Cram The Pance - S1E44 MSK Lower Extremity

Episode Date: March 12, 2022

MSK Lower Extremity review for your Pance, Panre, and Eor's.►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportIncluded in review: Hip Fracture, Hip Dislocations, Slipped Capital Femoral Epiphysis, Legg-Calve-Perthes Disease, Osgood-Schlatter Disease, Anterior Cruciate Ligament Injury, Posterior Cruciate Ligament Injury, Medial Collateral Ligament Injury, Lateral Collateral Ligament Injury, Meniscal Injury, Tibiofemoral Dislocations, Patellofemoral Syndrome, Iliotibial Band Syndrome, Ankle Sprain, Achilles Tendon Rupture, Plantar Fasciitis, Interdigital (Morton’s) Neuroma, Jones Fracture, Lisfranc (Tarsometatarsal) InjuryBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right, so let's talk about MSK lower extremities. If you've listened to any of my podcast, 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-yield stuff. So I may not go over every single condition for a lower extremity, but I will focus on the ones that seem to come up on exams. So let's go ahead and get started with MSK lower extremity. As always, thank you so much for the really nice comments, the 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 and falls. Approximately 90% of hit 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 seen 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, intertrochanteric fractures. Trocanteric 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 formal neck fractures, avascular necrosis. So if the femoral neck fractures, you need to know, this type is associated with one of the

highest risks of avascular necrosis, the blood supply to the femural neckurals. So the femoral neck is pretty poor. It's similar to the scaphoid bone that we'll talk about in the wrist. So any trauma to this area, like a fracture, can lead to a disruption in the tenuous blood supply and can lead to complications like avascular necrosis, which is just death of the tissue, the bone due to insufficient blood supply. So remember, increased risk of abascular necrosis with femoral 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 present with the leg being externally rotated and shortened. This is important because with the 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 a 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 I. and then dislocation has an eye in it but not an e so remember internal rotation for dislocation

because that has 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 a vignette so sometimes you're looking just for those little details treatment is surgical in most cases or i f which stands for open reduction with internal fixation versus another versus another option which would be arthroplasty don't focus too much on treatment it's not going to it's not really high yield with most of ms. likely not going to be what you're tested on. Let's talk about hip dislocations. Really three things you need to focus on for dislocations.

So first, large force 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 their most common causes of hip dislocations. It can also be associated with high energy impact sports, American football, rugby, skiing, snowboarding, gymnastics. But focus on your large force trauma like an MBA. Posterior dislocation is going to be your most common, almost always, posterior, 80 to 90%. So you have posterior anterior anterior dislocation. Posterior is way more common. That's the one you need to memorize.

90% 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. 90% of the time. So this will be the presentation you're going to see shortened, internally rotated. Interior dislocations will have exterior rotation, but who cares? Don't memorize that.

That's very rare. If you see a hipto dislocation, be thinking internal rotation. Again, the way you remember that is because dislocation has an I, not an E, so internal rotation. Fracture has an E, not an I, so external rotation. Remember that. Treatment, again, not high yield. Pretty straightforward. Reduce 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 avascular necrosis. Moving on to slipped capital femoral epiphasis. So this is a weakness in the proximal femoral growth plate that leads to displacement of the capital femoral epiphysis. So to put this simply, the femoral head is slipping off of the femoral neck. Sometimes it's described as ice cream falling off of a cone because if you look at it, 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 greatest risk factor. More than 60% of patients with this condition

measured greater than or equal to the 90th percentile in weight. Males are much more prevalent in males, approximately a 1.5 to 1 male to female ratio. The age you're going to see this in, 12 years and girls, 13.5 years in boys. That's going to be the peak age. So the mean age of presentation, 12 years and girls, 13.5 years in 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 7-year-old skinny female. The patient in 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 12 to 13 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

an altered gait, so a painful limp. The classic complaint will be a child complaining of dull, aching pain in the hip, groin, possible even in the knee with no preceding trauma. So be careful because 15, around 15% 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 optorator nerve, which runs along the medial thigh from the knee up through the hip,

so they may just have 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 slip cap is usually made just with plain radiographs classic appearance will reveal a posterior displacement of the femoral epithesis 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 femoral head 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 the gold standard for slip cap, a single canulated screw placed in the center of the epiphasis 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 osteoenocrosis or avascular necrosis of the hip. So the blood supply to the head of the femur gets disrupt.

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 range on your vignette more common in males even more so than when we talked about in slip caps So one to four male to female ratio so very high incidence in males Clinical manifestations painless limp this is something a little bit a little contract So painless limp. So they absolutely may have pain in this condition, but I'm generalizing this for the sake of the exam.

And I'm saying painless limp. It's not so clear cut in real life, but normally this disease has this insidious onset. It 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 be referred to the thigh or knee. Most exam questions are going to present this to you as a patient. 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 100% nothing is in medicine. Lake Calvay can be painful. Slip cap can be painless. But for the exam, it's best to remember lay calvay as painless and slipped cap as painful. And if you ever forget which one has a painful lip, which one has a painless limp, painless with an L, painful with an F. And if you ever forget which one has a painless, painless with an L. Painful with an F. Remember painless with an L. Only late Calvay Prithesis 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 Calvay and the first letters has an L in it, but it doesn't have an F in any of the first letters. Painful with an F, only

slip capital femoral epiphysis has an F in the first letters of the words. So that helps you remember femoral epiphosis slip cap femoral epiphysis is painful doesn't have an l anywhere in the first letters hopefully that wasn't too confusing and hopefully i explained 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 lay calvate prosthesis is conservative non-weight bearing physical therapy around 60 to 70 percent of hips affected 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 lay calvay, 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 exam. So let's go again over the key differences. So slip cap generally going to be older children like 12 to 13 years old, late calvee younger children around 5 to 8. Slip cap generally pain full. Lake Calvay for the sake of the exam. Remember it's painless. And then finally, slip cap. Surgery will commonly be the treatment of choice where lay Calvay 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, Osgood Schlauter disease. This is an injury caused by repetitive strain and chronic evulsion of the apophysis of the tibial tubercle. So in younger children, the tibial tuberosity where the petalular tendon attaches to. It hasn't ossified yet, which basically just means it hasn't completely turned to bone. It still contains some cartilage, so it's weaker. So in kids who are active, play a lot of sports, jumping and kicking, squatting, that pateller ligament is constantly pulling on the attachment side of the tibule tubercle. And eventually this causes separation of the pettler tendon from the tibule tubercle and some trauma and inflammation. Eventually the area, as it begins to heal,

a callous is formed and it leads to this tibule, tibule tubercle, becoming more pronounced and generally that's what we see on x-ray or when we palpate on our physical exam, this elevation of the tibial tuberosity. As far as the age range, 13 to 14-year-old boy during a growth spurt can be seen in ages ranging from 9 to 14, but it's more common in boys than the 13-to-14-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. Think basketball, as most vignettes are going to mention, a young male playing basketball that presents with anterior knee pain. On physical exam, pronounced tender tibule tubercle. So remember, all that callous formation is causing this area to become more pronounced. And then as far as treatment, it's really just going to be conservative. So it's typically a benign and self-limited condition.

And conservative measures are going to be the mainstay of therapy. So N says physical therapy, self-limited condition, symptoms generally resolve as the growth playsosophy. It's rare to require surgery. Okay, so you're going to get an exam question. It's going to be a young kid. It's going to be hip or knee pain exacerbated by sports. And the answer choices, you're going to have Lake Calvay, Slipcap, Osgich, Lodder.

Trust may have been there. You're going to have no idea which one is which, which one affects the hip, which one affects the knee. So this is the mnemonic I had. It's dumb, but it helped me remember enough about Osgood Schlauter that I could remember the little bit about it that I needed to differentiate from slip cap and the other ones. So, Osgood Schlaugher is the one that evolves the knee. It's usually worse with squatting.

So I used to remember instead of Osgood Schlaugter disease, you're going to remember Osgood squatter denies. So squatter, because the pain is usually worse with like squatting, kneeling, sometimes jumping, and denies because it's a condition of the knee, the pettler ligament and the tubule tubercle. these dumb things are going to help save you on an exam. So remember, Osgood Schlaugert disease, remember Osgood squatter-Din-Neas. All right, so let's talk about some more knee stuff. Of all of the lower extremity MSK questions, a 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 ACL tears are going to occur from athletic injury. So the type of injury you're looking for is a non-concuitary. contact pivoting injury. Most common cause. So the typical mechanism for an ACL injury involves a 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 tibious slides anteriorly on the femur and pop goes the ACL. 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 acute swelling after, which is hemarthro.

which led to the swelling. Up to 77% of patients presenting with acute 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, most sensitive exam test, therefore this is the one you should commit to memory. You do this test with the knee in 30 degrees of flexion, stabilize the distal femur with one hand while pulling the proximal tibia anteriorly towards you with the other hand. An intact ACL is going to limit the anterior translation, how far the tibial will go. If this isn't the case, there's increased anterior translation compared to the unaffected knee. This patient likely has an ACL tear. The way that you're

going to remember, Lockman is the most sensitive exam test for an ACL tear is that the first three letters are ACL rearranged. So Lockman, Lockman, LAC, is ACL rearranged. So you'll always know if you see a lockman test, look at those first three letters, ACL rearrange. This is your most sensitive exam test for ACL 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 up bony 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 I'd memorize for an ACL tear, the pop and swell for the ACL, that pop felt in the knee, followed by hemarthrosis, causing the swelling. And remember your Lachman test, best physical exam test. Lockman, LAC, first three letters are ACL rearranged. Moving on to posterior cruciate ligament injury. Very little to know here. This isn't a very high-yield topic. It's rare to see this as an 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 test, so there's a few different physical exam maneuvers for a PCL tear, but posterior drawer test is generally considered the most accurate maneuver for diagnosing PCL injury, aka that's the one you should know. So knee at 90 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 posterior tibial displacement compared with the uninvolved leg, suggest a tear of the PCL. M.R. to confirm, of course. Treatment's going to be conservative versus surgical, conservative like rest, ice, et cetera.

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 2% of all college football players presenting for the exam prior to the NFL draft had an asymptomatic PCL tear. So they were playing football with this tear and they had no idea. So conservative versus 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. We'll 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 we'll 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 athlete's trying to change direction quickly. The key is the valgus stress. Whatever the cause, something caused the knee to be pushed inward, valgus stress, that's what you need to remember. Now positive valgus stress test, the diagnosis of an MCL injury is often made clinically based upon the history of clinical presentation and exam findings and the physical exam test you need to know as a valgus stress test. You do this with the knee at both 30 degrees of flexion 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 associate with MCL. MCL Valgus has the word Gus in it.

So when you see Gus and Valgus, I want you to think of gusto as in Mucho gusto, Mucho because Mucho starts with an M. So that helps you remember MCL and gusto from the Valgus. Mucho gusto in English means nice to meet you. And this helps you remember the new. knee is being pushed inward from lateral force and the knees are getting closer together and meeting together. It's ridiculous way to remember it, but I never forgot it. So as soon as you see Val Gus, think Mucho gusto. M in Mucho gusto helps remember MCL injury. Nice to meet you 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. So talk about lateral collateral ligament injury, the opposite. So this occurs due to a sudden varus force to the knee. As a post of valgus. So these are among the least common knee injuries, but they can occur when the knee joint is struck from the inside, so varus stress. And it's really rare to have this as an isolated injury. It's much more common in combination with other injuries. So positive verus stress tests. So you do this at both 30 degrees of flexion and zero degrees of full extension while applying vera stress. So remember MCL has a positive valgus test because much augusto, knees are meeting together. Much

Augusto, nice to meet you. And then when we have LCL injuries, by method of exclusion, it's the exact opposite. So Verus, legs being pushed outward, LCL positive Verus stress test. I also used to remember that Leaky pipes rust because of rust in Verus. Leaky helps me remember the L and LCL. So hopefully one of those stick, whether it's Much Augusto or Leaky Pipes rust in LCL with Verus stress. So remember that. Remember your test for those. Let's move on to you. menisical injury. So acute menisical 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 pop, lock, and drop it. So when you think of minusical tears, remember pop, lock, and drop as the most common clinical manifestation. So patients with untreated minuscal 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, minusical 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 non-specific, 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 flexion 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 minuscal 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 test. There is other tests with this type of injury. There's the Appley, the Thessaly. They're not as commonly used or tested on. I'd focus on the McMurray test as that's the one you need to do. You'll likely need to do in an OSCE and the one you'll get tested on. This is how you can remember McMurray test is associated with meniskel. So Murray is obviously a man's name. And miniscal when you broke when you break down the words of miniscal is men is called. So men is called, men is called, and men is called Murray. So as soon as you see minusical tear in a question, hopefully your head thinks, men is called, what are men called?

They're called Murray. That helps you remember the McMurray test. So men is called Murray, as a meniscal tear as you use the McMurray test. All right, moving on to the tibial femoral dislocation, the knee dislocation. This is a potentially limb-threatening injury. Dislocations of the tibial femoral joint of the knee are true surgical emergencies. they have a high rate of neurovascular injury. And if there's a popliteal artery injury caused from the dislocation, that goes unrecognized.

About eight hours after, the majority of patients are going to require amputation of the lake. So this is a really serious injury. It's normally going to occur from high energy trauma. It's a relatively rare injury, but when it does take 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, popliteal artery. This is the most dangerous complication following a tubular dislocation.

Delay and 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 popliteal pulses. This can be done with an ankle index, a bedside ultrasound if available, also, of course, palpating. If there's signs of vascular compromise, these patients need emergency surgery consult to keep them from losing the leg. And then also you may have an injury of the peronial nerve. So focus on the popliteal artery, but also be aware that the peronial nerve is injured in about 23% of patients with knee dislocations. Main takeaway with knee dislocations, assess for vascular compromise, don't miss a popliteal artery injury.

Moving on to patellofamoral syndrome. anterior knee pain. This is what you're looking for in the vignette, anterior knee pain with patellofamoral syndrome. So it's an overuse disorder that involves the patellofamoral region, and it will present as anterior knee pain around or behind the pate 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 in sometimes this is even called runner's knee um i used to remember this because the name instead of being patello femoral 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 female run syndrome, aka Patello Femoral Syndrome. So remember Patello Femal Rund Syndrome, you'll remember, female runner, that's who's likely going to be in the vignette. Treatment is conservative, Ns, rest, etc. Takeaway, female runner, anterior knee pain. That's what you need to know for this. Now, iliotibial band syndrome. This is going to sound very similar to Patello Fomoral Syndrome.

The main difference is the location of the pain. And this is the second most common cause of knee pain due to overuse patello femoral 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 across the lateral femoral epiondial. Runners, you're going to see this in. So again, primarily seen in runners. It can also be seen in cyclists, basically any athlete undergoing exercises with repetitive knee flexion and extension. But primarily runners will be what you're looking for in the vignette.

Not so much of a predilection, though, for females as we saw in Patelo femoral syndrome, aka Patelof Female Run Syndrome. Remember it that way. Treatment, conservative, Ns, arrests, et cetera. There's some physical exam test for this, the Noble, the Ober test. I don't think they're worth the time memorizing. Way more high yield things for you to focus on for MSK. So, Patellofamoral syndrome, iliotivial band syndrome, very similar.

Treatment similar. Usually in the vignette, they're going to be a runner. Main thing to focus on to differentiate is where the pain is. Patello femoral syndrome, anterior pain. Remember, that's where the patella is. So you remember it's Patella, Patello. So you remember it's the patella. Patello is obviously in the anterior side of the knee.

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 know. 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 70 to 90% 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 talofibular ligament. This is the ligament injured the majority of ankle sprains. 73% of ankle sprains.

Know this one. There's obviously other ligaments that can be injured, but this is the one you need to commit to memory. It's the one that I was asked. That's the one that you're going to be asked. And remember, the way that you can remember this is anterior telophibular 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 spraints. Remember, anterior talofibular 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 to x-rays of the ankle or the midfoot, 96 to 99% sensitive. They're really just very common sense. Basically, it states if you can walk after the injury or you're, and 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 follows. So 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 posterior edge or the tip of the lateral or medial maliolis, 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 officer of 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 endsets. Ankle x-rays, if you get a question, it's likely going to be about the anterior talofibular ligament. So if you remember only one thing about ankle sprains, remember, ATF ligament always tears first. Let's talk about ankle Achilles tendon rupture.

Two things that I would know for Achilles tendon rupture. Risk factors, fluoroquinolones. So fluoroquinolones can put patients at an increased risk for tendon rupture. Is it common? No. And actually a large case study was only seen in 12 patients per 100,000. But just because something isn't common in real life doesn't mean it's not a common exam question. This one is one of the favorites for exam questions, so I would just know that.

Another common cause is going to be a sports related injury. Over 80% of ruptures occurred during recreational sports, particularly stopping go sports as like tennis, basketball, softball, but for the exam, focus on some history of fluoroquinolone use. No need to focus on the clinical manifestations. They're pretty common sense. Basically they're going to have a pop and some severe pain in the posterior ankle. What you should know though is the Thompson test.

So definitely be familiar with the Thompson test. To do this, the patient lies prone with their feet dangling off the table. You squeeze the calf, the gastroachnibus muscle, and then you watch for plantar flexion of the foot. The absence of plantar flexion is going to mark a positive test and it'll be indicative of a rupture. This is an important test because other indicators of an Achille tendin rupture, they're not always accurate.

For instance, asking somebody just to plantar flex the foot is not always accurate to assist in diagnosis because you can actually plantar flex your foot using accessory muscles like the tibialis posterior. So always perform the Thompson test in a suspected 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. Killies tendon rupture. Remember your fluoroquine use and know the Thompson test. Plantar fasciitis, very little to know here. So this is chronic overuse that leads to micro tears and inflammation in the origin of the plantar fascia.

So they're going to have heel 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 heel 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 be 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 plantar fascia, calf muscle, silicone heel shoe inserts, insides. 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 metatarsals 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 percestages.

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. What you're looking for in the description of the pain is burning pain most common in the third intermeditarsal space. So a patient with the neuroma will most commonly be complaining of this burning pain in the third inneroma.

metatarsal space between the third and the fourth distal metatarsals. It's a clinical diagnosis for the most part. You can use ultrasound to actually visualize the neuroma, but it's usually not necessary. And nothing really to know for 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 inner the tarsal space. I used to remember this because the M in Morton's neuroma, if you turn the,

if you turn an M to the side, it's a three. And that helps to remember the third intermetotarsal 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, 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 remember. So Morton's neuroma, turn that M to the side. It's a three-third intermeditarsal 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 metatarsal. Specifically, a fracture of the proximal diaphasis at the junction of the metaphysis and diaphasis. 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. 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 tuberosity of the fifth metatarsal. I used to remember that because I would remember Jones is a fracture of the fifth metatarsal. Sudo-Jones adds a P there and just helps them remember it's a little bit more proximal at the base of the tuberosity, 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

Frank or a tarsom-metatarsal injury. This is an injury in which the metatarsal bones are displaced from the tarsis. So the Liz Frank ligament consists of three ligaments that run from the second metatarsal to the medial cuneiform. So when you have a tarsal 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 because the second metatarsal, when it fractures, it loses its anchor that holds it in place, which is the LIS-Frank ligament, so it spreads apart. Look for something called a flex sign.

This is pathonomonic for a Liss-Frank injury. So a flex sign is when there is an evulsion fracture at the origin or the insertion point of the Lys-Frank ligament. So either at the medial cuneiform or the base of the second metatarsal where the LIS-Frank ligament transverses. Oftentimes you'll see a bony fragment in this first intermeditarsal space. So this finding pathonomonic for Liz Frank injury because you know the anchor of the LISFranc ligament has been fractured off.

So either at the origin or the insertion point of the ligament. Surgical intervention. So these can be treated conservatively with a cast and immobilization, but the problem is even relatively minor injuries to the tarsal metatarsal joint can lead to severe disability. So whereas some of their other injuries can be treated with supportive measures, Liz Frank injury more often than not, it's going to be surgical repair because if it's not treated properly, diagnosis is missed, it 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, 27-year-old male 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 end point. What type of injury to this patient likely sustain? 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, very common presentation for an ACL tear. Up to 77% of patients with acute hemarthrosis after injury of the knee have an ACL tear. When you have that positive Lachman test as well, we know that's a sensitive test for an ACL tear. Remember that because the first three letters of Lachman are ACL rearranged. All signs point to an ACL tear. have the pop and swell, and then we also have the Lachman test ACL first three letters.

We know this is an anterior cruciate ligament injury. Question two, a 14-year-old boy presents to the office complaining of interior knee pain. He states the pain is most severe when he plays basketball or squats down. On exam, you know it a pronounced tender, tibule 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 Osgold Schlauter disease. We have a 14-year-old boy fits the demographics already as an

Osgood Schlaughters most common in males, 9 to 14 years of age range. Peak incidence in boys, 13 to 14 years when they're going through their growth spurt. Pain exacerbated by squatting, jumping, et cetera when he's playing sports, all very typical. And then on exam, the pronounced tender tibial tubercle seals the deal. As we know, this is an injury caused by repetitive strain and chronic evulsion of the apophysis of the tubule. Mainstay of treatment for Osgoch-Schlater disease is conservative with ensigns, etc. Surgical repair is rare. remember Osgood Schlauter

disease remember instead Osgood squatter knees 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 telophibular 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 a suspected Achilles tendon rupture that involves squeezing the gastroachnemia muscle and watching for plantar flexion of the foot. That is going to be your Thompson test. So you squeeze the calf and look to see if the foot planter flexes. If not, this is a positive test indicating a likely Achilles tendon rupture. Question five, last question. A 31-year-old male 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 30 degrees of flexion. What structure of the knee did this patient likely injure? 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 a positive valgus stress test. again if you forget which test is positive with which ligament remember mcel is tested with the valgus stress test valgus think of mucho gusto much starts with an m that helps you remember mccl gusto for valgus and remember

mucho gusto means nice to meet you and that's because the valgus force from the knees is being pushed inward meeting at the middle all right so that is everything that i think you need to know if you're lower extremities thank you so much for listening and good luck on your pants your panery your e-orrs and good luck in pa school