Hello and welcome to episode 109 of the Physician Assistant Exam Review Podcast. This week we’re going to be continuing the lower extremity, talking about the knee and foot and ankle. So one thing that’s funny about what I just said is that foot and ankle seems to always get this short shrift, right? If you don’t realize that. What’s funny is that I worked in foot and ankle orthopedics for four years. That was the first job I had out of PA school, and I loved it. And there’s so much going on there and so much to do and so much surgery and so many different things.

And I still, as being in that world for so long, I still just blew over it. Anyway, my name is Brian Wallace. I’m the founder 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, right? That’s our goal, get you to your job. Get out in the world helping people doing what you want to be doing.

Now, if you find the show helpful, if you find the way I teach, if you find the way I do things, helps you do better. Please do me and your friends and classmates a favor and share the show. Tell them about it. Tell them where you found it, where you are finding how to do better in school. Please, that helps me tremendously, but it also helps them and makes you look really good too in the process, right?

All right. So one other thing I’ve got for you today before we get started. I have something very special going on next week. Next Wednesday on 5-17, May 17th, I’m going to be doing a webinar presentation. I’ve recently come across some incredible evidence, some of which is published inside the Journal of Physician Assistant Education, that has really taken what I do here and pushed me to a whole new level. And honestly, I’ve been thinking for a long time, actually since I’ve been in PA school, but over the years and then more recently with the 33 Days to Pass the PANCE program and seeing the results I’ve been getting in there, I’ve been thinking that we’ve been doing PANCE prep wrong. I’ve been thinking that we’ve been missing a large chunk of what we need to know and ways we can make life so much easier, so much better.

You can get higher scores. You can move the needles substantially, but we’ve been doing things wrong and focusing on the wrong things. And like I said, recently, I’ve been in contact with a couple of different PA programs, talking about coming in and doing workshops for their students to help them get through the PANCE, get through school. And as I was doing that, I went back to do a little bit of research and I uncovered some two, in fact, two unbelievable studies that really back up everything I’ve been talking about for a long time now. And I want to share those with you, but this is not the platform to do that in. So I am going to do that on the 17th, May 17th at 8 p.m. That’s next Wednesday, if you’re hearing this the day that it’s released.

And you can go and find out more about how to get into that webinar at physicianassistantexamreview.com/PANCEprep. And what I’m going to do there is I’m going to explain to you exactly what I found, exactly why what I think we’ve been doing for so long is not the best way to get ready for your exam. And then I’m going to show you what is the best way, right? More importantly, I’m going to help you cross that finish line with the highest possible score. And we’re going to do that on Wednesday, 5, 17 at 8 PM. Again, go to physicianassistantexamreview.com/PANCEprep.

All right. So I’m excited for that. But for today, let’s go ahead and keep moving along through musculoskeletal with lower extremity disorders of the knee and the foot and… let’s start with our priming questions. If you can only choose one physical exam test to test for an ACL injury, which should you choose? If you can only choose one physical exam test to test for an ACL injury, which should you choose? Which fifth metatarsal fracture has a high rate of nonunion?

Which fifth metatarsal fracture has a high rate of nonunion? Anterior knee pain in a 13-year-old soccer player. What is the most likely diagnosis? What is the most likely diagnosis for a 13-year-old soccer player with anterior knee pain? That’s a better way to say it.

All right. Let’s get into disorders of the knee. We start with fractures and dislocations. And that’s all the information that the blueprint gives us, right? There’s not a whole lot. So when someone comes in with a fracture or dislocation, usually they’ve got a history of trauma, right? They’re not just walking into your office and you discover this fracture.

It’s not how that works. So again, you need to be picturing the setting. You need to be picturing what’s going on. Are we in the emergency department? Are we in an office? Are we at the hospital? Are we in an urgent care?

Where are we and what’s going on. Lab studies and physical exam findings. Well, what you’re going to do is you’re going to start with palpation, strength and range of motion. Unless there’s some kind of like obvious deformity, you’re not going to torture the person, right? But you can get a lot of information from some of these, from the, from the physical exam, right? Just putting them through a range of motion stuff, passive and active range of motion stuff and palpation again, if there’s no obvious deformities. If we’re talking about a patella fracture or suspected patella fracture, a straight leg raise is going to be how you test for that with a physical exam.

Then obviously our next step is going to be x-rays and CAT scans. X-rays will be our preliminary. Get some good information. CAT scans are generally reserved for difficult surgical cases. That line’s a little bit blurred, of course. But the standard practice is to get an x-ray and then get a CAT scan if you need it to get some more information for surgery or to prove that there’s a fracture if you’re uncertain and you believe, and clinically you believe that there is, but the x-ray is coming back negative. Again, that varies depending on where we are, but it’s a general, it’s not, it’s a general practice.

I guess it’s a good way to think about it. Treatment. So you’re going to start with anatomical reduction. Again, depends on the setting, depends on what’s going on. There’s a hundred different factors here, but we know as far as our test is concerned, anatomical reduction is a good place, a good goal. Then we’re going to do immobilization. And then if we need to, surgical repair.

Immobilization is going to be things like casting and splinting, right? And then surgical repair. So in the case of the knee, we’re basically talking about three different types of fractures. We have a patella fracture, which is going to get screws or wires to pull the pieces of the patella back together and create compression there. You can have a distal femur fracture, right? And this is probably going to wind up with plate and screws or a femoral nail, depending on the location of the fracture, how close it is to the joint. And you can have a tibial plateau fracture, right?

So the very top of the tibia. These are pretty nasty, and they usually require a whole mess of screws and at least one, if not multiple plates to put those back together. So that’s our knee fractures and dislocations. Osgood-Schlatter disease. This is always a fun one, and this was easy to remember because I had a buddy, a couple of friends actually, when we were in middle school, who had issues with this, playing basketball or playing soccer. And this is the epiphysitis of the tibial tubercle gets inflamed. Basically what you have is you have, generally this is in active middle school age boys.

And the problem is they’re growing and running and moving faster than their body can keep up. So that tibial tubercle gets inflamed. And it gets sore and it gets tender. And that’s really what the problem is, is just that needs to get calmed down. There’s not much, a whole lot to do about it. It’s not an actual, they’re going to get better, but they can be in a lot of pain from this. But this is a good one to hold onto because it’s a good test question.

Clinical presentation. Again, my son is complaining of anterior knee pain, which is usually worse after activity. Lab studies and physical exam findings. You get that enlarged tibial tubercle. Pain is reproducible by resisted extension of the knee. That’s a good one to hold on to. Pain is it reproducible by resisted extension of the knee.

Treatment. NSAIDs, and again, it’s self-limiting once the growth plates have closed. Rest is really going to be a mainstay of treatment here, but that’s going to be tough if you have kids who are getting this because they’re active, then you’re going to ask them to reduce their activity to heal this. And that, you know, if you’ve ever worked in a in an orthopedic office, this, this cycle goes round and round and round. Unfortunately, I’m running into the same thing with a bunch of the kids on my son’s baseball team. They’ve got about four or five kids down with arm injuries. And if they would just rest them, they’d be okay.

There was a kid down last year, pretty much the whole summer with a hamstring tear. And if he could have just rested, he probably would have been okay, but it went on the entire summer because every time he felt better, he’d go back out and play or go play football or whatever in the yard and he’d be right back hobbling along. So encourage rest, but it’s going to be very difficult. Next we have meniscus injuries. These are easier once you understand what a meniscus is than just trying to remember these as data points. Remember, remembering single data points is not a good way to practice, right? It’s not a good way to study.

It’s not a good way to retain anything. The meniscus, meniscus is Greek for crescent, right? So that crescent shape, That’s what these look like. These are a crescent shape. And the medial lateral meniscus provide cushion and stability for the knee. So it’s kind of like a little piece of gel foam that sits one medial, one laterally, little crescents that sit there, and they provide some stability, and they provide some cushion between the tibia and the fibula. I’m sorry, the tibia and the femur, the knee, right?

To the tibia and the femur. And it’s important to understand what they do and where they sit to understand why they would be injured and what the results of that look like. So this can be degenerative, so just over time they kind of wear, or it can be traumatic. Traumatic is usually secondary to a twisting of the knee while the foot is planted. Clinical presentation, my knee’s been bothering me for a few weeks and it locks up and sometimes it pops and sometimes my knee gives out. Those are all words that a patient might say if they come in with a meniscal injury. That locking tends to be the test question thing, though, because it stands out on its own.

There’s not a lot of other things that are going to happen. And what that locking is, is that you’ve got a torn meniscus, and the section that’s torn is kind of broken free and flipped over. So now it’s doubled up on itself, and you have something that’s actually just blocking the knee from moving. Lab studies and physical exam findings, the patients will likely have joint line tenderness. Right. So if you’re basically if you’re pushing on the torn meniscus, it hurts. Right.

That’s what the joint line tenderness is for. The patient that may not be able to fully extend the knee. Effusion within the knee. And then there are three physical exam tests you can do. The McMurray, which is you put the patient through a passive flexion and extension of the knee while you apply pressure in order to externally rotate it. The Apley, which is the patient is prone on the table with the knee flexed to 90 degrees. You then press the patient’s heel directly towards the floor while internally and externally rotating the foot.

I always think of this as like kind of like trying to grind on that meniscus. And the Thessaly test, which is a patient stands on one leg and flexes the knee to 20 degrees. The patient then internally and externally rotates the knee. So again, that kind of like that grinding on the meniscus. Repeat this maneuver with the tibia rotated internally. So those are three different tests they could ask you about, but that’s really, you’re trying to put pressure onto that meniscus and elicit some pain.

Now, if somebody comes in complaining of knee pain, you’re going to get an x-ray. It’s just standard of care, but really it’s not, that’s not going to help you diagnose the meniscus other than to rule out fractures and other things, but you’re going to get an MRI to really diagnose this. Rest, ice, compression, and elevation, our mainstay of treatment for orthopedics. You can do some physical therapy. And then finally, there’s surgical correction, which is going to be arthroscopically going into that knee, looking around, finding that torn meniscus and either repairing it or removing it or cutting out the piece that’s kind of flopping around. There’s a couple of different options there, but it’s really just, it’s arthroscopically done in most cases. Moving on to ligaments within the knee, the anterior cruciate ligament, the ACL.

This is the most popular, right? Because it’s also the most commonly injured knee ligament. The ACL prevents the anterior translation of the tibia. That’s important. And I talk a lot about if you can picture the disease state, if you can picture the problem, everything else is easier. So in this case, if you can remember that the ACL prevents the tibia from sliding forward, anterior translation of the tibia, then the rest of this gets easier. Now an ACL injury is more common in women than in men.

So if I’m writing a test question on this, I’m thinking about a female soccer player, something like that, a collegiate soccer player with an ACL tear. Does it happen in men? Of course it happens in men, absolutely, but women, because of their anatomy, are at a higher risk for an ACL injury doing the same activities. Clinical presentation: I felt a pop in my knee and now it feels unstable, especially coming down the stairs. Lab studies and physical exam findings, so you can get a knee effusion. Two tests here, although there are hundreds, but these two tend to be the two most common. And see what we talk about, the anterior drawer, which is the patient is supine with the knee flexed to 90 degrees.

You sit on the patient’s foot and pull on their tibia. You just yank it forward while you’re sitting on their foot so the foot can’t move forward. And the ACL should hold the tibia in place in the knee. But if it’s not, if that’s been ruptured, you can translate that tibia forward just a bit. The Lachman test is the other one. The patient’s knee should be in 30 degrees of flexion. You then stabilize the distal femur with one hand and pull on the proximal tibia with the other.

If asked about which is the best, use the Lachman test. So again, if someone comes in with knee pain, you’re going to get an x-ray, but that’s not going to help a whole lot for an ACL tear. An MRI is going to be how you’re going to prove this. You could also use an ultrasound. The treatment is going to be your rest, ice, compression, and elevation. Then you’re going to wind up with some physical therapy and finally a surgically replaced ACL. We’re going to go in again arthroscopically and cut out the remnants of the ACL and replace it.

And then doing the exact opposite job is the posterior cruciate ligament, the PCL. The PCL prevents posterior translation of the tibia, right? So just the opposite of our ACL. This usually occurs secondary to a direct blow of a flexed knee. So think hitting the dashboard in a motor vehicle accident with your feet up kind of, and you whack your shins or your tibias on the dashboard, and that will snap the PCLs and the tibias will translate backwards. Clinical presentation, knee pain and instability. You can get an effusion.

The posterior sag sign, something you can use to test for this in the office. A patient is supine, hips and knees are flexed to 90 degrees, so exactly like we would be for the anterior drawer. And you look for the posterior translation of the affected tibia and no clear step off. So, you’re looking to see, does that tibia sag backwards in the knee? The posterior drawer is going to be sitting in the same position, but now you’re going to push on the proximal tibia. Instead of pulling on it for the anterior drawer, you’re going to push on it for the posterior drawer. You’re just going to move it, try to translate that tibia posteriorly.

And again, this is not, this kind of thing falls into my list of things that you should not be memorizing. You should be understanding. You should be thinking about what does an anterior cruciate ligament do? What does a posterior cruciate ligament do? And then I don’t have to memorize the rest of this. Everything else makes sense. Yes, I might have to memorize the names of these tests, but they all should just make sense.

And in the same vein, we’re just going to do rest, ice, compression, and elevation, physical therapy, and surgical correction of a posterior cruciate ligament injury.

Next, we have the collateral ligament injuries. These are the ligaments that are on either, on the medial and lateral. I was going to say on either side, but we have specific terms to make that easier to understand. You have the medial collateral ligament and a lateral collateral ligament. No, maybe not easier to understand, but more clear, the language is. So the MCL, so this is the medial collateral ligament. So on the medial side of the knee, you have a ligament that stabilizes the knee against valgus stress.

On the lateral side of the knee, you have a ligament that stabilizes the knee against valgus stress. Valgus stress is when you take the knee, you hold the foot in place, and you take the knee and you push it medially, right? And just the opposite for varus stress. You hold the foot in place and you push against the knee from the medial side, trying to push the knee laterally. And you can picture how those ligaments running down either side would help to prevent gapping or opening up of the knee.

Now, this isn’t going to matter for your test, but if you’re in the office, I had somebody come in one time when I was working in the orthopedic clinic with knee pain. Actually, I can’t even remember if it was knee pain. But regardless, I was doing a very thorough exam, right? So I put them through a bunch of different tests, and one of them was varus and valgus knee stress. And what I found on one side was they had ridiculous gapping. I was like, holy crap, this is unbelievable. You know, just really crazy gapping on one side.

I think it was laterally. So I go out to tell my attending and I was like, wow, you got to check this out. We really need to do something about this. And he went in and taught me something that I will never forget is that he went and did the same test on the opposite knee and got the same exact result. This patient had very loose ligaments and could gap the same exact amount on both sides, meaning that he was not having a problem, right? So, one thing nice about orthopedics is people have two sides. You can test the other side to see if it’s normal for them.

You don’t need a baseline because you sort of have a baseline in the contralateral anatomy. You have something to look at. So, we’ll often do that as we get to foot and ankle when we’re trying to decide on an Achilles rupture or if someone has a collapsed arch, and you can get a good idea by looking at the contralateral side. So anyway, something just to keep in mind if you’re in the clinic, don’t get too worked up until you look at the patient and see what’s normal for them. Complete side story, but my youngest son had an eye exam yesterday where he had to get his eyes dilated and the doc had to, you know, look inside. And I was laughing to myself because when I was in PA school, I really struggled to do this. And she’s trying to show me the vessels coming over the rim of the optic nerve and showing me how it was bulging a little bit, which I could not see at all.

I couldn’t in PA school. I couldn’t yesterday. But the point was what she was showing me is that he has a little bit of pressure behind his optic nerve. So they bulge a little bit. And what she was saying is that it really doesn’t matter. It’s not a problem. There’s nothing going on.

She said the problem is that it’s normal for him, and if he walks into the ER with a head injury and they look in his eyes and see that, they’re going to think his brain is swelling. So the point is it’s nice to know what’s normal for your patients. Right? Another similar story was we had a patient we were doing a hysterectomy on, and after the hysterectomy, a lot of times you’ll do a cystoscopy. So you’ll look into the bladder to make sure that the ureters are still working because you are, if you know your anatomy, you are working very close when you are taking down the uterine arteries, you’re working very close to the ureters. So a lot of times we’ll stick it, we’ll put a scope into the bladder to look and make sure we see the ureters firing. And in this one case, we were waiting around and sometimes it takes a little time, right?

The ureters don’t always go as quickly as you’d like. So sometimes you’re waiting around 15, 20 minutes or so trying to get, trying to see what you want to see, wondering, is there a problem? And then they fire and you’re okay. Well, on this one patient, we were waiting around especially a long time. And after about 30, 40 minutes, someone had been digging back through their chart and found out that they had had, that they were, they only had one kidney. So the other side was never going to fire and it wasn’t the thing that we did. It was that they, I don’t remember if it was congenital or it had been removed, but they only had one kidney.

So anyway, the point is knowing a little bit more about your patients can be helpful in these situations.

All right, that’s a little far afield here when we’re talking about orthopedics.

Let’s get back on track. Disorders of the foot and ankle. One thing just from being in practice, again, this probably will not come up on your exam, but always get weight-bearing films if possible. Always, always, always get weight-bearing films if possible. Ankle sprains will be on your exam. The one thing that is probably going to come up is that the most common ankle sprain involves the anterior talofibular ligament. Ankle fractures can involve the lateral malleolus, so fibula, and the medial malleolus, which is a tibia, one or the other or both.

There are two fifth metatarsal fractures you should know about. One is an avulsion fracture, which is just where the very base of that fifth metatarsal gets broken off. That can happen from a crush injury, being stepped on, because if you look at the x-ray, the base of that fifth metatarsal sort of hangs off the rest of the foot. So it’s sort of a, it’s at risk for this fracture. Now the other fracture you need to know about is the Jones fracture, which is a fracture at or just distal to the metaphyseal-diaphyseal junction of the fifth metatarsal. And it’s just proximal, basically just proximal to the middle of the fifth metatarsal. And the problem there is that it gets a weak blood supply, so it can often go on to a non-union.

So these can be treated non-operatively, but a significant portion of them will go on to need a screw in order to get them to heal. But there’s a difference between a Jones fracture and a fifth metatarsal avulsion fracture. The avulsion fractures here heal just fine because those are really proximal. It’s that one that’s just a little bit more distal, that Jones fracture that you have to be worried about. Something else here is our Achilles tendon ruptures. These come in from time to time. And you should be able to diagnose these because the patients, and I’ve seen a lot of these in my former practice, the patients come in saying exactly what it says in the textbook, and that doesn’t usually happen, but it happens with Achilles ruptures.

They come in saying it felt, I was out playing basketball, I was out playing soccer, I was playing with my kids, and it felt like someone kicked me from behind or shot me, and I turned to look and there was no one standing there. I’ve seen that written in books and I’ve seen, I’ve heard patients come in and tell it to me. On physical exam, you can figure this out. There’s often a palpable gap in the tendon. So if you have the patient lay down prone and run your finger along the Achilles tendon, again, comparing it to the contralateral side, you can usually feel a gap in the tendon. Not always, but usually. The Thompson test can also be helpful.

So I learned this with the patient lying prone. You have them bend their knees up to 90 degrees. One, you just look at the feet because again, comparing to the contralateral side, one side will look kind of like plantar flexed, like the toes pointed a little bit, even if they’re laying on their belly with their feet at 90 degrees. And the other one will have flattened out because it doesn’t have that Achilles pulling down on it. That again, not always, but you may see this if you compare it to the other side. Next is the Thompson test. You squeeze the calf and if the tendon is attached, if the Achilles tendon is attached, then the foot should move into a little bit more plantar flexion.

If it’s not, then it might not move. Again, these aren’t 100% but they are good tests to evaluate. And that means it can be treated non-operatively in a cast with the foot down in equinus, but you don’t want… in plantar flexion, but usually you’re going to want to go ahead and surgically repair these. A couple other issues for foot and ankle: posterior tibial tendon insufficiency. This is pretty common. This gives you a flat arch and an inability to push off through the great toe.

Plantar fasciitis is another one that comes up quite a bit. This is where the plantar fascia becomes inflamed and extremely painful. Most commonly patients complain about this when they get up first thing in the morning because the feet have been plantar flexed all night. And then when you go to get out of bed, you stretch them out. So you’re stretching out that plantar fascia and that causes a ridiculous amount of pain in people who suffer from this. The mainstay of treatment here is going to be stretching and physical therapy. Oh, I missed for posterior tibial tendon insufficiency.

The mainstay of treatment there is going to be bracing, not physical therapy because what you’re getting is that tendon is getting kind of loosened up and irritated. Physical therapy will just exacerbate that problem. You want to get it calmed down. So Lisfranc injuries are next. This is a disruption of the medial cuneiform and the base of the second metatarsal. So these are high energy injuries. And these are really important to keep an eye out for because a misdiagnosis will result in chronic pain for these people.

It will be a life-changing injury. They can be fixed through surgery, but not if they are missed initially.

All right. Moving on from disorders of foot and ankle, we’re going to move into one last thing for today, which is going to be compartment syndrome. I moved compartment syndrome into this section because it generally tends to, it happens the most with tibia fractures. So, I kind of felt like I sort of went here. We’ll pick up with upper extremity next week. So, we’ll slide right into it. It can happen with upper extremity fractures.

But again, the most common seems to be tibia fractures. Compartment syndrome, and this is another one. Understand what compartment syndrome is. Don’t memorize it. Understand it. I died trying to memorize the presentation, the symptoms, what you would find for compartment syndrome.

Now, with the way I do things now, I wouldn’t ever memorize this. I would understand it, and it makes perfect sense, and it’s not hard, but if you try to memorize the list, it’s almost impossible. It’s just a different approach.

All right, so understanding what compartment syndrome is. Compartments are created by layers of fascia, which do not stretch. I know fascia is a hard subject for students when you haven’t really dealt with it yet or seen it. Once you work with it in surgery, it becomes a whole lot more obvious, but it is a very sturdy connective tissue holding your body together and it does not stretch in most cases. And these compartments are created by these fascial layers separating apart the muscles in most cases or holding the rest of you together, which we’re not going to talk about right now. But an insufficient blood supply to an area of the body, this is an insufficient blood supply to an area of the body due to an increase in pressure within a compartment. So if I get an increase in pressure within a compartment created by fascia, which doesn’t stretch, but inside that compartment, the pressure goes up, I’m going to have trouble moving blood, right?

Because blood flow requires a pressure gradient, right? Arteries to veins, high pressure to low pressure. But if my pressure is the same throughout, or for some reason I’ve created a situation where the pressure is higher than arterial pressure and I can’t move the blood in, this is how I wind up with a compartment syndrome. When that happens, I get a backup of blood in the system and fluid then will leak out of the vessels, making the problem worse and increasing that pressure. Compartment syndrome usually occurs after trauma, like a broken bone and then surgery. And again, it’s most commonly seen in tibia fractures. Clinical presentation.

You should have an eye out for this if you work in lower extremity surgery or even upper extremity surgery or trauma or anywhere where there’s been injuries.

Now, the clinical presentation. One way to think about this is that they’re not getting blood into the tissue because of the excessive pressure in the area. So, you might as well have a tourniquet on the leg and leave it on. Those are going to be their presenting symptoms. That’s it. So, think for just a minute here. If I put a tourniquet on your leg and I inflated it high enough to cut off the blood supply, if I inflated it higher than your arterial pressure, significantly higher, and then I left it there, for four hours, what would your symptoms be?

What would happen? What would your physical exam look like? So yes, you can memorize the six Ps of compartment syndrome. Or you can think about what it would feel like, what it would look like, and how the exam would look on someone who you turn a tourniquet all the way up on and left it on for four hours. Now let’s go through the six Ps and see if they just make more sense. The first thing that’s going to happen is they’re going to have pain. It’s going to hurt, right?

You ever sit on your foot in class? That’s the same thing. It starts to hurt. And then you get paresthesia. Then you get some paralysis. Same as sitting on your foot while you’re sitting in class and then going to walk, right?

Now, the next step here is if the pressure is high enough, you get pulselessness. There’s no pulse because the pressure is too high. You can get pallor, so it turns white. Again, totally makes sense if I put up a tourniquet. And then the last P is poikilothermia, which again is something that to me is a terrible way to get you to remember something is to give you a word that you can’t pronounce, and that just means that the limb is cold. So, if I’m not getting blood into the tissue, I get pain first, then I get paresthesia, then I get paralysis, pulselessness, pallor, and a cold limb. It’s not hard.

But if you’re trying to remember this list, it’s impossible. I couldn’t do it. I spent a year trying to remember this list. I remember trying to do it, and I couldn’t. Now it’s so easy, right? Because if you understand what compartment syndrome is, the symptoms make total sense. Lab studies and physical exam findings.

Again, the physical exam findings is going to be those six Ps. And you can measure the intracompartmental pressures to decide what to do next. Treatments this is going to be key if you work anywhere because you’re going to see patients who may have this and step one is if you have someone who comes in and you suspect they have a compartment syndrome following an injury where they have a cast or a splint on, take it off. Yes, might you screw up the reduction of the fracture? Absolutely. But that’s insignificant next to a compartment syndrome and the damage to the tissue that’s going to happen as the tissue dies because it’s not getting blood. So remove the cast, remove the splint, get that off if you suspect a compartment syndrome.

You know, this is why when I worked in foot and ankle surgery, you do not put a cast on a patient coming out of the OR. You don’t put a cast on. You put a splint on. Why? Because the cast is circumferential. And that plaster doesn’t move. So as they swell into the cast, there’s nowhere to go.

So the pressure goes up and up and up. And you create a compartment syndrome because eventually the blood can’t get into the leg because the pressure is so high because of the cast. You put a splint on because that has some flexibility to it. It holds the patient pretty much immobilized, but usually the splints are three-sided and wrapped with an ace. So the patient doesn’t realize it’s not forced, it’s not circumferential, but it really isn’t. And it has some give to it. And then the final treatment is going to be a fasciotomy.

You actually go in and cut through the fascia planes to allow the tissue to swell out, and this will decrease the pressure and allow the blood to move in. And that’s pretty nasty. Anyway, all right. So, that’ll take us through lower extremity, musculoskeletal. Again, a lot of people seem to struggle with musculoskeletal. It’s not that difficult. It’s just a little bit different way of thinking, but you’ve applied the same techniques that I’ve been teaching for a long time and it should start to jump off the page at you.

Now, I was going to cover some study tips today, but we’re already getting a little bit long and I did a lot of work throughout this discussion on the idea of understanding rather than memorizing. And I want you to take that away and I don’t want to spend time on anything else today. So take that away. Understand compartment syndrome, understand why those symptoms would be that way. Understand what the anterior cruciate ligament does, and then you don’t have to memorize all of the symptoms and all of the tests. Understand what the meniscus does, and you’ll sort of get why it hurts when it hurts. And everything else becomes easier.

Before I move on to the priming questions, I just want to remind you again, on May 17th at 8 p.m. Eastern time, I am going to be covering some information that is going to really help you pass the PANCE, that your PANCE prep is going to be substantially improved if you show up on Wednesday at 8 p.m. I am not going to be doing a recording of this, so I’m sorry for those of you who are listening to this in the future or who missed it on the front end. I’m going to be starting right at 8 p.m. So, I’d really recommend that you’re there at that time, and you bring your notebook and a pencil, because there’s going to be some things you’re going to want to get down, and things that I’m going to ask you to stop doing, and things I’m going to ask you to start doing that are going to make a tremendous difference for you. And you can find out more about that at, I’m sorry, yes, you can find out more about how to get into that meeting at physicianassistantexamreview.com/PANCEprep.

All right, let’s go ahead and finish up with our priming questions. If you can only choose one physical exam test to test for an ACL injury, which should you choose? You remember we did that, seems like a long time ago now. The Lachman test. Which fifth metatarsal fracture has a high rate of non-union? Which fifth metatarsal fracture has a high rate of non-union? The Jones fracture.

Probably worth looking up a picture of that. Anterior knee pain in a 13 year old soccer player. What is the most likely diagnosis? Osgood-Schlatter.

All right, there’s a ton of questions I could have pulled out of this, so please be aware as you study it. There’s a lot you could do, a lot of ways to look at this stuff. But thank you for joining me. Thank you for being part of this amazing community. Things have really been taking off around here. I hope they’re doing the same for you. And like I said, if you are coming up on your PANCE, if you are taking your end of rotation exams, please come and join me for that webinar on Wednesday, May 17th.

Wednesday night at 8 p.m. physicianassistantexamreview.com/PANCEprep to find out more and how to get the link to get in there. But I think it’s going to be incredibly valuable for you. Definitely, definitely eye opening. Like I said, I’ve just I’ve been discovering some some things recently that I want to share with you. And you’ll see what I mean then.

All right. Take care. Until next time. Good luck on your exams and best of all. Best of luck. Take care.