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All right, welcome everybody. Uh So this is the final uh TP a tutorial session, uh got every FSK exam today. So I'll try and be quite to take the top the longest or the most uh technically difficult exam. Um So, yeah, that's good. It's like, so who are we going to go through? So, so the MSK exam is primarily, it's pretty much it's in the exam. So we'll go over some the anatomy, we'll go over the different components of the exam. Please look, feel, listen, it's a slightly different things to come, look, feel. Uh And then we got some special tests which you need to learn, which will most definitely get else to do in the CK uh some practice questions of images. Uh So, uh this is just uh what kind of example, uh if someone comes in with a knee issue, you'll be expected to do all these tests and examine any. Uh it's quite important. So, um as with all see base stations, there's the, the correct position and exposure for the patient to have a look, need to inspect, need to feel you need to move the joints. In this case, and some special test that vibrates just the questions you get asked again. And of course, before that, they'll ask you to, uh, introduce yourself the weight gain. It's a position of appropriate which, uh, three would have covered in previous session. I think that's what you been practicing, uh, with every CPA exam. So we'll go with some basic, uh, it's not that complicated and there are only a couple of things which you really need to focus on. Um you ought to be professional this example. So kind of the basic bones in the knee. So obviously, we've got, so uh we've got the bones of the legs. So we got the bone of the leg, sorry with the femur. Uh we've got the bones of the lower leg, which are the tibia and fibula. So importantly, there are three bones that are involved in the needle and the femur and the tibia and the teller uh the fibula is not actually uh involved in the joint, it's just on the side there and it's the lateral one, the other. Yeah, the fibula is the lateral bone of the joint. So that's how you can looking at someone like that's how you know, uh you're feeling the tinea on the whether it's on the medial aspect of elected. Importantly, the patella is an example of the testimony book. You got testimony bones in your, in your hands as well. But I think the patella is the most. Well, known enough. Um It's a bone that's not connected to any musculature. It's just kind of floating there with two tender. Uh And we have so it's very lucky. So we've also got some important ligaments which are very vibrant this later. Uh We've got the collateral ligaments which are the lateral uh media ligaments of the insurance. We've got the cruciate ligaments which are the anterior and posterior. Um a number of uh so we've got muscles and so very simply um we've got, so you think about the leg, uh the supply, we've got the anterior compartment, which is the extensive um it doesn't need extension. So that's kicking your leg out. We've got the quadriceps, which is uh which consists of four different heads. Uh And then if we think of the posterior compartment, which is the flexor compartment, we've got a couple of distinct, we've got the biggest one. I don't see the hamstrings muscles. Uh But we've also got some attachment properties, muscle, which is a small uh basket inside the needle as well. Then we got uh some of the muscles and importantly, the main tender that we're worried about is the patellar tendon. So the quadriceps muscle because there's a full different heads, uh lateralis, medialis, uh intermediate director several uh and they will converge into form one big quadriceps tendon which touches to the patella, patellar attaches to the ability of curiosity via a big patellar tendon. Okay. So that's pretty simple. I've got a bigger diagram here. So for this diagram, what I want you guys to look at is a, there's a point there. Um is this picture over here um that shows you the anterior uh post you appreciated. So if we look at this part here, that's obviously the patellar, uh that's a good way to orange yourself in redirecting changes to tell us this big kind of floats, not attached to anything. That's how you know the anterior aspect. And then we've got number five here, which goes from the posterior aspect to the anterior aspect of the tibia. And that's the anterior cruciate ligament because obviously air touches and materially on the tibia, we've got the posterior cruciate ligament which goes in the opposite direction. Now, one of the big things to think about here is um what are these ligaments and do all these ligaments stop from happening if you try and pull the tibia forward, the anterior cruciate ligament is going to stop the tibia from being translated forward because obviously it attaches at the front. So it's going to stop that forward movement. If you try and push the tibia backwards, pull the tibia backwards, the posterior cruciate liquid stop it from being displaced. Uh Yeah, that's quite important station uh with some of the specialists uh later on as well. Okay. So that's kind of an overview of basic. Yeah. Uh and then we've got some important uh neurovascular ship and it is on that complicated. Um And we won't be, we probably won't be asked about this. So, uh we've got the relevant analysis as well. We've got the regular, uh we've got regular, also called the perineal nerve, um which are the two major nuts. We've got the deepest structure in the property of foster. So the property of foster is the compartment uh at the back of the knee. Uh It's where you feel for the populist feel artery is part of uh cardio exam. I think in the CPA uh when you're doing all of the lips, uh all of the pulses, right? And it's the deepest, most serious structure in the. So it's really hard to feel property artery. Um And we've also got the property of it. Okay. So let's go some quick questions. Was that Boris patellar? Just point? It's one of the special ones we talked about. Um And what that said, you probably just have to learn them. Remember the uh question is quite popular in the questions that you get after your exam. Uh It's conveying to foreheads uh simple something. Um So to investing gets to learn that, remember that the fastest intermediate is the is the deepest one you can't actually see uh property lost. Uh which the next the figure is at risk of damage seems obvious. Commentary. New 57. Uh we talked about this, what ligament possess a preventative it from sliding backwards. It's a post you appreciated really when you think about it. Uh in terms of physics and try and imagine your head is quite satisfactory uh backwards on the posterior to anterior movement forward with the anterior ligament, it doesn't make sense. Um So position exposure, I'll be really quick in these. So typically they're relying on the couch um and there'll be a 45 degrees. Although it depends on who's doing the exam really, it doesn't really matter because you want to pay four of these tests, you water the patient uh sitting at 45 degrees. Um and there will be very short. And so that's really to see the body steps and uh your muscles and the and then you joined adequate. So I'm going to look. So, um what can you actually see by the enemy without public take? I think it was helpful to get examples. So we've got scars from previous surgeries, probably an ACL or uh secretary ligament or specifically ligament repair, reconstruction, knee replacement, etcetera were also wasting sweating. Who we've got valgus and various. So, scars precepts, monetary muscle wasting can be a sign of, you know, cachexia. Uh If someone's had an injury hasn't used, uh their leg is immobile quite common. Also comment in Lomotil Europeans. Uh Well, it can be caused by a variety of conditions which program bit later. Uh Valgus and various. So how do we differentiate between valgus and various? So, Valgus, Jenny, vulgar, uh valgus is whether that needs uh uh collapse together, collapsing with various is outwards, kind of helpful result you want to extend here, Jenni Falconer come makes your knees stay together. So that's bogus about them. And there is when you can spread apart, that's how you can tell the difference is easier to remember that. Now, you don't need to know this, but it's kind of how we calculate uh the extent of the volume of iron uh to cue angles. Okay. So now against the medium because uh I feel so don't look, don't look inspected. Uh you know about some of the different authorities that can cause uh different pathologies. So what exactly were feeling for? Obviously run to wash your hands. So feeling it starts with temperature and the temperature is easiest. So potentially we want to do is use the back of your hands and doing both things the same time. You're assessing temperature with both hands on the back of your hand. So you just taking uh recognize onto the, onto each of the patient's. Uh So you want to gently touch at the patella above the patella and below the patella. Um and that's temperature, you're essentially feeling for if one is more than the other uh or if anything is particularly cold uh that's police of this country. So part patient um I think the population anxious way to go about this is just think through it logically um and forcible steps. So it's only a couple of things, you need to feel more. So obviously, you feel around the patella, you want to feel the inner aspect of the knee to the medial joint line. You want to feel the lateral joint lines and you want to feel um below the knee for the tibial to grow three, which is the burning problems of the tibia and the head of the fibula, which is the burning prominence of the fibula. And you also want to reach around and feel in the property. Important pathology here, selling the property of foster is addictive on a bacon cyst. And you can't just into that. It's quite common question. Okay. So then we've got two special tests. So we've got the uh feeling for infusions, which is the uh build up of excess I number with you. So how do you actually do this? So we've got to method. Uh we've got a tap method. So we've got the sleep method. So attack method, it's a lot simpler, especially that we were doing is your kind of massaging the fluid downwards down their side. Um And then you're going to hold the fluid there and then you're going to tap down gently on the top of the patella right here. Um And she different stuff, okay. And then so some messages is fairly similar. Uh So I think this week that is a bit more complicated. So essentially what you're doing here is you're moving the um you're moving the fluid from the medial side of the electoral side of money, you're going in the sweeping motion um up and around over the lateral side and then you're going to, once you've done that a couple of times, you're going to keep your hands on the lateral side, lift your hand up on the medial side and see whether that couch refills with fluid. Okay. Um And these are the kind of uh all important test for decisions. Um So for the top method of positive sign, I believe it's going to be uh when you hear, you know, quite affordable pack, uh put the patella down. Uh okay. So as you can see here, uh it's not particularly obvious, but you can see kind of loss of, of the definition of the, of the joint line with me on the affected side to some practice questions. So uh I wouldn't worry about exposure, but if they ask it's enough to see the knee joint, sorry uh was like totally not eat. Uh So that's kind of one of the prison you won't get off. Um Everything back to the uh the diagram are here, Jenny Jenny bug on the Vargas. I would say Jenny Walden. Jenny varies in the example. Um So knock kneed is, is obviously when your knees are knocking together, they're, they're, they're close together. So you want, you want to uh be able to distinguish puberty on which side you sleep upwards when performing the sleep test of small effusions. Uh So as we said, it's uh video towards Latrix sleep offers on the medial side and then downwards on the luxury side. So now we're gonna move aspect, which I think is a big easier. So um we talked to them about muscles. So we've got the flex and muscles, hamstring muscle uh will be extensive muscles which is the quadriceps muscles. Uh Only for this. Um Look at, look at the patient's place. Oh, they're bad. Look at the range of movement. Um Is there a reduced rent movement? Uh is the full range of movement? Uh reduced range of motion can be uh objective, remain before use. So for passive movement, uh tell them to just flex and extend their legs, just move, move their legs full extension, uh and full flexion. Um and then important. So that's pretty self explanatory. Um An important one is when you look for hyper extension. So lift that leg without bending the knee at all and look for hyperextension indeed. So look for that excess extension. Uh So this can be go up to 10 degrees, but if it's exaggerated, then it's not long because uh a diagram here, Reflection century. Um So let's take a look at these. So I think importantly, 11 of the important things to take away for the C P A uh is that they will ask you a lot of these things. So I think it's helpful if you guys take a look at the slides and they look some of the information. Uh So these questions are kind of cotton ones that you'll be on. So, uh important you don't want to hold it in the knee joint when assessing the hyper extension because that's gonna impact the results that you get to make sure you hold on the ankle, just lift the leg up from the ankle. Uh, arthritis is a very service mandatory, a decreased radio ocean because of pain, uh degeneration instructions in the knee joint, uh normal range of motion is about 0 240 degrees. Okay. So now we've got a special test. Uh So we've got two special tests. So we've got uh we've got to tests. Uh We've got one test, 70 ritual, one test, the posterior uh sag we've got one test. Well, I guess one test that we did the collaterally uh okay. So serious side. So essentially what you want to do here is going to affect any like flat on the couch. I want to look for a post serious side. So as we talked about before, the posterior cruciate ligament is what stops the uh ticket from being translated backwards. So any kind of uh posterior cruciate ligament rupture uh quartet is going to is going to illustrate a positive posterior effect, right? Because the PCL more of the tibia post theory goes from uh anterior to the post anterior of the femur to the posterior of uh of where it has, it's the tibia, so it stops the uh so it stops the TV from going backwards. So if it's been torn, you're going to get it uh sagging down. Okay. So I think that's uh what's important, distinguish, distinguishing feature. So anterior protest is a bit of a piece a bit different. So you get them to uh flex any as famous in the posterior flat test. And then you kind of hold the tibia uh with your, with your thumbs and then you reach your fingers down to the top of your pasta and you off and you, you kind of just essentially just pull their uh tibia forwards, right? Um And if they've hired an ACL ruptures until cruciate little uh tear or rupture because the ACL stops the tibia from being translated forwards, you'll get more movement. Um In this test that is not a small degree is no, but it will be really exaggerated if someone has the ACL set, it's important point here, a positive anterior tool in the presence of a posterior of a positive post suicide is clinically inconclusive wise. This, well, because the postive anterior protest um is about the ACL whereas the posterior side test um is for pizza. So I think the general rule is always test for suicide before you uh here a protest. Okay. So that's the anterior protest. Um Remember to pull gently uh and have a lot of thumbs um on the tibial to brothy essentially just pull the tibia forward, right? Because the function of the anterior cruciate enigma is to stop that one because it attaches uh to the front and the anterial front end of the ticket. Okay. So, an important test here is the lab test. So that contest is uh differently anterolateral test slightly, essentially have the patient like flat and the degree of reflection is different. Instead of having their foot uh close to 90 degrees, you have that foot that around 20 to 30 degrees, you often externally rotate slightly, uh s certainly rotate their foot slightly. Uh kind of the tibia is facing upwards and then you essentially pull on the tibia in the same way. Okay. So positive references um uh indictable Annecy. Oh yeah. So the collateral ligament test, this one is very satisfied. So the collateral ligaments run uh So your medial collateral ligament, which is the medial aspect of the lateral collateral ligament for the lateral aspect of the knee. So essentially you apply valgus and various pressure. So I think the way I was told to do this schools hold the, hold the ankle in the crook of your elbow and then using your thumbs, uh both of your hands, you apply the uh pressure immediately, which is a various pressure. So you're looking for various uh it's any extent. Uh If uh if it's, it's a, yeah, it's a various pressure and you're essentially looking for more over the need that is normal. Um And it's, it's quite all this when you're in person. Um you know what's going on. Um So, yeah, so we do it on both sides. So you, you apply pressure immediately which is going to be a various pressure uh because we're looking for them to kind of uh extent uh outlets. Uh and then you apply valgus pressure on the lateral aspect. Um So that translates this way. Yeah. And so I remember uh it's always the opposite. So if you're, if you're pushing immediately, um then you're testing the lateral collateral ligament and if you're pushing. Um so yeah, you're pushing immediately, your testing lateral collateral ligament. If you're pushing uh naturally, you're testing the medial lateral. It's obviously the lateral collateral ligaments are like either side of it. So if you push them on into, we test your a one on the other side. So yes. So the lateral and medial joint lines, if they're open, then it suggests damage to Taiwan. Okay. So I think we've got moving on to the final partner. So both writing very stressful which leg is being tested. So the various stress remember that knee's, that's kind of needs going outwards so that you're pushing on the medial aspect is pushing the medial aspect, then the uh it's not the medial casual ignorance because it's electrical. Uh it's an easy way to look uh where the politician uh, physician place went from the anti original test quality Zebroski post, he recites remember his knees bent and 90 difference. Okay. So now we've got some practice questions. I'll be very quick running to use. You can go through the urine side. Um So importantly to the, uh, the CPA is usually going to be an MRI of the knee. Uh huh or an extra. Uh, typically Mri's the violence of issue, uh, issue Lopata, they're typically favored. Um So X ray, so be able to identify the months. Um and this kind of goes uh just generally interpreting extras as well. Look at uh look at the joint lines, are they continuously not continue to look for any obvious deformities uh displacement uh space. So, so of tissue. So this is an MRI image and you can see here is the patella. Uh uh Yes, I don't think we covered the minister but the minister of fiber cartilage inside the joint uh before the media, ministers of electoral ministers which sit inside the knee joint. So which means is, so, you know, I think we, I think I mentioned this earlier about the uh fibula is always the lateral drin, right? So if you try and position yourself as if you're the one having this X ray taken, so the fibula is on the left side. So it's going to be the left. Uh It's strange to get your head round, but once you get used to it So what such great inventions been for? It seems like a silly question, but it's one that might come up until the replacement. Um It's a very characteristic all that depreciation. Well, I think the infrastructure, so the medial meniscus um so you can only identify the three Peter here that started. Uh So that's, that's the lateral ministers. Uh So the minister and they sit uh they say inside the knee joint and I like to think of them as being protected caps over uh lateral uh kind of plate of the tibia. Hello, they essentially, they actually just sit there. Uh importantly, the media ministers connects to the medial collateral leading as well. That's why damage to the medial collateral ligament can affect the minister, media ministers as well. Okay. So what test will be positive if the foreign structure is talk? So this is quite a common question. So they're asking two things, they're asking you to identify what it is. And then number two, they're asking you to say what's going to happen if, if this is Russia. So, so I think that's actually the easiest thing to do is identify yourself with big landmark. So the easiest one is to is to develop, that's the color, this is anterior, this side is the anterior. Um and if we think, okay, so this ligament is clearly running between the femur and the tibia and it goes from the posterior aspect to the anterior aspect. So it's going to be the ACM, correct. Um So all of the city ACL is to we get a positive anterior Juul set. Um So this kind of work, I think the hardest part is always uh muscles. So I think the easiest thing to do for these questions uh is kind of revise the lower um anatomy. Uh That's probably the main thing as part of your anatomy revision and you'll be all set for the uh CPA as well. So important to eat in restaurant, genius attaches to the fever, what the tibia. Uh So it's one of those uh calf muscles. That's a bit strange. So, here, it's quite interesting question because, so let's go over why, how can we orient ourselves? So obviously, this is the tibia. So the tibia here, uh and this is the estimated fever. He kind of has this characteristic. Uh I guess that's an upside down U shape. Uh And then here we can see a bone. So, you know, okay, what's next to the tibia? Okay, that's the fibula. Um And what's ligament travels laterally across the knee? Um Yeah, you know, it's a lateral collateral e and so I think again, like with all these questions, worrying yourself using big structures and landmarks, which is easy to identify. So sorry, it's good for you. So we have uh so I think the easiest way to go through this is learn the branches of the able to kind of distant uh So we have, there's only able to become very common femoral with whatever spaces to eat them more superficial panel and then property uh all the branches uh kind of uh iterative posterior to be uh with the fibula, your perineal. And then we got into toilets uh into the, the, the large. So I would say, uh I think it's, it's probably really hard to, to get these questions wrong just because um you could always say the large artery, right? So it's, it's always going to be something like the federal artery because if you forget everything kind of descends from the, from the common femoral artery, very important change. So, in the pub, so I think the biggest part, the biggest thing to take away here is it can be really tricky to tell, especially if you've got this, this transverse view. Uh You don't really know whether you're looking at the femur or the tibia, but importantly, the patellar, uh it's kind of higher, it's probably higher up than anything. So you wouldn't see the patella, which is here. It's kind of obviously like what you're looking at in terms of the patella. So just try to remember that it's apple, ever fever, not the tibia, it's slightly higher up anything. Yeah. And you can see in this diagram here as with all the other diagrams, uh you would imagine that it's, it's kind of in the middle of the joint. Uh but it's really not it's higher than you expect. Uh So uh this is just an extra, somewhat posterior side. Um You can kind of tell that there's more, uh there's one more displacement of the tibia that is to be uh to be expected, right? It kind of just looks like it's signing, there's that there's the characteristic group of the news here as well. X rays, I think they're a bit easier than we are. This was um this kind of less thing to learn, nothing to look out for. Um But again, the M S K stations is very specific. So if they give you something, chances are you're not going to have to hard of a time identifying. So, um if someone's got pain with a, with a history of trauma to the knee and the X ray shows joint space narrowing and osteophytes. Um again, like with a lot of these questions, it's a lot of pattern recognition. So if you go off and you revise to be RS and you revive all your different MSK A pathology, uh it would be fair to have uh the patient has osteoarthritis. Again, there are probably probably lots more differentials for this presentation. But in the simplest of terms, the joint space narrowing, the officer fights kind of do give it away, integral fuel talks, close the tap, tap test. So knee tender of your top, okay. That's a sign of information cause the top test that will fluid and reduce range of motion. Uh This is a very, very common question, what pathology to you first uh suspect uh accepting arthritis. There are lots of differentials for a uh kind of swollen uh painful during reduce range of motion. Uh Number one, you always need to exclude septic arthritis and that's an emergency. So if someone has an opening, medial joint line, uh postal anterior drawer test and pain on passive flexion. Uh a multivitamin typically damages, damages these structures. So the open media joint number that's damage to the medial collateral posted anterial uh ACL ruptures, pain on passive flexion could be attached many different things. Uh I remember getting a question like this in my C P A uh and it should be pretty easy. So people would play football, rugby players, people that engage in contact sports or sports in general, to be honest, um are more likely to have the issues of the injuries, blood slight. So this is something I was talking about earlier and it kind of demonstrated for the medial collateral ligament attaches to the media minister, which is different to the lateral part because the lateral collateral ligament does not attached to the actual uh damage to the medial collateral ligament can affect the medial, medial collateral ligament can affect the sinuses, sorry, uh and vice versa. Okay. So yeah, I'm sure you guys have lots of, lots of practice for the CPA. So far you have the opposite. Uh I'm sure some of the workers again teetering and stuff like that. But do practice, uh, practice with friends. The MSG exam is a lot of strange exams, uh, that you kind of just have to learn isolation and that won't be transferrable to other exams. So, uh, I think it's helpful to practice it a bit more in depth than the other exams and make sure you really know what your visit, um, as well as, as the usual, uh obviously videos that the university puts on insanity, which you can use as a reference guide. Okay, thank you very much.