ranging
from nine to fourteen, but it's more common in boys than the thirteen to
fourteen year old age range, as this is a common time for a growth
spurt. It could also be seen in girls, but it's not as common.
So in the vignette, again, be looking for a boy in their
early teens. On exam, you're looking for or clinical manifestations. You're looking
for anterior knee pain which is exacerbated by activity, so kneeling, running,
jumping, squatting. I think basketball, as most vignettes are going to mention
a young male playing basketball that presents with anterior knee pain on physical exam pronoun
pronounced tender tibule, tubercle. So remember all that calous formation is causing this
area to become more pronounced. And then as far as treatment, it's really
just gonna be conservative. So it's typically a benign and self limited condition,
and conservative measures are going to be the mainstay of therapy, so And says
physical therapy self limited condition symptoms generally resolve as the growth plays ossified. It's
rare to require surgery. Okay, so you're gonna get an exampt question.
It's gonna be a young kid, it's gonna be hip or knee paying exacerbated
by sports, and the answer choices you're gonna have lake Helva, slipcap,
Osgat schlatter trust may have been there. You're gonna have no idea which one
is, which, which one affects the hip, which one affects the knee.
So this is the mnemonic I had, and it's it's dumb, but
it helped me remember enough about Osgat Schlatter that I could remember the little bit
about it that I needed to differentiate from slipcap and the other ones. So
Ozgat Schlatter is the one that evolves the knee. It's usually worth worse with
squatting, So I used to remember instead of osgod schlatter disease, You're gonna
remember Osgood's squatter denise. So squatter because the pain is usually worth worse with
like squatting, kneeling sometimes jumping, and denise because it's a condition of the
knee, the potellar ligament, and the tibial tubercle. These dumb things are
gonna help Sabi on an examp. So remember Osgod osgod schlaughter disease. Remember
Osgod's squattered in knees. All right, so let's talk about some more nice
stuff. Of all of the Loric's extremity MSK questions, the majority are going
to be about the knee. So let's start with one of the biggest ones
in that's interior cruciate ligament injury. So the ACL is the most commonly injured
knee ligament, and the majority of a CL tears are going to occur from
athletic injury. So the type of injury you're looking for is a non contact
pivoting injury most common cause. So the typical mechanism for an ACL injury involves
running or jumping athlete who suddenly stops and changes directions like they're cutting. They
pivot or the land in a way which involves rotation and valgus stress of the
knee and the tibia slides anteriorly on the femur and pop goes the a CL
history, pop and swell. So the way this will be described on a
vignette, of course, in real life, is the patient felt a pop
in their knee at the time of the injury and then had a cute swelling
after which is hemarthrosis which led to the swelling. Up to seventy seven percent
of patients presenting with a cute traumatic knee hemarthrosis will have an ACL injury.
So remember pop, then sudden swelling, pop and swell for the ACL.
That little rhyme there, pop and swell for the ACL physical exam Lockman test
the most sensitive exam test. Therefore, this is the one you should commit
to memory. You do this test with the knee and thirty degrees reflection,
stabilize the distal femur with one hand while pulling the proximal tibia anteriorly towards you
with the other hand, and attacked. ACL is going to limit the anterior
translation how far the tibia will go. If this isn't the case, there's
increased anterior translation compared to the unaffected knee, patient likely has an ACL tear.
The way that you're going to remember Lachman is the most sensitive exam test
for an ACL tear is that the first three letters in Lockman are ACL rearranged,
So Lackman Lockman LAC is ACL rearrange. So you'll always know if you
see a Lockman test, look at those first three letters ACL rearranged. This
is your most sensitive exam test for AL tears. Of course, imaging,
I'm not going to really go into this for most of these because it's going
to be repetitive, But like most extremity injuries, you start with an X
ray to rule upon the abnormalities, do an MRI to make the actual diagnosis
of the tear. Treatment is going to be individualized to each patient. Most
active, younger patients and athletes are going to opt for surgical reconstruction. Older
patients may go the conservative route with physical therapy, so conservative or surgical repair.
Two things that memorize for an ACL tear the pop and swell. For
the ACL, that pop felt in the knee, followed by him arthrosis causing
the swelling. And remember your Lockman tests best physical exam test Lockman LAC.
First three letters are ACL rearranged. Moving on to post tior cruciate ligament injury.
Very little to know here. This isn't a very high y old topic.
It's rare to see this as an isolated injury. Isolated PCL injuries,
they're just very uncommon. It's usually going to be in combination with other multiligament
trauma to the knee, so the mechanism is usually going to be a direct
blow to the proximal tibia with a flex knee like a dashboard injury. So
the main cause of a PCL injury is a high energy trauma, most often
involving motor vehicle collisions. Second most common would be sporting related activities, but
focus on your motor vehicle accident direct blow to the proximal tibia with a flex
knee when it hits the dashboard. As far as the test, posterior drawer
tests. So there's a few different physical exam maneuvers for a PCL tear,
but posterior drawer tests is generally considered the most accurate maneuver for diagnosing PCL and
injury. AKA, that's the one you should know. So knee at ninety
degrees of flexion, Wrap both hands around the patient's proximal tibia normally sitting on
the foot to keep the leg fixated. Then apply a posteriorly directed force to
the proximal tibia so you push back on the tibia with the knee flexed.
Increased posterioria displacement compared with the uninvolved leg suggest tear of the PCL m riot
A confirm of course, treatment's going to be conservative or surgical, conservative like
rest ice itself. Nothing specific to know here, and it's really surprising how
well some individuals can do with this type of injury. They did a study
and two percent of all college football players presenting for the exam prior to the
NFL Draft had an asymptomatic PCL terror, So they were playing football with this
terror. They had no idea, So conservative verse surgical, depending on the
patient. Nothing high yield to memorize there, all right, moving on to
medial collateral ligament injury. Just a couple of things to commit to memory for
MCL and LCL injuries will go over both of those. So medial collateral ligament
injuries are caused by a valgus force to the lateral aspect of the knee.
So really two mechanisms of injury will see with an MCL injury, either from
direct valgus stress from a blow to the lateral aspect of the knee, or
via an indirect stress like if the foot gets caught on the floor when the
athletes trying to change direction quickly. The key is the valgus stress. Whatever
the cause, something caused the need to be pushed inward valgus stress. That's
what you need to remember. How positive valgus stress test. The diagnosis of
an MCL injury is often made clinically based upon the history, clinical presentation,
and exam findings, and the physical exam tests you need to know as a
valgus stress tests. You do this with the knee at both thirty degrees reflection
and zero degrees of extension. You apply valgus stress and you look for laxity
of the joint. You feel how much the medial joint line widens. Okay,
so the only thing I would remember for your medial collateral ligament injury is
valgus you have to remember valgus force, valgus stress. This is associated with
MCL injuries. How do you remember what valgus is? How do you remember
what it's associated with? So this is how you remember it. This is
how you associated with MCL. MCL. Valgus has the word gus in it,
So when you seek gus and valgus, I want you to think of
Gusto as in Muccio gusto muccio, because Mucco starts with an M, so
that helps you remember MCL and gusto from the valgus. Muccio gusto in English
means nice to meet you, and this helps you remember the knee is being
pushed inward from lateral force, and the knee is are getting closer together and
meeting together. It's a ridiculous way to remember it, but I never forgot
it. So as soon as you see valgus, think Muccio Gusto m and
mucho Gusto helps to remember mc L injury. Nice to meet because the knees
are being pushed in and meeting together. Treatment is going to be very low
yield, conservative or surgical. Nothing to bother memorizing talk about lateral collateral ligament
injury the opposite, so this occurs due to a sudden various force to the
knee as opposed to valgus. So these are among the least common knee injuries,
but they can occur when the knee joint is struck from the inside,
so various stress, and it's really rare to have this as an isolated injury.
It's much more common in combination with other other injuries, so positive varus
stress tests. So either do this at both thirty degrees offlection and zero degrees
a full extension while applying various stress. So remember MCL has a positive valgus
test because muccio gusto knees are meaning together mucho gusto ns to meet you.
And then when we have LCL injuries by method of exclusion, it's the exact
opposite, so varus legs being pushed outward LCL positive virus stress test. I
also used to remember that leaky pipes rust because of rust and va russ leaky
helps me remember the l and LCL, so hopefully one of those stick,
whether it's mucho gusto or leaky pipes rust in LCL with virus stress. So
remember that remember your test for those. Let's move on to miniscal injury.
So cute miniscal tears most often are going to be from twisting injury. So
the tears typically happen when a person quickly changes direction while rotating or twisting the
knee when the foot is planted. In older adults, we can see chronic
degenerative tears and these can occur with minimal twisting or stress. In some cases
no trauma at all, but in general though, be thinking some sort of
twisting of the leg in the vignette. As far as the manifestations, I
want you to remember pop lock and drop like poplock and drop it, So
when you think of miniscal tears, remember pop lock and drop as the most
common clinical manifestation. So patients with untreated miniscal tears are going to complain of
the knee popping locking where they can't fully extend the knee, and then sometimes
the knee will even give out where they drop because the knee just gave way.
So remember miniscal tears pop lock and drop it. They're also going to
have joint line tenderness on the exam, So on exam, joint line tenderness
is really the most sensitive physical exam finding. It's nonspecific though, so the
physical exam test you should know about as it's the most commonly tested on is
known as the McMurray test. So the McMurray test is a test of repeated
passive flection and extension of the knee. Place your fingers at the joint line
while you're performing the test, and you're feeling for a painful pop or click
in the knee indicating a likely miniscal tear. Just an fyi in case you
don't know that. I do have a YouTube channel where I have like pictures
of all these things and it's a lot easier to go along with the explanations
if you have time to look at the videos, just to get a better
idea, because it's hard to explain these physical exam tests. There is other
tests with this type of injury. There's the apple, the thessaly, they're
not as commonly used or tested on. I'd focus on the McMurray tests as
that's the one you need to do, you'll likely need to do in an
osci and the one you'll get tested on this is you can remember McMurray test
is associated with meniscal tears, So Murray is obviously a man's name, and
meniscle when you broke, when you break down the words a miniscle as men
is called, so menace call men is called, and men is called murray.
So as soon as you see miniscal tear and a question, hopefully your
head thinks men is called? What are men called? They're called murray.
That helps you remember the McMurray tests. So men is called murray as a
miniscal tear as you use the McMurray test. All right, Moving on to
the tibiofamoral dislocation, the knee dislocation. This is a potentially limb threatening injury.
Dislocations of the tibiophomoral joint of the knee are true surgical emergencies. They
have a high rate of neurovascular injury. And if there's a populateal artery injury
caused from the dislocation that goes unrecognized about eight hours after the majority of patients
are going to require amputation of the leg. So this is a really serious
injury. It's normally going to occur from high energy trauma, so relatively rare
injury, but when it does takes place, it's certainly going to be a
serious high energy trauma like a motor vehicle accident, fall from very high up
complications. These are the main things that you need to know about tibio from
oral dislocations. First one poplteal artery. This is the most dangerous complication following
a tibial from oral dislocation. Delaying diagnosis and repair can lead to amputation like
I talked about before, So what we do to avoid missing this diagnosis is
after the dislocation is reduced, we assess the distal and the poplteeal pulses.
This can be done with an echo break index of betside ultrasound if available.
Also of course palpating. If there's signs of vascular compromise, these patients need
emergency surgery console to keep them from losing the leg. And then also you
may have an injury of the pernial nerves. So focus on the poploteal artery,
but also be aware that the proneal nerve is injured in about twenty three
percent of patients with need dislocations. Main takeaway with need dislocations, assess for
vascular compromise, don't miss a popliteal arter injury. Moving on to Patello famral
syndrome antior knee pain. This is what you're looking for in the vignette,
antior knee pain with Patelo famorl syndrome. So it's an overuse disorder that involves
the Patelo for moral region and it will present as antiior knee pain around or
behind the patello. Who you're looking for in the vignette is going to be
runners and women in the vignette. It will be a female runner. That's
your demographic. That's who's going to be in the vignette. That's who this
is seen most commonly. And sometimes this is even called runners knee I used
to remember this because the name instead of being Patello for moral syndrome, I
remembered it as Patello female run syndrome. So just help me remember. If
I see a vignette it's a female and she's a runner, I should be
thinking of Patello from female run syndrome aka Patello for Moorl syndrome. So remember
Patelo female run syndrome. You'll remember female runner. That's who's likely going to
be in the vignette. Treatment is conservative and says rest et cetera. Takeaway,
female runner antior knee pain. That's what you need to know for this
now, eliot tibial band syndrome. This is going to sound very similar to
Patello fhamoral syndrome. The main difference is the location of the pain and this
is the second most common cause of knee pain due to overuse, patelophamoral being
the first lateral knee pain in this case instead of anterior, so overuse injury
of the lateral knee. The pain develops where the iliotibial band runs a clock
across the lateral famoral epicondo runners, you're going to see the sin so again
primarily seen in runners, can also be seen in cyclists basically any athlete undergoing
exercises with repetitive knee flection and extension. But primarily runners will be what you're
looking from the vignette. Not so much of a predilection though for females as
we saw in patelo femoral syndrome aka patello female run syndrome. Remember it that
way. Treatment conservative and SAIDs, rests, etc. There's some physical exam
tests for this. The noble the overtest i don't think they're worth the time
memorizing. Way more high yield things for you to focus on. For msk
SO Patelo famoral syndrome, iliotibial band syndrome, very similar treatment similar usually the
vinet vinet, they're going to be a runner. Main thing to focus on
to differentiate is where the pain is. Patelo formoral syndrome, antior pain.
Remember that's where the patela is. So do you remember it's patela patelo,
So you remember it's the patella. Patella is obviously in the anterior side of
the name. That's where the pain is. And then iliotibial band syndrome pain
is going to be lateral. That's the main takeaway to differentiate these two.
Otherwise it's very little to no moving on to an ankle sprain, So,
lateral ankle sprains are going to be your most common inversion of the plantar flexed
foot. That's going to be the most common mechanism of injury in an ankle
sprain. Medial ankle sprains are actually very rare. They're not going to give
you that. Remember, they're going to give you the common stuff. That's
where you're going to be tested on. So it's going to be a lateral
ankle sprain that's involved in seventy to ninety percent of all sports related ankle sprains.
And the ligament that's most commonly going to be injured in the vignette is
going to be the anterior talo fibular ligament. This is the injury the ligament
injuring the majority of ankle sprains, seventy three percent of ankle sprains. No,
this one. There's obviously other ggaments that can be injured, but this
is the one you need to commit to memory. It's the one that I
was asked. This is the one that you're going to be asked, and
remember. The way that you can remember this is anterior taalofibular ligament is sometimes
referred to as the ATF ligament, and ATF in your mind is going to
stand for always tears first, because it's the most likely ligament to tear in
an ankle sprains. Remember anterior taalofibular ligament aka the ATF ligament, always tears
first. Let's talk about the Ottawa Ankle rules. So the Ottawa Ankle Rules,
they're very sensitive for excluding ankle fractures and determining whether or not you need
X rays of the ankle or the midfoot ninety six to ninety nine sensitive.
They're really just very common sense. Basically, it states if you can walk
after the injury or you're basically, if you can walk after the injury and
you're not tender in the ankle or the midfoot, it's probably a sprain and
you don't need X rays. The specific guidelines are as followed. So if
you're unable to bear weight both immediately after the injury and for four steps in
the office or the ear plus you have tenderness at the posterior edge or the
tip of the lateral or medial malleolis, you need an ankle X ray.
And then the other one is if you're unable to bear weight both immediately after
the injury and for four steps in the office or the er plus you have
tenderness at the base of the fifth metatarsal or the navicular, you need a
foot X ray. If you don't present with those things, you probably don't
need an X ray and it's a sprain. Nothing to know for the treatment
of a sprain, it's just ice elevation end sets ankle X rays. If
you get a question, it's likely going to be about the interior tail of
fib ligament. So remember only one thing about ankle sprains. Remember atf ligament
always tears. First, let's talk about ankle achilles tendin rupture. Two things
that I would know for achilles tendin rupture risk factors floral quinolans SOW. Fluoroquinolones
can put patients at an increased risk for tendin rupture. Is it common?
No? In Actually a large case study was only seen in twelve patients per
one hundred thousand. But just because something isn't common in real life doesn't mean
it's not a common exam question. And this one's one of the favorites for
examp questions. So I would just know that another common cause is going to
be a sports related injury. Over eighty percent of ruptures occurred during recreational sports,
particularly stopping ghost sports as like tennis, basketball, softball. But for
the exam focus on some history of fluoroquinolone use. No needs to focus on
the clinical menifestations. They're pretty common sense. Basically, they're gonna have a
pop in some severe pain in the posterior ankle. What you should know though,
is the Thompson tests, so definitely be familiar with the Thompson tests.
To do this, the patient lies prone with their feet dangling off the table.
You squeeze the calf the gastro acnemius muscle, and then you watch for
a plant our flection of the foot. The absence of plant our flection is
going to mark a positive test and it will be indicative of a rupture.
This is an important test because other indicators of an Achille tendon rupture they're not
always accurate. For instance, asking somebody just to plant our flex the foot,
it's not always accurate to assist and diagnosis because you can actually plant our
flex your foot using accessory muscles like the tibialis posterior. So always from the
Thompson tests and a suspect Achilles tendon rupture, squeeze the calf, that's what
you're going to be asked. Diagnosis of a rupture can be made solely by
the clinical exam. You can get an MRI or even an ultrasound to confirm,
but the treatment can range from splinting all the way to surgical repair.
It's not important know the two things Chilles tend in rupture, remember your fluoroquinolone
use and know the Thompson test. Plant or fasciitis. Very little to know
here, So this is chronic overuse that leads to micro tears and inflammation in
the origin of the plant or fascia. So they're gonna have heal pain that's
worse with their first few steps in the morning or after a period of inactivity.
This is what you're looking for in the vignette. They'll have some heal
pain when they first wake up in the morning. It's normally how it's going
to be presented. This is mainly a clinical diagnosis. X rays would really
just to be able to rule out some differentials like maybe a calcaneal stress fracture,
but nothing really to know for imaging or lab tests. Treatment is conservative
stretching exercises for the plant or fascia, calf muscle, silicone heelshoe inserts and
sets. You can even use corticosteroid injections. Very little to know there.
Interdigital Morton's neuroma. This is a compressive neuropathy of the interdigital nerve that leads
to plantar four foot pain. So basically something is squeezing on the foot,
causing the metatarsos to squeeze together and put pressure on the nerve between the two
structures, which leads to proliferation and a benign growth of the nerve tissue.
This can lead to numbness, burning, et cetera on the foot like those
parascesaes. Who you're looking for in the vignette, women with tight fitting shoes,
women wearing high heels in the vignette. This will absolutely be a female
as they're approximately five times more likely than males to develop more neuroma. They
may mention something about wearing shoes that are too tight, wearing high heels.
High heels cause overpronation of the foot, and that's one of the risk factors.
And then tight shoes are also associated with this condition. While you're looking
for in the description of the pain is burning pain most common in the third
inner metatarso space. So patient with the neuroma will most commonly be complaining of
this burning pain in the third inner metatarso space between the third and the fourth
distal metatarsals. It's a clinical diagnosis. For the most part. You can
use ultrasound actually visualize the neuroma, but it's usually not necessary and nothing really
to know if for a treatment, it's mainly conservative metatarsal support, padded shoe,
insert specialized orthopedic shoes. So two things that I would focus on to
identify it in the vignette. It's going to be a woman in the vignette,
and the pain will likely be in the third in a metatarsal space.
I used to remember this because the M in Morton, Sonoma, if you
turn if you turn an M to the side, it's a three and then
helps remember the third intermetatarsal space will be the most common area for the burning
pain. If you turn an M upside down, that's a W and it
helps you remember this is most common in women. The other thing that I
used to remember too is if you turn it. If you turn an M
upside down, it kind of looks like the heels in high heels. I
don't know, Maybe that one makes no sense to you better with the visuals
on YouTube, but that's the main things that I that I remember so more
in Sonoma. Turn that M to the side, it's a three. Third
intermetatarsal space most common. Turn the M upside down, that's a W.
Remember it's most common in women. Moving on to Jones fracture. Jones fracture
is a fracture of the fifth metatarso specifically, a fracture of the proximal diaphysis
at the junction of the metaphysis and diaphysis. You can remember Jones fracture is
a fracture of the fifth metatarsal because Jones has five letters. And then there's
something called pseudo Jones fracture, so you may hear of this. Pseudo Jones
fracture terminology isn't being used as often, but if you hear it, it's
the same thing. It's a fracture of the fifth metatarsal, but it's just
a little bit more proximal. In this case, it's the fracture of the
base or the tuberocity of the fifth metatarsal. I used to remember that because
I would remember Jones is a fracture of the fifth metatarsal. Pseudo Jones adds
a p there and just helps him remember. It's a little bit more proximal
at the base of the tuberocity the base or the tuberosity of the fifth metatarsal.
So that's Jones fracture. Not too much to know there either. And
then Finally moving on to Liz Franc or a Tarso metatarsal injury. This is
an injury in which the metatarsal bones are displaced from the tarsis. So the
Liz Franc ligament consists of religaments that run from the second metatarsal to the medial
cuneiform. So when you have a Tarso metatarsal fracture or other trauma in this
area, it can lead to a disruption between the medial cuneiform and the base
of the second metatarsal, which can lead to widening between the first and the
second metatarsal basis. Because when because the second metatarsal, when it fractures,
it loses its anchor that holds it in a place, which is the List
Franc ligaments what spreads apart, look for something called a flex sign. This
is pathnemonic for a Liz Franc injury. So a flex sign is when there's
an evulsion fracture at the origin or the insertion point of the List Franc ligament,
So either at the medial cuneiform or the base of the second metatarsal,
or the List Franc ligament transverses. Oftentimes you'll see a bony fragment in this
first intermetatarsal space or this finding path indemonic for list Franc injury because you know
the anchor of the liszt Franc ligament has been fractured off, so either at
the origin or the insertion point of the ligament surgical intervention. So these can
be treated concern patively with a cast and immobilization. But the problem is even
relatively minor injuries to the tarso metatarsal joint can lead to severe disability. So
whereas some of their other injuries can be treated with supportive measures, Lizz Frank
injury, more often than not it's going to be surgical repair because if it's
not treated properly, diagnosis his mystic can lead to osteoarthritis and long term disability.
All right, So those are the main things that I think you need
to know for the lower extremities. Let's move on to five quick questions and
we will wrap it up. Question one, twenty seven year old Mail presents
to the office with pain and swelling of his left knee. He was playing
soccer with friends and he was running. He stopped short to change directions and
felt a pop in his left knee, followed by pain and swelling. A
Lockman test is performed, which demonstrates increased anterior translation of the tibia compared to
the uninjured leg with no distinct endpoint. What type of injury to this patient
likely sustained? You should know this one. That's your anterior cruciate ligament.
So first the history of a pop in the knee followed by immediate swelling.
That hemarthrosis a common presentation for an ACL tear. Up to seventy seven percent
of patients with humor throsis after an injury of the knee have an a CL
tear. When you have that positive Lockman test as well, we know that's
a sensitive test for an ACL tear. Remember that because the first three letters
of Lackman or a CL rearrange all signs point to an ACL tear. We
have the pop and swell, and then we also have the Lockman test ACL
first three letters. We know this is an interior cruciate ligament injury. Question
two. A fourteen year old boy presents the office complaining of interior knee pain.
He says the pain is most severe when he plays basketball or squats down
on exam. You know to pronounced tender tabule tubercle. What is the main
state treatment for the likely diagnosis in this patient? So that is going to
be conservative and says ice rest elevation. So this is og Schlatter disease.
We have a fourteen year old boy fits the demographics already as an osgit Schlatter's
most common in males nine to fourteen years of age range, peak incidence in
boys thirteen to fourteen years when they're going through the growth spurt, paying exacerbated
by squatting, jumping, et cetera, when he's playing sports. All very
typical. And then an exam the announced tender tibio tubercle seals of the deal.
As we know this is an injury caused by repetitive strain and chronic revulsion
of the hypothesis of the tibio tubercle. Mainstay of treatment for osgod Schlatter disease
is conservative with n sets, etc. Surgical repair is rare. Remember osgod
schlaughter disease remember instead Osgood's squatter denees. Remember it's exacerbated by activity like squatting,
and Denise helps you remember it's an issue of the knee. Question three,
what is the most common ligament to injure in an ankle sprain, So
that of course is going to be your anterior taalo fibular ligament, your atf
ligament. Remember atf ligament ATF in your mind stands for always tears first,
because this is the ligament in the ankle most likely to tear in an ankle
sprain. Question four, which test is performed as part of the physical exam
and is suspected Achilles tend rupture, then involves squeezing the gastro acnemius muscle and
watching for plant our flection of the foot. That is going to be your
Thompson test. So squeeze the calf and look to see if the foot plant
reflection plant or flexes. If not, this is a positive test indicating a
likely Achilles ten rupture. Question five last question. A thirty one year old
Mail was playing football with friends when one of his friends landed on the lateral
aspect of his right knee in an attempt to tackle him. Immediately felt a
tearing sensation, which was followed by severe pain. A Valgus stress test is
performed, which displays pain and laxity at approximately thirty degrees offlection. What structure
of the need, did this patient likely injured? So that is going to
be the medial collateral ligament. So we have a patient with lateral trauma to
the knee and a positive Valgus stress test, So an MCL injury would be
the most common structure to be injured in the setting of this type of trauma
and confirmed with the positive Valgus stress test. Again, if you forget which
test is positive with which ligament, remember MCL is tested with the Valgus stress
test valgus. Think of mucho gusto. Mucho starts with an M. That
helps you remember MCL Gusto for valgus, And remember mucho gusto means nice to
meet you. And that's because the Valgus force from these is being pushed inward,
meeting at the middle. All right, So that is everything that I
think you need to know if your lower extremities. Thank you so much for
listening, and good luck on your pants, your pantry, your ears,
and good luck in PA school.