Arthritis & Surgery Flashcards
- During reporting of a series of GP plain film, a chest radiograph shows superior rib notching. Which of the following is a cause of superior rather than inferior rib notching?
A. Aortic thrombosis
B. Subclavian obstruction
C. Pulmonary AVM
D. Rheumatoid arthritis
E. Superior Vena cava (SVC) obstruction
D. Rheumatoid arthritis
Other causes of superior rib notching include SLE, scleroderma, Sjögren’s syndrome, hyperparathyroidism, Marfan’s syndrome and osteogenesis imperfecta.
NF can cause superior and inferior rib notching.
- In a 50-year-old man with joint pains, involvement of which of the following indicates ochranosis rather than calcium pyrophosphate dihydrate crystal deposition disease (CPDD)?
A. Annulus fibrosis of lumbar intervertebral discs
B. Nucleus pulposis of the lumbar intervertebral discs
C. Sacroiliac joints
D. Triangular fibrocartilage in the distal radioulnar joints
E. Glenohumeral joint
B. Nucleus pulposis of the lumbar intervertebral discs
CPDD never involves nucleus pulposis, unlike ochranosis.
- Which of the following indicates grade 4 chondromalacia patellae on T1 MRI?
A. Loss of sharp dark margin between articular cartilage of the patella and trochlea
B. Focal hypointense areas extending to the articular surface but not down to the osseous surface
C. Focal hypointense areas extending from subchondral bone to cartilage surface
D. Focal hypointense areas extending to the cartilage surface with preservation of sharp cartilage margins
E. Focal hypointense areas not extending to cartilage surface
C. Focal hypointense areas extending from subchondral bone to cartilage surface
Grade 1: focal hypointense areas not extending to cartilage surface
Grade 2: focal hypointense areas extending to the cartilage surface with preservation of sharp cartilage margins
Grade 3: loss of sharp dark margin between articular cartilage of the patella and trochlea and focal hypointense areas extending to the articular surface but not down to the osseous surface.
- Which is the most characteristic feature in haemachromatosis?
A. Chondrocalcinosis
B. Small subchondral cysts with a fine rim of sclerosis
C. Symmetric joint space narrowing
D. Generalised osteopenia
E. Hook-like osteophytes on the radial aspects of the metacarpal heads
E. Hook-like osteophytes on the radial aspects of the metacarpal heads
Although all of the answers are features, hook-like osteopohytes are the most characteristic. Arthropathy is seen in 50%, and chrondrocalinosis in more than 60%, with knees being most commonly affected.
@# 29. Considering the imaging features of extraarticular Pigmented Villonodular Synovitis (PVNS):
A. Typically manifests as a soft tissue mass in 20% of cases
B. Osseous abnormalities are present in the vast majority
C. Extrinsic erosion is the most common osseous abnormality
D. Radiographs are normal in 80% of cases
E. Extensive erosions are more common in the knee
C. Extrinsic erosion is the most common osseous abnormality
Manifests as a soft tissue mass in 50-70% of cases, with normal radiographs in 20% and osseous abnormalities in 5-25%.
The most common osseous abnormality are extrinsic erosions which are more often present in the ankle and foot.
- Which of the following favours a diagnosis of rheumatoid arthritis rather than tuberculous arthritis?
A. Periarticular osteopenia
B. Marginal erosion
C. Relatively late sparing of joint space
D. Joint effusion
E. Uneven and thick synovial proliferation
E. Uneven and thick synovial proliferation
The remaining answers are also seen in TB arthritis. Even and thin synovium, large bone erosions, rim enhancement around bone erosion and extra-articular cystic masses are more frequently seen in TB arthritis.
- In a 50-year-old woman with arthralgia, which of the following favours rheumatoid arthritis over Systemic Lupus Erythematosus (SLE)?
A. Prominent subluxation of metacarpal phalyngeal joints (MCPJ)
B. Usually bilateral and symmetrical
C. Absence of erosion
D. Radiographically similar to Jaccoud’s arthropathy
E. Hyperextension of Distal Interphalyngeal (DIP) and flexion of Proximal Interphalyngeal (PIP) joints
E. Hyperextension of Distal Interphalyngeal (DIP) and flexion of Proximal Interphalyngeal (PIP) joints
A-D are features seen in SLE.
- Ivory phalanx, tuft resorption, and pencil-in-cup deformity of the middle phalynx in a patient with asymmetric arthritis are most likely to represent:
A. Psoriatic arthritis
B. Haemachromatosis
C. Rheumatoid arthritis
D. Reiter syndrome
E. Scleroderma
A. Psoriatic arthritis
Hands are more commonly affected in psoriatic arthropathy, whereas feet are more commonly affected in Reiter’s
- A patient under joint care of cardiology and nephrology has bulky soft tissue nodules, well-marginated erosion, preserved joint spaces involving the wrists, elbows, shoulder and hip joints. Which is the most likely diagnosis?
A. Multicentric reticulohistiocytosis
B. Amyloidosis
C. Ochranosis
D. Wilson’s disease
E. Haemachromatosis
B. Amyloidosis
Multiple sites can be involved and there is characteristic preservation of joint spaces.
15) On plain radiographs of the hands in a middle-aged male patient complaining of bilateral joint pain and swelling, which single feature is most likely to support a diagnosis of psoriatic arthritis over rheumatoid arthritis?
a. new bone formation
b. joint space loss
c. periarticular osteoporosis
d. periarticular erosions
e. soft-tissue swelling
a. new bone formation
New bone formation is the hallmark finding of psoriatic arthritis and is not seen in rheumatoid arthritis. Conversely, periarticular osteoporosis is seen in rheumatoid but is not a feature of psoriatic arthritis.
Both conditions may cause soft-tissue swelling (typically a sausage digit in psoriatic arthritis), joint space loss and erosions, which are marginal in psoriatic and marginal and/or central in rheumatoid arthritis.
Another distinguishing factor is the distribution of involved joints in the hands, which is typically, but not always, interphalangeal in psoriatic and metacarpophalangeal in rheumatoid arthritis.
22) A 32-year-old woman with a long history of right knee pain undergoes radiography for atraumatic swelling of the joint and is found to have an effusion and soft-tissue swelling but no other findings. MRI shows a large anterolateral lobular intra-articular mass of low signal on T1W and T2W images, and a blooming artefact is seen on gradient echo sequences. What is the most likely condition?
a. malignant fibrous histiocytoma
b. pigmented villonodular synovitis
c. synovial osteochondromatosis
d. Baker’s cyst
e. intra-articular haematoma
b. pigmented villonodular synovitis
Pigmented villonodular synovitis is a benign proliferative disorder of the synovium that has a propensity for young to middle-aged adults and typically has a long history.
On plain radiographs, joint space and bone mineralization are typically preserved until late in the disease, but softtissue swelling or effusion may be apparent early on.
Haemorrhage is relatively common and can result in haemarthrosis and blooming artefact seen on gradient echo MRI sequences.
Malignant fibrous histiocytoma is the most common soft-tissue sarcoma after age 50.
Synovial osteochondromatosis is more common in men and is characterized by proliferation of the synovium with formation of cartilaginous nodules (that often calcify), but does not show haemorrhage.
Baker’s cyst has synovial fluid characteristics on MRI and is located posterior to the joint.
(CNS) 32) A young man complains of early morning back pain and stiffness, and undergoes plain radiographs followed by MRI of the whole spine. Which single feature is most likely to suggest a diagnosis of psoriatic arthritis over ankylosing spondylitis?
a. syndesmophytes
b. parasyndesmophytes
c. asymmetrical sacroiliitis
d. ankylosis
e. patchy bone marrow oedema
b. parasyndesmophytes
Seronegative spondyloarthritis is an umbrella term for inflammatory joint or spinal conditions that are not associated with rheumatoid factor or rheumatoid nodules.
There are five described subgroups: ankylosing spondylitis, psoriatic arthritis, arthritis associated with inflammatory bowel disease, reactive arthritis (e.g. Reiter’s syndrome) and an undifferentiated subgroup.
The subgroups may overlap both clinically and radiologically, and the diagnosis is more easily made on the basis of clinical history and examination.
Imaging plays a limited role in differentiation, particularly early in the disease when there can be considerable overlap of appearances.
The main exception is the identification of parasyndesmophytes, which are seen almost exclusively in psoriatic arthropathy.
In addition, bone marrow oedema can involve the entire vertebral body in psoriatic arthritis, which may be a further useful distinguishing feature.
Undifferentiated spondyloarthritis is diagnosed when there is no clinical or radiological evidence of sacroiliitis.
All types may eventually progress to ankylosis.
40) On plain radiographs, which of the following is the most specific indicator of prosthetic loosening following total hip replacement?
a. sclerosis at the tip of the femoral component
b. 3 mm, lucent line at the cement/prosthesis interface
c. heterotopic bone formation
d. periprosthetic fracture
e. femoral periosteal reaction
b. 3 mm, lucent line at the cement/prosthesis interface
The artefact created by metallic prostheses on CT and MRI means that plain radiography has an important role in the evaluation of postoperative arthroplasty joints.
Cemented prostheses may normally show a 1–2 mm lucent line at cement interfaces, but definite loosening is diagnosed with progressive widening of this zone.
Other specific indicators of loosening in both cemented and uncemented prostheses include migration of components or a new abnormality of alignment.
Periosteal reaction and sclerosis can be normal findings, particularly in uncemented prostheses.
Serial imaging is often required to confirm the diagnosis of loosening.
46) On plain radiographs of the hands, hyperflexion of the proximal interphalangeal joint of the index finger, with hyperextension of the distal interphalangeal joint of the same finger, describes which deformity?
a. swan-neck
b. Boutonnie`re
c. mallet finger
d. baseball finger
e. Z-deformity
b. Boutonniere
The Boutonniere deformity is commonly caused by injury or inflammatory conditions such as rheumatoid arthritis, and more commonly affects the index than middle fingers.
It consists of four stages. Stages 1 and 2 are mild and moderate, passively correctable extension lag, whereas stages 3 and 4 are mild and advanced flexion contractures.
The proximal flexion deformity is due to disruption of the central slip of the extensor tendon, with the proximal phalanx herniating through the defect and the lateral slips lying on either side. The position of the proximal phalanx stretches the lateral slips and pulls the distal phalanx into extension.
Swan-neck deformity has similar causes but the opposite configuration, with extension at the proximal interphalangeal joint and flexion distally.
Mallet (or baseball) fingers have a passively correctable flexion deformity of the distal interphalangeal joint caused by avulsion of the extensor digitorum tendon by a hyperflexion injury.
Z-deformity is the name given to a Boutonniere-type deformity seen in the thumb.
58) An elderly female patient has plain radiographs performed in an outpatient clinic for bilateral painful, stiff hips, which demonstrate joint space narrowing. Which additional feature is more likely to support a diagnosis of rheumatoid arthritis rather than osteoarthritis?
a. eccentric joint space loss
b. soft-tissue swelling
c. subchondral sclerosis
d. subchondral cysts
e. protrusio acetabuli
e. protrusio acetabuli
Even or eccentric joint space reduction representing cartilage loss is seen in both types of arthritis and not a distinguishing diagnostic feature.
Although osteoarthritis is said to be classically eccentric, this is difficult to assess accurately on many hip radiographs, as they are not routinely taken in the upright, weight-bearing position.
Subchondral sclerosis and cysts are typically associated with degenerative osteoarthritis.
Although soft-tissue swelling is a feature of rheumatoid arthritis, the depth of the hip joint and the copious surrounding soft tissues mean that any synovial swelling is unlikely to be appreciated clinically or radiologically.
Subtle osteophytes (in osteoarthritis) or erosive change/osteoporosis (in rheumatoid arthritis) can distinguish between the two entities.
An inflammatory cause should be considered in young adults with hip pain and, if protrusio or other abnormalities are found, the sacroiliac joints should be examined.
65) A 40-year-old woman presents to the emergency department with a painful, stiff shoulder, 12 hours after undergoing arthrography of the same joint. She describes onset of symptoms 8 hours previously with progressive worsening. She feels otherwise well with a temperature of 37.3 There is no overt joint swelling or overlying erythema. What is cause?
a. septic arthritis
b. chemical synovitis
c. joint haemarthrosis
d. joint effusion
e. allergic contrast reaction
b. chemical synovitis
Post-arthrography pain due to sterile chemical synovitis is the most common complication of the procedure, typically beginning after 4 hours and peaking at 12 hours. Other, less common, immediate and short-term complications include allergic contrast reaction (rare in intra-articular injections), introduction of infection and vasovagal reaction.
73) A 70-year-old man has plain radiographs of the hands and knees for joint pain and swelling, which show joint space narrowing and chondrocalcinosis. Which additional finding would support a diagnosis of haemochromatosis over pseudogout?
a. periarticular calcium deposition
b. metacarpal hooked osteophytes
c. eccentric joint space narrowing
d. large subchondral cysts
e. intra-articular loose bodies
b. metacarpal hooked osteophytes
Haemochromatosis is excess iron deposition in the tissues and can be either primary (autosomal recessive genetic disorder) or secondary to ineffective erythropoiesis or iron overload.
Skeletal manifestations include osteoporosis (which is proportional to the extent of iron deposition), small subchondral cysts, arthropathy (50%), concentric joint space narrowing, chondrocalcinosis, and characteristic hooked osteophytes on the radial aspect of the metacarpal heads.
Other organs can be affected by iron deposition, most commonly the brain, liver, pancreas and spleen.
80) A 72-year-old women presents to the rheumatologist with a long history of shoulder pain affecting her dominant arm that began at night with associated stiffness, but has suddenly worsened over the past few weeks. Radiographs show a superiorly subluxed humeral head forming a pseudarthrosis with the acromion, glenohumeral joint space loss, humeral head collapse with cysts and sclerosis, and periarticular soft-tissue calcification. Ultrasound scan demonstrates an effusion with widespread degeneration of the rotator cuff and a complete tear of the supraspinatus tendon. Examination of aspirated joint fluid shows calcium hydroxyapatite crystals. What is the most likely diagnosis?
a. Milwaukee shoulder
b. pseudogout
c. myositis ossificans progressiva
d. erosive osteoarthritis
e. scleroderma
a. Milwaukee shoulder
Milwaukee shoulder is a crystal deposition disease of basic calcium phosphate, predominantly affecting elderly women and resulting in a dysfunctional shoulder from destruction of the rotator cuff. It is often bilateral but always involves the dominant side.
Radiographic findings include superior subluxation of the humerus due to loss of the superior rotator cuff, often forming a pseudarthrosis with the clavicle or acromion.
Glenohumeral degeneration manifests as sclerosis and collapse of the humeral head, joint space narrowing and osteophyte formation.
Erosion at the site of rotator cuff insertion and periarticular soft-tissue calcification is also a feature.
Examination of effusion fluid is stereotypical, revealing spheroid-shaped aggregates of hydroxyapatite crystals.
The condition is also seen in the knee, where, unlike osteoarthritis, it predominates in the lateral compartment.
90) A 30-year-old man visits his general practitioner complaining of recent onset of acne and discharging pustules on his palms. He has a history of several years of pain and swelling at the medial end of his right clavicle. Radiographs of the shoulder demonstrate hyperostosis and early ankylosis of the sternoclavicular joint. What is the most likely diagnosis?
a. SAPHO syndrome
b. suppurative osteomyelitis
c. psoriatic arthritis
d. Reiter’s disease
e. recurrent multifocal osteomyelitis
a. SAPHO syndrome
Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome is a term encompassing several disease entities that demonstrate an association between rheumatological and cutaneous lesions. There may be a delay of several years between the onset of osseous symptoms and cutaneous manifestations. It is thought to be similar to chronic recurrent multifocal osteomyelitis in children. The dominant radiographic abnormality is new and bizarre bone proliferation, with the sternoclavicular joint affected in 70–90% of cases.
95) A 70-year-old man attends a 6-week follow-up appointment after cemented total hip arthroplasty, complaining of a poor range of motion. Radiographs taken during the appointment show small areas of pericapsular bone, and formation of small bony spurs at the acetabular margin. CT demonstrates these areas to have well-defined mineralization peripherally and indistinct centres. Which of the following processes are responsible?
a. femoral component loosening
b. heterotopic ossification
c. periprosthetic fracture
d. postoperative infection
e. stress shielding
b. heterotopic ossification
Heterotopic ossification, also known as myositis ossificans, is a benign, self-limiting process of ossification occurring within skeletal muscle.
Seventy-five per cent of cases are due to trauma (including iatrogenic trauma), with other causes including paralysis, burns, tetanus and intramuscular haematoma.
The areas of new bone are surrounded by fibrotic connective tissue, which can be seen as a soft-tissue mass on MRI.
Some heterotopic ossification is seen in half of all total hip replacements, with one-third considered clinically significant. It is classified radiographically according to the Brooker classification.
(CVS) 94) A 56-year-old female has arthralgia. A chest radiograph shows erosion of the lateral ends of the clavicles, superior notching of the third to fifth ribs, and narrowing of the humeral–acromial space. What is the most likely diagnosis?
a. hyperparathyroidism
b. rheumatoid arthritis
c. osteoarthritis
d. cleidocranial dysostosis
e. neurofibromatosis
b. rheumatoid arthritis
Erosion of the lateral ends of the clavicle is seen in several conditions, including rheumatoid arthritis, hyperparathyroidism and cleidocranial dysostosis. The associated rib notching and loss of the space between the humeral head and acromion (due to wasting/rupture of supraspinatus) are typically seen with rheumatoid arthritis. Clavicle erosions are not features of neurofibromatosis or osteoarthritis.
(GU) 98) A plain abdominal radiograph is acquired for left-sided abdominal pain. The lumbar spine is osteoporotic with intervertebral disc space narrowing, vacuum phenomenon and calcification. Marginal osteophytes and endplate sclerosis are also present. In addition to nephrocalcinosis, a radio-opaque calculus is noted along the path of the left ureter. Which of the following is the most likely pattern of inheritance?
a. autosomal recessive
b. autosomal dominant
c. autosomal dominant with partial penetrance
d. mitochondrial
e. X-linked
a. autosomal recessive
Alkaptonuria is the unifying diagnosis and is usually autosomal recessive. In this condition the absence of homogentisic acid oxidase causes accumulation of homogentisic acid, which is excreted in urine and sweat. Ochronotic deposition in the cardiovascular system causes atherosclerosis, aortic and mitral valve calcification, and myocardial infarction.
15 A lady suffers from long-standing rheumatoid arthritis. She is noted to have splenomegaly on a clinic visit. A diagnosis of Felty’s syndrome is suspected clinically. Which of the following is not a recognised feature of Felty’s syndrome?
(a) Ulceration
(b) Neutropaenia
(c) Skin pigmentation’
·
(d) Weight loss
(e) Low titres of rheumatoid factor
(e) Low titres of rheumatoid factor
Felty’s syndrome is characterised by the combination of longstanding rheumatoid arthritis, splenomegaly and neutropaenia. Associated features include weight loss, leg ulceration, and brown skin pigmentation. Almost all have high titres of rheumatoid factor.
16 A patient presents with back pain. He is found to be HLA- 827 positive and a diagnosis of ankylosing spondylitis is suspected. Plain films of the spine are requested. Which of the following would be the least supportive of this diagnosis?
(a) Calcification of the anterior longitudinal ligament
(b) Osteitis
(c) Syndesmophytes
(d) Sclerosis of the costotransverse joints
e) Ankylosis of the costovertebral joints
(a) Calcification of the anterior longitudinal ligament
Ossification of the posterior, rather than anterior longitudinal ligament is typical of ankylosing spondylitis.
(Ped) 31 Which of the following features is not a feature of Juvenile Chronic Arthritis?
(a) Growth retardation
(b) Iridocyclitis
(c) Rheumatoid factor positive
(d) Spinal involvement typically precedes peripheral arthritis
(e) Oligoarthritis
(c) Rheumatoid factor positive
JCA by definition sjarts < 16 years old, it can be oligo- or poly- arthritis and the majority of cases are seronegative. The large joints are typically affected first, diffuse ankylosis is common and periosteal reaction is typically present. Although there is often overgrowth of the epiphyses due to increased perfusion, there is usually growth retardation due to early closure of the growth plates.
41 A patient with joint pain has plain radiographs of the hands and spine. The differential diagnosis is considered to be between psoriatic arthropathy and rheumatoid arthritis. Which of the following features is more common in rheumatoid arthritis rather than psoriatic arthropathy?
(a) Phalangeal enthesophytes
(b) Involvement of the distal interphalangeal joints
(c) Fusiform soft tissue swelling of the digits
(d) Asymmetric joint involvement
(e) Involvement of the wrist joints
(e) Involvement of the wrist joints
The wrists are more commonly involved in rheumatoid arthritis
49 The pelvic radiograph of a young woman reveals bilateral, symmetrical triangular areas of subchrondral sclerosis on the inferior aspect of the iliac side of the joint. The joint spaces are normal and the joint margin is well-defined. There is no evidence of bone or joint disease elsewhere. What is the most likely diagnosis?
(a) Osteitis condensans ilii
(b) Infection
(c) Osteoarthritis
(d) Hyperparathyroidism
(e) Alkaptonuria
(a) Osteitis condensans ilii
Osteitis condensans ilii produces this radiographic appearance, typically in young frlultiparous women. Possible differential diagnoses include: ankylosing spondylitis, rheumatoid arthritis (both would be associated· with joint space changes) and Paget’s disease.
3 A patient presents with joint pain and plain radiographs are taken. Which of the following features would favour the diagnosis of osteoarthritis over rheumatoid arthritis?
(a) Marginal erosions
(b) ‘High-riding’ shoulder
(c) Periarticular osteoporosis
(d) Superolateral migration of the femoral head
(e) Involvement of the proximal joints of the hand
(d) Superolateral migration of the femoral head
In RA , the femoral head tends to migrate axially, whilst in osteoarthritis, it tends to migrate superolaterally.
10 A gentleman presents with knee swelling, pain and stiffness. Plain radiographs and subsequent MR imaging were performed, and a diagnosis of pigmented villonodular synovitis is suspected. Which of the following is not typical of this disease?
(a) Preservation of bone density
(b) Synovial low signal intensity on gradient echo MR imaging
(c) Well-defined erosions on both sides of the joint
(d) Joint space narrowing early in the disease
(e) Joint effusion
(d) Joint space narrowing early in the disease
PVNS is a proliferation of synovium that occurs in joints, bursae and tendon sheaths. The joint space is well preserved until late in the disease.
30 A pelvic radiograph reveals sacroilitis. This is most prominent on the lower and middle thirds of the joints, particularly on the iliac side. The changes are bilateral and symmetrical. These appearances are most commonly seen in which of the following conditions?
(a) Reiter’s syndrome
(b) Rheumatoid arthritis
(c) Gouty arthritis
(d) Osteoarthritis
(e) Ankylosing spondylitis
(e) Ankylosing spondylitis
Ankylosing spondylitis typically produces a bilateral, symmetrical sacroiliitis, whilst the other conditions typically result in bilateral but asymmetrical disease. Other conditions producing bilateral, ·symmetrical sacroiliitis include: inflammatory bowel disease, psoriatic arthropathy, osteitis condensans ilii, hyperparathyroidism and paraplegia.
@# 41 A 35 year old woman presents with gradually progressive knee pain over several years with locking of the joint. Plain radiographs show multiple round, well defined calcified loose bodies in the joint with no osteoporosis, and widening of the joint space. Which of the following is the likeliest diagnosis?
(a) Synovial osteochondromatosis
(b) Pigmented villonodular synovitis
(c) Lipoma arborescens
(d) Synovial sarcoma
(e) Osteochondritis dissecans
(a) Synovial osteochondromatosis
Cross sectional imaging shows a soft tissue mass of near water attenuation on CT containing calcifications, and a lobulated intraarticular mass which is isointense to muscle on T1 W and hyperintense on T2W with foci of low signal intensity.
45 A 25 year old man presents with chronic back pain. X-rays show bilateral irregularity of the sacro-iliac joints and paravertebral ossification on the AP view. Radiographs of the feet demonstrate destruction of the interphalangeal joint of the great toe with an exuberant periosteal reaction and bony proliferation at the distal phalangeal base. Which of the following is the likeliest diagnosis?
(a) Ankylosing spondylitis
(b) Rheumatoid arthritis
(c) Psoriatic arthritis
(d) Reiter’s syndrome
(e) Inflammatory bowel disease
(c) Psoriatic arthritis
The changes in the feet are characteristic of psoriatic arthropathy with soft tissue swelling and erosive changes leading to a ‘pencil-in-cup’ deformity. When seen, the changes at the interphalangeal joint of the great toe are pathognomonic. The SI joints are involved in 40% of cases and involvement can be either uni- or bi-lateral. As with Reiter’s syndrome, a large bulky paravertebral area of ossification (‘floating osteophyte’) is often seen.
56 A 50 year old man presents with gradual onset pain in multiple joints. Radiographs and MRI examinations show bilateral olecranon bursal effusions along with well defined, homogeneous, enhancing soft tissue masses which are isointense to muscle on T1 W and hypo intense on T2W which involve the wrist, ankle and knee joints. What is diagnosis?
(a) Rheumatoid arthritis
(b) Gout
(c) Pseudogout
(d) Psoriasis
(e) Amyloidosis
(b) Gout
Gout is polyarticular in 10% of cases. The soft tissue components have characteristic appearances and may calcify. Bilateral olecranan bursal effusions are considered pathognomonic
57 A 34 year old woman is found to have bilateral hilar lymphadenopathy on CXR along with elevated serum ACE levels. Which of the following radiological features would not be in keeping with the likely diagnosis?
(a) Acro-osteolysis of the distal phalanges
(b) Erosions involving the joints of the hand
(c) A lacelike trabecular pattern in the metaphysis of the metacarpals
(d) More advanced changes in the middle and distal phalanges than the proximal phalanges and the metacarpal bones
(e) Sclerosis of multiple vertebral bodies
(b) Erosions involving the joints of the hand
The joints are rarely involved in bone sarcoidosis. Other musculoskeletal features include the presence of paravertebral soft tissue masses, osteolytic lesions of the skull and well defined cystic bone lesions.
59 A 27 year old man presents with ongoing pain in the region of the sternum. There is no history of trauma. On examination there is tenderness, pain and swelling over the sternoclavicular joints; he is systemically well but is noted to have yellowish intradermal blisters on his hands. There is sclerosis and ankylosis of the right SCJ, with hyperostosis and hypertrophy of the left SCJ noted. What is the likely diagnosis?
(a) Ankylosing spondylitis
(b) Caffey’s disease
(c) Osteomyelitis
(d) Paget’s disease
(e) SAPHO syndrome
(e) SAPHO syndrome
SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) is a rare inflammatory bone disorder that is associated with skin manifestations. The associated hyperostosis is frequently located at the points of the bone where tendons attach, and the SCJs are the commonest site affected (70-90% ). The patient is the wrong age for options (b) and ( d); osteomyelitis is the main differential, but the patient is systemically well and the other features support a diagnosis of SAPHO.
62 A 45 year old woman has hand radiographs for multiple joint pains. The radiographs show fusion of the distal interphalangeal joints. Which is the least likely diagnosis?
(a) Erosive osteoarthritis
(b) Reiter’s syndrome
(c) Rheumatoid arthritis
(d) Psoriatic arthropathy
(e) Ankylosing spondylitis
(c) Rheumatoid arthritis
In rheumatoid arthritis, the changes classically affect the MCP and PIP joints but spare the DIP joints.
67 A 60 year old man who had a THR a year previously presents with discomfort and a clicking sensation in that hip. Which of the following features are considered normal?
(a) 3 mm radiolucent zone at the cement bone interface
(b) Endosteal sclerosis at the tip of the femoral component
(c) 5 mm subsidence of the femoral component
(d) Progressive metal bead shedding
(e) Cement fracture
(c) 5 mm subsidence of the femoral component
Serial radiographs are required for full assessment of the joint replacement. As a minimum the British Orthopaedic Association suggest post-operative radiographs, then check radiographs at 1 year, 5 years and every subsequent 5 years. Other signs include progressive radiolucency at the cement bone interface, the presence of well-defined lucencies at the interface which may suggest granulomatous disease and acetabular migration. A degree of subsidence of the femoral component is considered normal and either progressive change or an absolute value of greater than 10 mm is abnormal.
(Ped) 70 A 6 year old boy presents with a 2 day history of limp and right hip/ anterior thigh pain. He has a low-grade fever and the ESR is 30 mm/hr. An US is requested to help differentiate transient synovitis (TS) from septic arthritis. Which of the following is true?
(a) Capsular distension of 2 mm diagnoses an effusion
(b) Definitive US features can exclude septic arthritis
(c) Synovial membrane thickening favours a diagnosis of TS
(d) US is more sensitive than hip X-Ray for detecting Perthe’s disease
(e) US is performed with the hip in internal rotation
(a) Capsular distension of 2 mm diagnoses an effusion
TS presents at 5-10 years and is the commonest cause of a nontraumatic limp in this age group. US is performed with the child supine and the hip in the neutral position, or in slight external rotation. US typically shows an effusion (capsular distension > 2 mm), without synovial thickening. It is a diagnosis of exclusion, radiographs may help differentiate Perthe’s disease; fluid aspiration helps exclude septicarthritis.
- A 35 year old man presents with increasing stiffness in his knee and soft-tissue swelling around the joint. Plain films show multiple areas of irregular cyst-like radiolucencies in the distal femur. There are no areas of abnormal calcification and there is no evidence of periarticular osteoporosis. MR shows a low signal joint effusion on both T1 and T2 sequences. The most likely diagnosis is:
a. Synovial osteochondromatosis
b. Pigmented villonodular synovitis
c. Osteoarthritis
d. Reiter’s syndrome
e. Osteomyelitis
- b. Pigmented villonodular synovitis
Pigmented villonodular synovitis is a relatively rare condition which usually presents in the third or fourth decade. It is a monoarticular, painful disease which causes a decreased range of movement at the affected joint. It is most common at the knee (80%) followed by the hip, ankle, shoulder and elbow. Haemorrhagic ‘chocolate’ effusion is characteristic. Low signal effusion on all sequences at MR is characteristic. There is no calcification or osteoporosis, and joint space narrowing is a late feature.
- In a 21 year old man with symptoms of chronic back pain, pain in his feet, particularly the great toe and metatarsophalangeal joints, and bilateral sacroiliitis on plain films, the most likely diagnosis is:
a. Ankylosing spondylitis
b. Gout
c. Inflammatory bowel disease-related arthropathy
d. Reiter’s syndrome
e. Psoriatic arthritis
- d. Reiter’s syndrome
Reiter’s syndrome is the association of urethritis, conjunctivitis and mucocutaneous lesions. Sacroiliitis is usually bilateral but often persists asymmetrically. There is an association with the HLA B27 antigen. Reiter’s has a predeliction for the great toe and metatarsophalangeal joints.
(CVS) 11. A 51 year old man with long standing history of an erosive arthropathy of the acromioclavicular joints and bilateral arthropathy in his hands subsequently develops progressive shortness of breath. The most likely abnormality on his chest radiograph would be:
a. Cavitating nodules
b. Peripheral basal reticulonodular shadowing
c. Cardiomegaly
d. Bronchiectasis
e. Pleural effusion
- e. Pleural effusion
Pleural effusion is the commonest thoracic manifestation of rheumatoid arthritis, much more common in men (M:F 9:1). It is unilateral in the vast majority of cases. The fluid is an exudate with low sugar content and is often seen in the absence of other pulmonary changes.
- A routine pre-operative chest X-ray in a 62 year old woman shows bilateral erosion of the distal clavicles. Which one of the following conditions might be responsible?
a. Hypoparathyroidism
b. Rheumatoid arthritis
c. Langerhans’ cell histiocytosis
d. Ankylosing spondylitis
e. Sarcoidosis
- b. Rheumatoid arthritis
Myeloma, hyperparathyroidism, metastases, cleidocranial dysplasia and Gorlin basal cell nevus syndrome all cause absence of the outer end of the clavicle. Destruction of the medial end of the clavicle is caused by metastases, infection, lymphoma, eosinophilic granuloma, rheumatoid arthritis and sarcoma.