Musculoskeletal Flashcards
Which nerve lies adjacent to the cephalic vein in the cubital fossa?
- A) Axillary nerve
- B) Lateral cutaneous nerve
- C) Medial cutaneous nerve
- D) Radial nerve
- E) Ulnar nerve
Answer: B) Lateral cutaneous nerve
- The contents of the cubital fossa include vessels, nerves and the biceps tendon (lateral to medial):
- Radial nerve – This is not always strictly considered part of the cubital fossa, but is in the vicinity, passing underneath the brachioradialis muscle. As is does so, the radial nerve divides into its deep and superficial branches.
- Biceps tendon – It runs through the cubital fossa, attaching to the radial tuberosity, just distal to the neck of the radius.
- Brachial artery – The brachial artery supplies oxygenated blood the forearm. It bifurcates into the radial and ulnar arteries at the apex of the cubital fossa.
- Median nerve – Leaves the cubital between the two heads of the pronator teres. It supplies the majority of the flexor muscles in the forearm.
A 19-year-old man presented to the emergency department with bone pain. He says aspirin has relieved the pain.
Upon imaging, a lesion is visualised. There is a cortical tumour measuring ~1cm.
What pathology is shown in this xray?
Answer: Osteoid osteoma
A diagnosis of osteoid osteoma is made when pain is relieved by aspirin and imaging reveals a bony mass <2cm with a radiolucent core (this is osteoid).
George, an 18-year-old man, wakes up one morning after a night of heavy drinking. He has fallen asleep sitting upright in a chair with his arm around his girlfriend. His arm has been trapped all night between the chair and his girlfriend’s body. In the morning he finds himself unable to extend his elbow, or his wrist, and notices a patch of numbness on the back of his hand between the first and second digit. Which nerve has likely been affected?
- A ) Axillary
- B ) Lateral cutaneous
- C ) Median
- D ) Radial
- E ) Ulnar
= D) Radial
Which structure is NOT present in the carpel tunnel?
- A ) Abductor pollicis longus
- B ) Flexor pollicis longus
- C ) The flexor digitorum profundus tendons
- D ) The flexor digitorum superficialis tendons
- E ) The median nerve
Answer: Abductor pollicis longus
Which nerve supplies the medial compartment of the thigh?
- A ) Deep peroneal
- B ) Femoral
- C ) Obturator
- D ) Sciatic
- E ) Superficial peroneal
= C) Obturator
An 18-year-old woman has noted pain and swelling of her right distal thigh associated with activity for the past year. She has no history of any trauma.
On examination after performing physical exercise, there is tenderness on palpation immendiately above the right knee.
Radiographs demonstrate an expansile, eccentric, lytic lesion located in the metaphysis of the distal femur that is surrounded by a rim of reactive new bone. The radiologist tells you that it has a “soap-bubble” appearance.
Which of the following bone diseases is she most likely to have?
- A ) Aneurysmal bone cyst
- B ) Chondrosarcoma
- C ) Ewing’s sarcoma
- D ) Fibrous dysplasia
- E ) Osteoid osteoma
= A) Aneurysmal bone cyst
- The major differential diagnosis for aneurysmal bone cyst (ABC) is a giant cell tumor of bone. Although benign, an ABC can weaken the bone and predispose to fracture.
- Fibrous dysplasia is a localised, abnormal proliferation of fibrous tissue in bone arranged with haphazard trabeculae of woven bone. A polyostotic form of this disease associated with endocrinopathies is called McCune-Albright syndrome.
- Ewing’s sarcoma lesions are usually diaphyseal in location and can extend into soft tissues.
- Chondrosarcomas are more typically located at metaphyseal region in older adults, though there is a wide age range. They are usually not lytic lesions.
- Osteoid osteomas produce considerable pain for their small size. They are located in the bony cortex, with a central nidus surrounded by sclerotic bone.
What type of collagen does osteogenesis imperfecta impact?
- A ) Type I
- B ) Type II
- C ) Type III
- D ) Type IV
- E ) Type V
= A) Type I
A 67-year-old female presents to her primary care physician complaining of headaches in her left temple and scalp area, neck stiffness, occasional blurred vision, and pain in her jaw when chewing. The appropriate medical therapy is:
- A ) ANA and anti dsDNA
- B ) CT head for MS
- C ) Evaluate ESR and begin high dose prednisone
- D ) FBC to check for infection
- E ) X-ray to evaluate facial fracture
= C) Evaluate ESR and begin high dose prednisone
This patient has giant cell arteritis. Start with high dose steroid therapy to prevent ocular involvement.
Characteristic radiographic findings in osteoarthritis include all of the following EXCEPT:
- A ) Osteophytes
- B ) Subchondral bone sclerosis
- C ) Subchondral cysts
- D ) Subluxation
- E ) Symmetrical joint space narrowing
= E) Symmetrical joint space narrowing
The dorsalis pedis artery is a continuation of the ______________.
- A ) anterior tibial artery
- B ) deep genicular artery
- C ) lateral femoral artery
- D ) peroneal artery
- E ) posterior tibial artery
= A) anterior tibial artery
X-ray findings: A mushroom-shaped, pedunculated bony excrescence arising from the anteromedial aspect of the distal femoral metaphysis, attached to the parent bone and pointing away from the metaphysis.
This patient is 17 years of age. What is the likely diagnosis?
- A ) Aneurysmal bone cyst
- B ) Ewing’s sarcoma
- C ) Osteoblastoma
- D ) Osteochondroma
- E ) Osteoid osteoma
- F ) Osteoma
- G ) Osteosarcoma
= D) Osteochondroma
An osteochondroma is the most common benign bone tumour, and the most common skeletal neoplasm. It is typified by the imaging findings shown.
Which muscle is responsible for eversion of the foot?
- A ) Extensor hallucis longus
- B ) Fibularis longus
- C ) Soleus
- D ) Tibialis anterior
- E ) Tibialis posterior
= B) Fibularis longus
Fibularis (peroneus) longus, brevis, and tertius comprise the everters of the foot.
What cutaneous nerve innervates the area shown by pin C?
- A ) Anterior femoral cutaneous
- B ) Common fibular nerve
- C ) Common fibular nerve (deep branch)
- D ) Common fibular nerve (superficial branch)
- E ) Lateral cutaneous nerve of thigh
- F ) Obturator nerve
- G ) Posterior cutaneous nerve of thigh
- H ) Saphenous nerve
- I ) Sural nerve
- J ) Tibial nerve
= G) Posterior cutaneous nerve of thigh
A 51-year-old man has noted constant, dull right hip pain for the past 3 months. On physical examination, he has generalised decreased range of movement of the right hip.
A radiograph reveals a 10 x 13cm mass involving the right ischium of the pelvis. The mass has irregular borders and there are extensive areas of bony destruction alongside scattered calcifications.
The lesion is resected, and grossly the mass has a bluish-white cut surface.
Which of the following is the most likely diagnosis?
- A ) Chondrosarcoma
- B ) Enchondroma
- C ) Osteoblastoma
- D ) Osteosarcoma
- E ) Paget’s sarcoma
= A) Chondrosarcoma
- A chondrosarcoma is a malignant bony tumor, more likely occuring in men aged 20-60 years of age.
- An osteoblastoma is a large osteoid osteoma, and is a benign process.
- Osteosarcoma is the most frequent primary malignancy of bone, not chondrosarcoma, and typically arises in the first two decades of life.
- Distal cartilagenous tumors are more likely to be benign, whereas those in a central location are virtually always malignant.
X-ray findings: All bones are markedly dense with bilateral dysplasia of the femoral heads and necks. The marrow cavity is not evident (as it has been replaced by bone).
What is the likely pathology shown in this X-ray?
- A ) Ewing sarcoma
- B ) Giant-cell tumor of bone
- C ) Osteoblastoma
- D ) Osteochondroma
- E ) Osteoid osteoma
- F ) Osteoma
- G ) Osteopetrosis
- H ) Osteoprosis
- I ) Osteosarcoma
= G) Osteopetrosis
Osteopetrosis is a rare hereditary disorder that results in defective osteoclast function and a failure of proper reabsorption, resulting in sclerotic bone.
Clinical features include:
- Bone fractures
- Anaemia, thrombocytopaenia, and leukopaenia with extramedullary hematopoiesis due to the bony replacement of the marrow
- Vision and hearing impairment, secondary to bony impingement on cranial nerves
- Hydrocephalus from narrowing of the foramen magnum
- Renal tubular acidosis, as seen with carbonic anhydrase II mutation
This gait can be seen in disorders of the dorsal columns
- A ) Ataxic gait
- B ) Myopathic gait
- C ) Neuropathic gait
- D ) Parkinsonian gait
- E ) Sensory gait
= E) Sensory gait
As our feet touch the ground, we receive proprioceptive information to tell us their location. The sensory ataxic gait occurs when there is loss of this proprioceptive input. In an effort to know when the feet land and their location, the patient will slam the foot hard onto the ground in order to sense it. A key to this gait involves its exacerbation when patients cannot see their feet (i.e. in the dark). This gait is also sometimes referred to as a stomping gait since patients may lift their legs very high to hit the ground hard. This gait can be seen in disorders of the dorsal columns (B12 deficiency or tabes dorsalis) or in diseases affecting the peripheral nerves (uncontrolled diabetes). In its severe form, this gait can cause an ataxia that resembles the cerebellar ataxic gait.
What is the likely diagnosis for this x-ray?
- A ) Metastasis from melanoma
- B ) Multiple myeloma
- C ) Normal x-ray
- D ) Osteoma
- E ) Paget’s disease
E ) Paget’s disease
Which ligament connects the femur and fibula?
- A ) Anterior cruciate ligament
- B ) Lateral collateral ligament
- C ) Medial collateral ligament
- D ) Patellar tendon
- E ) Posterior cruciate ligament
= B) Lateral collateral ligament
What is the likely diagnosis of this x-ray?
X-ray findings: Two frontal views of the skull demonstrate an incidental rounded, sclerotic lesion growing into the right frontal sinus
- A ) Aneurysmal bone cyst
- B ) Chondrosarcoma
- C ) Ewing sarcoma
- D ) Osteoblastoma
- E ) Osteochondroma
- F ) Osteoid osteoma
- G ) Osteoma
- H ) Osteosarcoma
= G ) Osteoma
- Benign tumour of bone
- Most commonly arises on the surface of facial bones
- Associated with Gardner syndrome
- Paranasal sinus tumours associated with pain, headache, facial distortion, proptosis, visual changes, mucocele, sinusitis, CSF leakage, pneumatocele, meningitis, and cerebral abscess
Where does the long head of the biceps brachii originate?
- A ) Coracoid process
- B ) Coronoid fossa
- C ) Greater tubercle of the humerus
- D ) Supraglenoid tubercle of the scapula
- E ) Surgical neck of the humerus
= D) Supraglenoid tubercle of the scapula
A 20-year-old man presented to the emergency department with severe chronic pain (not nocturnal) that is unresponsive to NSAIDs. On imaging, a 2.5cm lesion is noted as seen below.
What is the likely diagnosis?
- A ) Aneurysmal bone cyst
- B ) Chondrosarcoma
- C ) Ewing’s sarcoma
- D ) Osteoblastoma
- E ) Osteochondroma
- F ) Osteoid osteoma
- G ) Osteoma
- H ) Osteosarcoma
= D ) Osteoblastoma
Which nerve injury would result in loss of plantar flexion and inversion of the affected foot?
- A ) Femoral nerve
- B ) Inferior gluteal nerve
- C ) Saphenous nerve
- D ) Sural nerve
- E ) Tibial nerve
= E ) Tibial nerve
Joanne, a 24-year-old Notre Dame medical student, has had lectures continuously for the past 10 hours. She is an enthusiastic note-taker, but has to lean on her right forearm and hand on the edge of the lecture desk to keep her hand steady. At the end of her last lecture she notices that she has pins and needles in the front and back of her hand, around her 4th and 5th digits. When she gets home, she finds herself unable to play the piano due to ‘clumsiness’ in her hand and is unable to reach a full octave, something she can normally achieve with ease. She attributes her symptoms to ‘writer’s cramp’. Which nerve is likely affected?
- A ) Axillary
- B ) Lateral cutaneous
- C ) Median
- D ) Radial
- E ) Ulnar
= E ) Ulnar
At what level does the inferior vena cava cross the diaphragm?
- A ) L1
- B ) T10
- C ) T12
- D ) T6
- E ) T8
= E ) T8
A 58-year-old female presents with diffuse pain and stiffness in the neck, pelvic girdle, and shoulder girdle. Her review of systems is positive for low-grade fever, tiredness and decreased appetite. On physical exam, there is decreased active and passive movements of her shoulders and hips secondary to pain without any obvious deformities or joint swelling. Her laboratory tests are notable anaemia and an ESR of 52 mm/hr.
What is the main diagnosis and what other disease is it often associated with?
- A ) Fibromyalgia associated with depression
- B ) Polymyalgia rheumatica associated with giant cell arteritis
- C ) Polymyalgia rheumatica associated with RA
- D ) RA associated with giant cell arteritis
- E ) RA associated with SLE
= B) Polymyalgia rheumatica associated with giant cell arteritis
A 75-year-old man has complained of lower back pain for 8 years. As part of a workup for a persistently elevated lymphocytosis, he has a right posterior iliac crest marrow biopsy performed. On microscopic examination hematopoiesis is normal, but the bone spicules are thickened with irregular cement lines forming a mosaic appearance with both increased osteoblastic and osteoclastic activity. Which of the following conditions is most likely to occur in conjunction with his underlying bone disease process?
- A ) Chronic renal failure
- B ) Congestive heart failure
- C ) Deep vein thrombosis
- D ) Hepatic cirrhosis
- E ) Multiple myeloma
B) Congestive heart failure
He has Paget’s disease of bone, and he has the classic phase of mixed osteolysis and osteogenesis. The increased blood flow into the involved areas of bone can lead to high output congestive heart failure in older persons with minimal cardiac reserve. Paget’s disease of bone is most often seen in older Caucasians.
Which muscle is a part of the anterior compartment of the lower leg?
- A ) Extensor digitorum longus
- B ) Flexor hallucis longus
- C ) Gastrocnemius
- D ) Peroneus longus
- E ) Soleus
= A ) Extensor digitorum longus
Which nerve would be most commonly injured as a result of a mid-shaft humerus fracture?
- A ) Axillary nerve
- B ) Median nerve
- C ) Musculocutaneous nerve
- D ) Radial nerve
- E ) Ulnar nerve
= D) Radial nerve
Tenderness on palpation of the anatomical snuffbox can suggest fracture of which bone?
- A ) Hamate
- B ) Lunate
- C ) Pisiform
- D ) Scaphoid
- E ) Trapezium
= D ) Scaphoid
Scaphoid fractures are important to diagnose, as the blood supply to the scaphoid is poor and places it at increased risk for avascular necrosis and nonunion.
What pathology is shown in this xray?
This patient is a 15-year-old male.
- A ) Aneurysmal bone cyst
- B ) Ewing sarcoma
- C ) Osteoblastoma
- D ) Osteochondroma
- E ) Osteoid osteoma
- F ) Osteoma
- G ) Osteosarcoma
= G ) Osteosarcoma
Imaging reveals a destructive mass with a ‘sunburst’ appearance and lifting of the periosteum, typical in osteosarcoma.
A 16-year-old boy has noted pain in his left knee after each hockey practice session for the past month. On examination, there is tenderness to palpation of his left knee, with reduced range of motion into both flexion and extension. A plain film radiograph of the left leg reveals a mass of the proximal tibial metaphysis that erodes the bone cortex, lifting up the periosteum where reactive new bone is apparent. The mass does not extend into the epiphyseal region. A bone biopsy is performed and microscopic examination shows atypical, elongated cells with hyperchromatic nuclei in an osteoid stroma. Which of the following neoplasms is he most likely to have?
- A ) Chondrosarcoma
- B ) Ewing sarcoma
- C ) Metastatic seminoma
- D ) Multiple myeloma
- E ) Osteosarcoma
= E) Osteosarcoma
- Metastases are unlikely to occur at this age. Overall, metastases are the most common malignancy involving bone. Primary bone tumours are not common.
- Ewing sarcoma has a peak incidence at a younger age. It most often involves the diaphyseal region. It does not produce osteoid.
- Chondrosarcomas do not make osteoid. They can occur over a wide age range.
- Myelomas are seen in older adults and produce lytic bone lesions filled with plasma cells.
This structure identified acts as the final insertion for the:
- A ) Achilles tendon
- B ) fibular collateral ligament
- C ) iliotibial tract
- D ) inferior extensor retinaculum
- E ) patellar ligament
= E ) patellar ligament
The prominence shown is the tibial tuberosity.
This patient is a 25-year-old man who is complaining of local pain and swelling around his knee. His x-ray shows a series of multicystic osteolytic lesions.
What pathology is shown in this X-ray?
- A ) Ewing’s sarcoma
- B ) Giant-cell tumor of bone
- C ) Osteoblastoma
- D ) Osteochondroma
- E ) Osteoid osteoma
- F ) Osteoma
- G ) Osteosarcoma
= B ) Giant-cell tumor of bone
This x-ray demonstrates a well-defined, osteolytic lesion at the proximal epi-metaphyseal region of the tibia. The lesion has a loculated “soap-bubble” appearance that is characteristic of an osteoclastoma.
The medial compartment of the thigh is supplied by the _____________ and innervated by the _____________
- A ) branches of the profunda femoris artery, sciatic nerve
- B ) femoral artery, obturator nerve
- C ) femoral artery, sciatic nerve
- D ) obturator artery, femoral nerve
- E ) profunda femoris artery and obturator artery, obturator nerve
= E) The medial compartment of the thigh is supplied by the profunda femoris artery and obturator artery and innervated by the obturator nerve.
- An 80-year-old woman falls out of bed, causing acute, sharp pain in her left hip. She is subsequently unable to ambulate without severe pain.
- PMH: Hypertension, dyslipidemia, obesity. No history of joint or bone pain. No night sweats/weight change/fatigue.
- SHx: she lives with her husband at their small retirment village home. She is a keen knitter, and she loathes outdoor activities except to tend to her respectable rose garden. She has never engaged in deliberate physical activity or exercise.
- Ix: Radiographs show not only a fracture of the left femoral head, but also a compression fracture of T10.
Which of the following conditions is the most likely diagnosis?
- A ) Metastatic breast carcinoma
- B ) Acute osteomyelitis
- C ) Osteogenesis imperfecta
- D ) Osteoporosis
- E ) Vitamin A deficiency
= D ) Osteoporosis
Upon a musculoskeletal exam of the shoulder, a patient cannot actively abduct from a normal position without marked scapular winging. The motion improves after the initial 15˚ of abduction, with normal scapulohumeral rhythm from 15˚-180˚ abduction. There is no painful arc.
What muscle controls the initial 15˚ of glenohumeral joint abduction?
- A ) Deltoid
- B ) Infraspinatus
- C ) Subscapularis
- D ) Supraspinatus
- E ) Trapezius
= D) Supraspinatus
Which of the following statements is true regarding Paget’s disease?
- A ) It can be complicated by osteosarcoma
- B ) It is characterised by a uniform pathology pattern
- C ) It occurs commonly after chemotherapy for lymphoma
- D ) It occurs more frequently in women than in men
- E ) It presents with abnormal calcium and phosphorus levels
= A) It can be complicated by osteosarcoma
What kind of fracture is shown?
- A ) Compound
- B ) Greenstick fracture
- C ) Impacted
- D ) Oblique
- E ) Spiral
= B) Greenstick fracture
A greenstick fracture is a partial fracture in which only one side of the bone is broken.
- A ) Ankylosing spondylitis
- B ) Osteoarthritis
- C ) Psoriatic arthritis
- D ) Reiter syndrome
- E ) Rheumatoid arthritis
= B) Osteoarthritis
A 23-year-old man notes some minor discomfort over the lateral aspect of his right knee after a day working in a cramped cubicle. On physical examination, he has a palpable ‘bump’ in this region. A radiograph of the knee reveals a lateral bony projection from the lower femoral metaphysis. There is no adjacent soft tissue swelling. The lesion is excised and is shown to be composed of a 3cm stalk of bony cortex, capped by cartilage. Which of the following is the most likely diagnosis?
- A ) Aneurysmal bone cyst
- B ) Enchondroma
- C ) Giant cell tumor
- D ) Osteochondroma
- E ) Osteoid osteoma
= D) Osteochondroma
- A ) decreased serum prostate specific antigen
- B ) Hyperparathyroidism
- C ) Hypocalcemia
- D ) Hypoparathyroidism
- E ) Increased serum prostate specific antigen
= E ) Increased serum prostate-specific antigen
While playing netball, a 33-year-old man jumps and lands awkwardly on his left foot. He develops pain in his left leg afterwards. On closer history, you ascertain that when he landed he twisted inwards on the loaded knee. On physical examination his knee is unstable.
What structure identified here has most likely been injured?
- A ) ACL
- B ) Laterial meniscus
- C ) Medial meniscus
- D ) Patellar tendon
- E ) PCL
= A ) ACL
- The ACL provides knee joint stability, and is the most common ligament tear that occurs during sporting activities.
- Typically, the tear occurs due to a valgus moment placed upon the knee (often a weightbearing, non-contact occurance in the “knee in, toes out” position- see Kobyashi et al., 2010).
- An ACL repair can be done with an allograft tendon.
- A ) Metastatic adenocarcinoma
- B ) Osteoporosis
- C ) Paget’s disease of the bone
- D ) Renal failure with renal osteodystrophy
- E ) Vitamin D deficiency
= C) Paget’s disease of the bone
A 53-year-old man has noted a slowly enlarging ‘bump’ on his left elbow. It has been present for the past 2 years. On physical examination there is a 2cm firm, non-tender mass over the left olecranon process. Microscopy of an aspirate shows elongated, needle-shaped crystals that under polarized light are negatively birefringent. The mass is excised and on sectioning has a chalky white consistency. Microscopically there is a granulomatous inflammatory infiltrate. Which of the following disorders is most likely to potentiate his findings?
- A ) Chronic obstructive pulmonary disease
- B ) Chronic renal failure
- C ) Hepatic cirrhosis
- D ) Inflammatory bowel disease
- E ) Peptic ulcer disease
= B) Chronic renal failure
Gouty tophi can develop with gouty arthritis. He has increased deposition of monosodium urate crystals in the soft tissue around a joint. Most patients with an increased serum uric acid do not have gouty arthritis, although it is known to occur. Most cases of gout (90% or more) have an elevated serum uric acid and are ‘primary gout’ from overproduction or underexcretion of uric acid, but usually without an identifiable cause. Underexcretion of uric acid is potentiated by renal failure.
An 11-year-old boy has pain in his left leg that has persisted for 3 weeks. His temperature is 37.9°C. A radiograph of the leg reveals a mass in the diaphyseal region of the left femur with overlying cortical erosion and soft tissue extension. A bone biopsy is performed and on microscopic examination, the lesion shows numerous small round blue cells. Karyotypic analysis of these cells shows t(11;22).
What is the most likely diagnosis?
- A ) Chondroblastoma
- B ) Ewing’s sarcoma
- C ) Medulloblastoma
- D ) Neuroblastoma
- E ) Osteoblastoma
= B) Ewing’s sarcoma
An otherwise healthy 85-year-old man has neck and right hip pain that has been worsening over the past decade. The pain is worse at the end of the day. On physical examination he has bony enlargement of the distal interphalangeal joints. A radiograph of the cervical spine is shown below.
Which of the following diseases is he most likely to have?
- A ) Metastatic breast carcinoma
- B ) Acute osteomyelitis
- C ) Osteoarthritis
- D ) Osteogenesis imperfecta
- E ) Osteoporosis
- F ) Vitamin D deficiency
= C) Osteoarthritis
A 56-year-old woman has a 27-year history of poorly controlled type 2 diabetes mellitus. She develops an ulceration on the ball of her foot that does not heal for 2 months.
Which of the following complications involving bone is she most likely to develop?
- A ) Charcot-Marie-Tooth disease
- B ) Osteomyelitis
- C ) Osteoporosis
- D ) Osteosarcoma
- E ) Squamous cell carcinoma
= B ) Osteomyelitis
A 52-year-old man required a transmetatarsal amputation a year ago. The structure identified in this image is not functioning adequately due to increased intracellular sorbitol concentrations.
Which of the following laboratory abnormalities is he most likely to have?
- A ) Antinuclear antibody titre of 1:320
- B ) Calcium of 12.3mg/dL
- C ) Fasting glucose of 217mg/dL
- D ) Hb of 7.5g/dL
- E ) PaCO2 of 70mmHg
= C) Fasting glucose of 217mg/dL
A social worker refers a 2-year-old child to the physician because of suspected child abuse with multiple bone fractures. On physical examination, the child has blue sclerae, diminished hearing in both ears, and misshapen teeth. There are no external contusions or lacerations of the skin. Radiographs of the child’s extremities show recent but healing long bone fractures. Which of the following is the most likely diagnosis?
- A ) Achondroplasia
- B ) Osteogenesis imperfecta
- C ) Osteopetrosis
- D ) Rickets
- E ) Trauma (‘shaken child syndrome’)
= B ) Osteogenesis imperfecta
- A ) Candida albicans osteomyelitis on a background of sickle cell anaemia
- B ) Clostridium perfringens osteomyelitis on a background of sickle cell anaemia
- C ) Group B Streptococcus osteomyelitis on a background of sickle cell anaemia
- D ) Pseudomonas osteomyelitis on a background of sickle cell anaemia
- E ) Salmonella enterica osteomyelitis on a background of sickle cell anaemia
= E) Salmonella enterica osteomyelitis on a background of sickle cell anaemia
Salmonella osteomyelitis is a feature seen in patients with sickle cell anemia. Other organisms that are frequent causes for osteomyelitis with sickle cell anemia include Staphylococcus aureus and gram negative organisms such as Klebsiella.
- A ) Fibroblasts
- B ) Giant cells
- C ) Metastatic renal carcinoma cells
- D ) Osteoblasts
- E ) Plasma cells
= E ) Plasma cells
What kind of fracture is shown?
- A ) Comminuted
- B ) Greenstick
- C ) Impacted
- D ) Oblique
- E ) Open
= A ) Comminuted
A comminuted fracture occurs when several breaks result in many small pieces between two large segments.
Which wrist flexor muscle is identified with pin C?
- A ) Brachioradialis
- B ) Extensor carpi ulnaris
- C ) Flexor carpi radialis
- D ) Flexor carpi ulnaris
- E ) Palmaris longus
= E ) Palmaris longus longus
What nerve is shown in this posterior view of the thigh?
- A ) Common peroneal nerve
- B ) Saphenous nerve
- C ) Sciatic nerve
- D ) Sural nerve
- E ) Tibial nerve
= C) Sciatic nerve
The sciatic nerve is derived from spinal nerves L4 to S3.
A 49-year-old man has complained of episodes of joint pain for over 10 years. This pain has occurred mostly in his hands and feet in a remitting and relapsing pattern. On physical examination, there are deformities of his hands and fingers, but excluding the distal interphalangeal joints.
His condition improves following methotrexate therapy.
Which of the following serologic tests is most likely to be positive in this man?
- A ) Anti-citrullinated peptide
- B ) Anti-double stranded DNA
- C ) Borrelia burgdorferi antibody
- D ) HLA-B27
- E ) Rapid plasma reagin
= A ) Anti-citrullinated peptide
The anterior compartment of the lower leg is supplied by the _________ and innervated by the ______________.
- A ) anterior tibial artery, deep peroneal nerve
- B ) anterior tibial artery, superficial peroneal nerve
- C ) peroneal artery, superficial peroneal nerve
- D ) posterior tibial artery, superficial peroneal nerve
- E ) posterior tibial artery, tibial nerve
= A) The anterior compartment of the lower leg is supplied by the anterior tibial artery and innervated by the deep peroneal nerve.
What pathology is shown in this X-ray?
- A ) Osteoarthritis
- B ) Osteomalacia
- C ) Osteomyelitis
- D ) Osteopetrosis
- E ) Osteoporosis
= A ) Osteoarthritis
This image shows severe osteoarthritis of the hip. The joint space is narrowed and there is subchondral sclerosis with scattered oval radiolucent cysts and peripheral osteophyte lipping.
Over the past 4 days, an 18-year-old man has developed marked pain and swelling in his right hip that makes movement difficult. He has no history of major medical problems. On physical examination, there is pain on movement of the right hip with diminished range of motion. A joint aspirate from the hip reveals cloudy fluid, and on microscopic examination demonstrates numerous neutrophils but no crystals.
Which of the following conditions is most likely to have preceded development of his hip problem?
- A ) Chronic obstructive pulmonary disease
- B ) Gonococcal urethritis
- C ) Rheumatoid arthritis
- D ) Sickle cell anaemia
- E ) Systemic lupus erythematosus
= B ) Gonococcal urethritis
Which pathology, associated with an autosomal dominant mutation, results in the inhibition of cartilage proliferation at the growth plate?
- A ) Achondroplasia
- B ) Osteogenesis imperfecta
- C ) Osteomalacia
- D ) Osteopetrosis
- E ) Paget’s disease
= A ) Achondroplasia
Pin C?
Answer: Palmaris longus
- A ) Chondrosarcoma
- B ) Chordoma
- C ) Giant cell tumour
- D ) Osteoblastoma
- E ) Osteochondroma
- F ) Osteosarcoma
= E ) Osteochondroma
Osteochondroma is the most common benign tumor or tumorlike lesion of bone. The radiographic appearance of this tumor is often diagnostic and reflects its pathologic characteristics, that is, a lesion composed of cortical and medullary bone with an overlying hyaline cartilage cap
Which cutaneous nerve innervates the area shown by pin I?
Answer: Tibial nerve
Answer: Ankylosing spondylitis
Note the characteristic “bamboo spine” as the vertebral bodies fuse together.
Answer: Sural nerve
Characteristic radiographic findings in osteoarthritis include all of the following EXCEPT:
- A ) Asmmetrical joint space narrowing
- B ) Osteophytes
- C ) Subchondral bone sclerosis
- D ) Subchondral cysts
- E ) Symmetrical joint space narrowing
= E ) Symmetrical joint space narrowing
Osteoarthritis can be thought of as a localised process in which mechanical forces are distributed in an unequal fashion over the joint surface, resulting in asymmetrical joint space narrowing. In contrast, the inflammatory arthropathies are mediated by the generation of soluble factors such as interleukin-6 and tumour necrosis factor α, which affect the cartilage in a global manner and result in symmetrical joint space narrowing. The new bone formation is characteristic of osteoarthritis but is not unique to osteoarthritis, because new bone formation can also be seen in Paget’s disease. Subchondral cysts appear in a variety of advanced joint diseases.
Picture labelled A shows a patient with RA
Picture labelled B shows a patient with OA.
Note the difference between symmetrical and asymmetrical joint narrowing.
Which disease complication is shown by the white arrows?
- A ) Osteoarthritis
- B ) Osteochondroma
- C ) Osteopetrosis
- D ) Osteoporosis
- E ) Rheumatoid arthritis
= A ) Osteoarthritis
An osteophyte is a bony projection associated with the degeneration of cartilage at joints, and is commonly seen in osteoarthritis.
Moira, a 56-year-old post-menopausal woman, has had multiple bone fractures. If a bone biopsy were to be taken, it would show decreased size of trabeculae and loss of apposition.
Given her likely diagnosis, which of the following molecules is likely to be increased?
- A ) Antibodies
- B ) IFNg
- C ) Monocytes
- D ) OPG
- E ) RANK
= E ) RANK
Answer: Flexor carpi ulnaris
Answer: Osteosarcoma
Osteosarcomas are malignant osteoid- and bone-forming tumours that arise from mesenchymal stem cells (osteoblasts) located in the periosteum.
In this x-ray, the tibial metaphysis shows extensive osteolytic medullary and cortical bone destruction combined with sclerotic bone formation (seen posteriorly in particular). The lesion affects the entire width of the bone, and there are marked periosteal reactions on both margins. On the posterior margin, massive invasion of the surrounding soft tissue can be seen.
What pathology is shown in this xray?
This patient is a 12-year-old boy.
Note: biopsy reveals small, round blue cells that resemble lymphocytes
- A ) Aneurysmal bone cyst
- B ) Ewing’s sarcoma
- C ) Osteoblastoma
- D ) Osteochondroma
- E ) Osteoid osteoma
- F ) Osteoma
- G ) Osteosarcoma
= B) Ewing’s sarcoma
This image shows a zone of decreased radiodensity in the proximal tibial diaphysis (red overlay) with a lamellated periosteal reaction, seen as the typical onion skin appearance (blue overlay and arrow) of Ewing sarcoma.
In Ewing’s sarcoma, a (11;22) translocation is characteristic. Biopsy will reveal small, round blue cells that resemble lymphocytes. It can be confused with lymphoma or chronic osteomyelitis, and often presents with metastasis. It is responsive to chemotherapy.
What is highlighted on this xray?
Osteophyte
A 28-year-old male accountant complains of hand pain. A radiograph is taken.
Which of the following is the most helpful diagnostic test?
- A ) Antinuclear antibody
- B ) Erythrocyte sedimentation rate (ESR)
- C ) Ferritin level
- D ) Lyme titer
- E ) Rheumatoid factor
= C ) Ferritin level
Abnormalities of the second and third metacarpal joints are classic for hemochromatosis. Hemochromatosis causes joint symptoms in men at an earlier age than in women, who are protected from excessive iron deposition because of menses. The mechanism of damage of hemochromatosis is believed to be direct damage to chondrocytes from ionic iron. This results in arthritis of affected joints.
The indications for laboratory tests in osteoarthritis are to exclude secondary causes of osteoarthritis, including metabolic diseases and the endocrinopathies. In this case, the factors that suggest a possible secondary cause of osteoarthritis are a relatively young age of the patient, who does not have an occupational risk for premature osteoarthritis, and the unusual distribution involving the metacarpals.
Laboratory tests in patients with primary osteoarthritis are generally normal, including the ESR. No indication to obtain tests for inflammatory processes such as rheumatoid arthritis or systemic lupus erythematosus exists when degenerative changes alone are noted on radiography.
Answer: Flexor carpi radialis
A 70-year-old man complains of right hip and thigh pain for the past 8 months.
O/E examination: reduced ROM in both hips. There is no tenderness or swelling on palpation.
Ix: X-ray of the pelvis and right leg show sclerotic, thickened cortical bone with a narrowed joint space near the acetabulum. Laboratory studies show calcium 9.5 mg/dL (8.5-10.2 mg/dL), phosphorus 3.4 (2.5 to 4.5 mg/dL) and alkaline phosphatase level 173 (30-110UL).
The figure shows the representative microscopic appearance of his pelvic bone.
Which of the following conditions is most likely to produce these findings?
- A ) Degenerative osteoarthritis
- B ) Hyperparathyroidism
- C ) Osteochondroma
- D ) Paget’s disease of bone
- E ) Vitamin D deficiency
= D ) Paget’s disease of bone
- *Answer: Malleolar fossa**
1. Fibula, 2. Tibia, 3. Distal tibiofibular joint, 4. Malleolar fossa, 5. Lateral malleolus, 6. Ankle joint, 7. Medial malleolus, 8. Talus.
Which artery supplies the quadriceps muscles?
- A ) Descending genicular
- B ) Femoral
- C ) Fibular
- D ) Popliteal
- E ) Posterior tibial
= B ) Femoral
What structure is indicated by pin 13?
- A ) Calcaneus
- B ) Cuboid
- C ) Lateral cuneiform
- D ) Navicular
- E ) Sustentaculum tali
= B ) Cuboid
- Fibula, 2. Tibia, 3. Ankle joint, 4. Promontory of tibia, 5. Trochlear surface of talus, 6. Talus, 7. Posterior tubercle of talus, 8. Calcaneus, 9. Sustentaculum tali, 10. Tarsal tunnel, 11. Navicular, 12. Cuneiforms, 13. Cuboid
Answer: Flexor carpi ulnaris
Answer: Medial epicondyle
Answer: Anterior femoral cutaneous
Answer: Flexor carpi ulnaris
Which dermatome corresponds to the big toe?
- A ) L1
- B ) L4
- C ) L5
- D ) S1
- E ) S2, S3
= B ) L4
Answer: Metatarsophalangeal joints
I-V: Metatarsals, 1,3: Distal phalanx, 4: Middle phalanx, 2,5: Proximal phalanx, 6: Interphalangeal joints, 7: Metatarsophalangeal joints, 8: Sesamoids, 9: Head of metatarsal, 10: Shaft of metatarsal, 11: Base of metatarsal, 12: Cuneiforms, 13: Navicular, 14: Cuboid, 15: Talus, 16: Calcaneus, 17: Tibia, 18: Fibula, 19: Tarsometatarsal joints, 20. Transverse midtarsal joint.
Answer: Common fibular nerve
Answer: Ewing’s sarcoma
The diaphyseal region of long bones is a site of origin for primitive neuroectodermal tumors, of which Ewing’s sarcoma is one. As the tumor grows, the cortex is eroded and invaded, producing pain.
Answer: Flexor digitorum profundus
Answer: Saphenous nerve
Answer: Olecranon fossa
Answer: Palmaris longus
