Hello, and welcome to episode 108 of the Physician Assistant Exam Review Podcast. In the last episode, we finished up infectious disease. So this week, we’re going to begin with musculoskeletal. My name is Brian Wallace. I’m the founder and creator here at Physician Assistant Exam Review, where we teach PA students how to dominate PA school, and ultimately pass the PANCE and land their dream job. I need something extra special from you this week. I need something, the community needs something extra special from you.

What we need, what I need, is a little bit of your help. I’ve been in contact recently with more and more students of the 33 Days to Pass the PANCE program, and I’m getting some fantastic results from people, people who have failed the PANCE more than once, people who have failed the PANCE two and three times. I was reaching out to a couple people today who were back in the November cohort who I haven’t heard from yet. And one of them was somebody who had painstakingly gone over with me before getting involved in the program. All of the details of the program, we exchanged multiple emails so that I could make her feel as comfortable as possible. And I hadn’t heard from her in a while. So I reached out to her today to see how she had done.

And her score, she was a little ashamed that she hadn’t reached out to me, but she had great news. Her score went from a 298 to a 405, more than 100 points she went up. And I’m hearing back more and more stories like that. I had someone just recently email me from the February cohort who went from a 326 to a 269 to a 404. Unbelievable. So here’s the point. Here’s what I’m asking for.

This program has been incredibly powerful. I’ve really been able to help move people’s scores. And I found the same thing on end of rotation exams. So it’s not as easy to mark them as it is on retakes at the PANCE. But people who have been very uncomfortable or just scraping by on end of rotation exams are being able to boost their scores up into the national average points and feel a whole lot better about it. So the point of this is, what I’m asking for is, if you’re someone who’s struggling, if you find that your scores aren’t what you want them to be, I’m setting up the, I’m sorry, the registration for the May cohort of the 33 Days to Pass the PANCE program is now open and will be closing on the 16th. And the June cohort is also now open.

So what I’m saying is if you are someone or you know someone or you are a faculty member and you have students who are, you know, you think might be struggling or in need of some help in areas that they can’t quite get or can’t quite get through their exams. I’ve been able to, like I said, really move the needle for people who have been struggling for a long time. And I’d really like to start reaching out further and helping as many people as possible as I’m hearing these stories roll. And it really has me excited and wanting to get in touch with as many students as possible to solve this problem for them. You know, struggling and not passing the PANCE is an absolute disaster. And like I said, I just really would like to be able to help more of those people before they get into that situation. So if you know someone who’s in that situation, if you’re in that situation, registration and more information, you can find it at physicianassistantexamreview.com/the numbers 33, just the numbers 33 will bring you to the information and registration page.

There you can register for either the May or June cohorts.

Now, I have cohorts set up for later in the year, for August, September, and November of this year. The registration is not open for those yet. If you’re not ready or you just want some more information, if you go to physicianassistantexamreview.com/YouTube, I’ve set up a YouTube channel there. I’m going to start posting the podcast on there, but I’ve also included interviews I’ve done with people who have graduated from the 33 Days program and have had spectacular results and just talk through a lot of what that program is about. So if you have more questions, you can go there. And lastly, I am going to be hosting some question and answer sessions where we’re going to go through my methodology, talk a little bit about the three parts to passing the PANCE that I believe in, give you an opportunity to ask questions about those. So even if you’re just in school and you’d like some more information on how to get through exams, how to prepare for exams, we’re going to cover all of that or a good chunk of that.

And if you have questions about the 33 Days program, I’m going to have a live discussion on Wednesday night at 8 p.m. Eastern. You can find that discussion at physicianassistantexamreview.com/live, L-I-V-E. That’s where I’ll be hosting that discussion this Wednesday night and also, again, on Sunday night. Obviously, that’s time sensitive, so it’ll be April 12th at 8 p.m. Eastern and Sunday, April 16th at 8 p.m. Eastern, physicianassistantexamreview.com/live if you’d like to come on and get some information on progressing through the methodology that I teach for passing exams and then also to get some more information about the 33 Days program.

So those are a couple options available to you.

All right. And again, and if you know someone, this is, you know, helping you is absolutely important to me, but also anyone that you know, if you know someone who’s been struggling, if you know someone who can’t get through their exams, if you have students or friends or people in your cohort who are struggling, then please pass this information along to them. I’d really like to be able to give them a hand.

All right, let’s jump in to musculoskeletal. One of the important things I want you to remember about musculoskeletal, one of the problems I have is I used to practice in orthopedics. So when I went back for my PANRE, I did struggle with some things because I couldn’t help get out of my own head with the way that we did things in the office. You know, if you’re in an orthopedic office with an x-ray machine available to you right down the hall, then almost anyone who walks through the door is going to get an x-ray and probably two or three x-rays because you usually x-ray the injured area and then you x-ray the joint above and below the injury. Because those, as we’ll talk about a little bit further along here today, because of where the complaint is, isn’t necessarily where the problem is. So anyway, I’m used to, very used to ordering x-rays on just about everybody and then making up a plan from there. The problem with that is on the exam, it’s more likely that they’re asking a question from the perspective of a primary care physician or a physician assistant, somebody in family practice.

Not necessarily, but probably. So you’re not going to have imaging readily available. You’re going to have to order imaging and have the person go get an x-ray, you know, at a different office, at a radiology office. Then you’re going to have to interpret it. So some of the questions are going to be, you know, should you order an x-ray? And to me, I struggle because my answer is always yes, you know, because that’s my bent as an orthopedic PA. But that’s not always going to be the first line if you’re in a family care office.

So as I’m teaching people to answer questions, one of the things I teach is, you know, step one is, is the patient stable or unstable? Step two is what is the topic we’re covering? So are we in orthopedics or in infectious disease? But then the next step is what’s the setting? What’s going on? What’s the patient look like? What’s the story that’s in front of you?

And that’s what’s going to help you decide between some of those answer choices that are going to be really frustrating because you’re going to want to order an x-ray, but that may not be the best choice if you’re in a family care office. I hope that that makes sense, but that’s how the questions are structured, and I see them come across that way, and it infuriates me, like I said, because of my background, but when you stop and think about it from a family care perspective, it makes a lot more sense. You know, I can remember specifically when I was a student on my family care rotations and we had a patient come in who had injured her foot. And I can’t remember a hundred percent how she had done it. I don’t know if she, I think she may have dropped something on it now that I’m thinking about it. She had a little difficulty walking and the practitioner I was working with, you know, looked her over, took down her story and then basically sent her away with, with some pain medication, you know, and rest. And I asked this practitioner, I said, Hey, are we going to, you’re not going to order imaging.

And she said, no, because they don’t usually fix foot fractures. So there’s no real point in, in order imaging. I was sort of horrified at the time, but I didn’t know enough to be as horrified as I am now. I worked in foot and ankle orthopedics for a very long time and we fixed lots of foot fractures. And there are some that can be devastating as we’ll get to in not today’s episode, but probably the next episode. The Lisfranc injury is one in particular that can just be devastating to someone if you don’t fix it. So anyway, the point is understand your setting, understand what you’re going to try to be doing, but be aware that all of these things are important regardless of your setting.

Let’s hop into our priming questions for today. You have an active 12-year-old boy complaining of knee pain. There has been no trauma, but you do observe he’s a little overweight. What diagnosis must you be considering? You have an active 12-year-old boy complaining of knee pain. There has been no trauma and you observe that he’s a little overweight. What diagnosis must you be considering?

What does avascular mean? Avascular. Describe Barlow’s maneuver. Describe Barlow’s maneuver.

Let’s begin by talking a little bit about fracture care in general. So, like I said before, x-ray is going to be your initial study of choice. It is usually enough to give a diagnosis of a fracture. You’re going to want to do x-rays on the joint above and below the injury to make sure that there’s nothing weird going on. If it’s a more complicated fracture, you’re going to want to get a CT scan for things like interarticular fractures, or if you suspect a fracture, but the plain film just isn’t showing it. An MRI can be used for this too, for what we call an occult fracture. Open fractures should undergo irrigation and debridement within eight hours of injury.

That’s important. There aren’t a ton of true emergencies in orthopedic surgery, but an open fracture is one of those. They should also receive a first-generation cephalosporin, and you could even add in an aminoglycoside. A treatment for fractures is anatomical reduction, either open or closed, immobilization, possibly internal fixation with plates and screws or other hardware may be required if reduction is unstable or if the fracture is intraarticular. Or interarticular, rather. So it’s pretty straightforward, orthopedics. I know it can be complicated.

But the reality is it’s not as complicated as you think. I understand that there are a lot of definitions. There are a lot of sort of tests you have to remember, all of these different things, but you have a couple of advantages going for you in orthopedics. One is you have a model with you during your exam, right? And I’ll talk about associations a little bit later today, But one advantage you have is that you have your body with you, right? So I had a student recently talking to me about how they would use or touch the different parts of their body as they studied or as they learned. And that helped to create connections to hold on to the information.

Then they had that with them in the exam. And that was a great idea. It’s definitely something that I use, but I don’t use it as fully as perhaps I could. And if you’re not doing that, then you absolutely should. You know, if you’re learning about, you know, the different bones in the hand, so you’re just, you know, you’re early on, you’re learning anatomy, use the model you have in front of you. Touch each of them as you describe them. It makes it so much easier for your brain to hold onto that information.

So you have that model with you. That’s one helpful thing. The other is to understand that a lot of it is memorizing terms, memorizing definitions. So don’t get too hung up. You know, memorizing the different tests, it’s all pretty straightforward. It’s new, so that makes it hard, but it’s pretty straightforward. And then the other thing that makes orthopedics manageable, at least I think so, is something that one of the orthopedic docs I work with shared with me early on once I had graduated.

He said, listen, this isn’t that hard. You know, we only have a handful of treatments. There’s only a handful of things we do for anyone who comes through the door, right? If you think about it, we do RICE, which is rest, ice, compression, and elevation. We give NSAIDs. Sometimes we give stronger pain medication. We do physical therapy, we can do a steroid injection, we can offer some kind of bracing, or we can do surgery.

That’s really the limit, right? There isn’t a whole lot else as far as treatment goes. You know, see, there’s not a whole, you know, for me, when I struggle with pharmacology, and I struggle with remembering names of medications, there isn’t a whole lot here that you have to remember, right? Yes, the diagnostic part is a little bit more difficult, but the treatment plans are a whole lot easier. So if you’ve been struggling with orthopedics, look at it from maybe a fresh perspective at what you can do and some of the things you can get out of this. I think you’ll find it’s easier than perhaps you thought it was.

All right, let’s move on. Disorders of the hip. Starting with avascular necrosis of the femoral head. Avascular means there’s no blood supply, right? Necrosis means death. So avascular necrosis of the femoral head means the femoral head is not getting any blood and therefore it dies. This destroys not just the bone, but the joint surface.

You know, I’ve seen patients come in with literally a square femoral head. And it’s, you know, it’s amazing. They can even walk. Risk factors. This is something that you must absolutely must know for this risk factors, long-term steroid use. So who are people with long-term steroid use? Well, people with a significant asthma or COPD or breathing issues are going to be on steroids for a long time.

People with autoimmune disorders like lupus or rheumatoid arthritis, not only are those conditions going to increase their risk for avascular necrosis, but they’re also going to increase their risks because of long-term steroid use, right? So consider that. Alcoholism is another place I’ve seen this, especially in the clinic. When we talk about key terms, this is another, I almost got into an argument with someone the other day, emailing back and forth about key terms and how they absolutely must, must, must be on your test, right? So for me, alcoholism is kind of a key term for avascular necrosis. It’s something that can very easily pop up as something you should know for this, right? That’s how I think about key terms.

But they may not say alcoholism, and your patient may not present with alcoholism. They may present with pancreatitis, right? They may present with liver disease. So although knowing the key terms is extremely important, they aren’t going to be as tight and clear as you might like, right? We’ve talked about that a whole lot. They may say something like a patient with a history of pancreatitis comes in with a significant limp, you know, something along those lines. And you need to be thinking avascular necrosis.

This could also be secondary to trauma and arterial embolism, sickle cell anemia for obvious reasons, those sorts of things. Clinical presentation is going to be groin pain and difficulty walking, lab studies and physical exam findings, x-ray and MRI. Treatment, there are two ways you could treat this. Step one could be a core decompression. So what they do is really just drill holes into the femoral head, and this may allow new vasculature to grow. I couldn’t quote you numbers on the success rate here, but the total hip replacement is the definitive treatment. Developmental dysplasia of the hip.

This was previously known as congenital hip dislocation. This is a spectrum of issues related to abnormal development of the hip joint. These occur mostly in otherwise healthy children. The clinical presentation is going to be the routine physical exam, or you may see gait issues as a toddler. But, you know, just as likely it’s going to be, that’s one of the things that you’re checking for in a pediatric exam. Lab studies and physical exam findings. Children should be assessed for instability as early as possible and up until they’re walking normally.

So we have two maneuvers here that we talk about in relation to developmental dysplasia of the hip. We have the Barlow maneuver and the Ortolani. Barlow’s, you begin by flexing the hips and knees to 90 degrees, right? So you take the child by their lower legs or by their feet, and you basically push their feet up, right? And that’ll get you to a hip and knees of 90 degrees. Then you’re going to adduct and internally rotate the hips while applying pressure to the knees in an effort to dislocate the hips. Flexion and internal rotation of the hip is the easiest way to dislocate a hip.

So for me, that’s key. Flexion and internal rotation of the hip is the easiest way to dislocate the hip. I know that from doing hundreds and hundreds of total hip replacements. That’s how you dislocate the hip, right? You flex and internally rotate the hip, and you can get it to pop out a joint. That’s what you’re trying to accomplish here. The Ortolani move, this is reducing the hip after it’s been dislocated using the Barlow maneuver.

So here you should feel a clunk as a joint is reduced, and this proves that the Barlow test was positive. This is performed by flexing the hips and knees to 90 degrees and externally rotating the hips while applying pressure over the greater trochanters. So again, that’s going to be just words and gobbledygook if you’re just listening to me, right? If you’re just out for a run or you’re driving your car and you’re staring off into space and you just heard me describe those two things, you’re not getting anything out of that, right? It’s a total waste. You need to stop and think about how that maneuver would look. Put your hands out in front of you.

Picture a baby or a doll. Run your mind through the idea of dislocating and relocating someone’s hip through internal and external rotation, and how that would feel and how that would look. That’s how you lock it into your brain. On physical exam, you may also find a limb length discrepancy. Another easy one to find is an uneven gluteal fold. You’re going to want to get x-rays and an ultrasound. Treatment is going to be bracing and splinting.

Fractures and dislocations of the hip. What we’re talking about here is mostly a proximal femur fracture. This is generally a pathological fracture with osteoporosis being the most common primary cause. So, generally speaking, and in my experience, the clinical presentation here is an elderly person who has fallen and can’t get up. Lab studies and physical exam findings. They have an injured leg is short and externally rotated. That’s a dead giveaway for a hip fracture, for a proximal hip fracture.

The x-ray should demonstrate that hip fracture. And if the x-ray is inconclusive, you can do an MRI as a further study. Treatment here is going to be surgical repair of the fracture. This is usually a hemiarthroplasty, but not always. Sometimes you can do a plate and screw, a side plate and screw. It depends on the type of fracture, which is way more than than the PANCE is going to need you to go into. I just want you to there’s a couple different methods, but generally speaking, it’s a hemiarthroplasty, which just means it’s a half of a total joint, right, hemi.

And because we’re going to replace the ball, but not the socket, because the socket’s just fine in these patients, generally speaking, we just replace half the hip, the part that’s broken. One question I came across as I was doing questions with a student the other day were sciatic nerve complaints following a hemiarthroplasty. And as you’re doing a total hip or a hemiarthroplasty, you are working right along the sciatic nerve. So there’s a couple reasons why it can give patients problems after surgery. And I was just looking up where the rates of sciatic nerve issues can be as high as 7%. That’s probably a touch higher than I’m used to seeing, but that’s a real number, obviously. And that can be from direct trauma.

I mean, a lot of times we visualize the sciatic nerve during the surgery, but it can also be from stretching of the nerve during the surgery. It can just be from stretching of the nerve if you bring the person, was it normally had a shortened leg to begin with and you bring them out to full length. There’s a couple of different reasons why that can be an issue, but something to think about is that that sciatic nerve can be, what’s the word I’m looking for? I don’t want to say damaged. I mean, it certainly can be damaged, but it can also just be irritated during the surgery. That’s the word I’m trying to find, irritated.

All right, our next and last one for the hip is slipped capital femoral epiphysis. This is also known as the SCFE for short. And it’s hard, slipped capital femoral epiphysis is hard because it’s hard to say, right? It’s hard to remember because it’s hard to say. I’ve talked about this a whole lot or I struggle with pharmacology, right? Because I struggle with pronunciation and spelling, I have trouble wrapping my head around these terms. Spend some time, write this one out, write it down a few times, make sure you can pronounce it, make sure you can say it.

I am confident that once you can say this, the diagnosis itself is not that complicated. The question you’re going to see on it is pretty easy and straightforward. This is one I would absolutely make sure I get right on my exam. You may not see it, of course, but if it came up, I would be thrilled.

All right, the cause here, it’s caused by a weakness in the proximal physis of the femur. In this case, the epiphysis of the proximal femur slips off the bone, and the epiphysis stays in the acetabulum, and the femoral neck displaces anteriorly. Generally, this is in a, I want to say like 11 to 13-year-old overweight males are your most common at-risk people for this, and especially if they’re active, if they’re soccer players, if they’re basketball players, that kind of thing. Clinical presentation here will usually be the child complaining of groin pain or of knee pain. And this is really important to note. And that’s one of the reasons why we get imaging of the joint above and the joint below. A lot of times this will present with knee pain.

And again, this is over, you know, can be over weeks to months. These complaints can be happening. Lab studies and physical exam findings, the patient prefers to have the hip externally rotated. And there’s a decrease in hip, internal rotation, abduction, and flexion. You’re going to get an x-ray of AP and a frog leg. And this has a very distinct picture on x-ray. It’s known as the ice cream cone or the ice cream falling off the cone because you’re looking at that separation, right, of the physis and the epiphysis.

So you’ll see the femur kind of as the ice cream cone and then the head of the femur as the ice cream and they’ll be sort of separated. It’ll have fallen off. Treatment is surgical correction. The one interesting thing here is a patient who has it on one side will often develop it on the other side. So you do want to consider bilateral fixation even if there’s no complaint on the opposite side.

All right, and that’ll wrap up hips for us today. I want to talk and move into a little bit on the study tip. And before you click ahead, I get emails from someone the other day who had gone through the 33 Days program, and she was saying how she’d always skipped the study tip. She’d always skipped through the beginning of the show. And now that she was struggling, she found that when she went back and paid attention to these parts, she started doing a whole lot better. These are not superfluous. These are, to me, as important, maybe the entire reason for doing the rest of the show is to get to this part.

So today’s study tip is going to be a little bit on association. Association, learning through association, I covered in great detail in issue 61, actually the five-year anniversary issue of the Physician Assistant Exam Scholars newsletter. I went through association and differentiation, two very powerful ways of studying so you can retain more and do better on your exams. I want to touch on association a little bit today because I’ve been talking about throughout today’s episode. There’s just been a ton of places to use association. Association is the idea of linking things you know to things you’re learning to create stronger neural networks with the things you’re learning. So if you have a powerful memory, something very strong, something that you hold really tightly, and then you associate or link something new to it, that new thing will be more readily available to you than if you just learned it as a single data point.

Single data points are almost impossible to remember. But through association, through linking things together, that’s how you retain things long-term. A couple examples for me in today’s session, and you heard me point out a couple of these as we went, but I have a few more. One is the Barlow test, right? The Barlow maneuver. This always stood out to me because Kurt Barlow is the vampire in the book Salem’s Lot by Stephen King. You may not be familiar with it, but that’s not really relevant.

I was, it was a book I loved. Really enjoyed. And as soon as that name popped up, I had something to associate it to, right? I had that strong neural network already created for that name. And all I had to do was link this way of moving a hip in a child to what I’d already known. Let me give you another example. Slipped capital femoral epiphysis.

I always struggled with this, just like, you know, I think most people do because of the pronunciation, like I talked about it. I had a hard time remembering it. The doctor I first worked for, the orthopedic surgeon, when I got out of school, told me a story about a slipped capital femoral epiphysis, and now I will never, ever forget it. And the story was his son actually had this. And to make the story stand out more, to make it a better story to tell, although a worse story for them, this was an orthopedic surgeon who’s, you know, had a, I think his son was 11 or 12 at the time, was a pretty big time soccer player, lacrosse player. And he was complaining of knee pain, complaining of knee pain. And, you know, this guy was saying, you know, like a lot of us dads do, we think our kids are being a little wimpy.

So we tell him to get back out there and stop complaining. And he did that for a month and finally brought him in for some x-rays and found out that he had a slipped capital femoral epiphysis. He decided initially to only fix the one side. So his kid was on crutches for a while, having the one side pinned. And then pretty much as soon as he went, back to full activity, the other side went, right? So he started over and it kind of killed that poor kid’s summer. Anyway, because I have that story, and now you do too, you know, it’s kind of funny knowing that this was an orthopedic surgeon, right?

But it happens to all of us, happens to everyone. And especially worse with your family. That’s why you don’t treat family members. I have this story. I have this very strong neural network. I know all the players. I know, I can picture it all in my head.

I can see exactly how it would have happened. It’s much easier for me to hold on to the whole thing than it is to just memorize these words as independent data points out there in the world, right? So I always want you to be looking for those associations, those places where you can tack on things you’re learning to things you already know.

All right, now let’s finish up with our priming questions and see how we did. Oh, this one’s going to be too easy. An active 12-year-old boy is complaining of knee pain. There has been no trauma. And you observe that he’s a little overweight. What diagnosis must you consider? So you have an active 12-year-old who’s a little overweight, complaining of knee pain.

This is a slipped capital femoral epiphysis. And to me, this is how this question is going to present on your test. There shouldn’t be a whole lot more to it. He may be complaining of hip pain. That’s possible. But generally speaking, you’re not going to get a female. You’re not going to get someone who’s skinny.

This is pretty much the path they’re going to send you down. What does avascular mean? Should be pretty straightforward. No blood. Describe the Barlow maneuver. Adduct and internally rotate the hips while applying pressure to the knees in an effort to dislocate the hips. Flexion and internal rotation of the hip is the easiest way to dislocate the hip.

Beautiful. Well done.

All right. This was a fantastic start to the musculoskeletal system. I’m really excited to get moving along and get through more and more of the content for you. It’s a lot of fun for me to sit and go through the information and pull it apart in the way that I do. I think if you start to see the way that I look at the material, if you start to see the way that I work with associations, with ideas, linking things together, I think you’ll find it a whole lot easier to retain all of this moving forward. No matter what area you’re studying, it doesn’t matter if you’re in orthopedics or you’re in cardiovascular. Vascular.

There’s certain styles, certain techniques to studying and certain ways to be looking ahead towards your tests that will really improve your scores. While I’m talking about that, once again, if you are someone who is struggling a little bit and wants to get higher scores, is unhappy and doesn’t think you’re getting the scores you deserve, or you know someone like that, please, please, please set them up. Have them go look at physicianassistantexamreview.com/33 and perhaps registering for the May or June 2023 cohorts of the 33 Days to Pass Your PANCE program is exactly what they need. But like I said, please take a look at that. Please send anyone you know who’s in that situation over. I would really, really like to help them.

All right. And if you are interested and still have questions, I’ll be doing live question and answer periods and a live walkthrough of my methods, my ideas of how to move through PA school through the PANCE and what the 33 Days to Pass the PANCE program is consists of. That’ll be on Wednesday night at 8 p.m. At physicianassistantexamreview.com/live.

All right, great. Until next time, take care and best of luck. Thank you.