Musculoskeletal

Question 1

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 1

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.

Question 2

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 2

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).

Question 3

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

Answer 3

= D) Radial

Question 4

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 4

Answer: Abductor pollicis longus

Question 5

Which nerve supplies the medial compartment of the thigh?

• A ) Deep peroneal
• B ) Femoral
• C ) Obturator
• D ) Sciatic
• E ) Superficial peroneal

Answer 5

= C) Obturator

Question 6

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

Answer 6

= 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.

Question 7

What type of collagen does osteogenesis imperfecta impact?

• A ) Type I
• B ) Type II
• C ) Type III
• D ) Type IV
• E ) Type V

Answer 7

= A) Type I

Question 8

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

Answer 8

= C) Evaluate ESR and begin high dose prednisone

This patient has giant cell arteritis. Start with high dose steroid therapy to prevent ocular involvement.

Question 9

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

Answer 9

= E) Symmetrical joint space narrowing

Question 10

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

Answer 10

= A) anterior tibial artery

Question 11

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

Answer 11

= 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.

Question 12

Which muscle is responsible for eversion of the foot?

• A ) Extensor hallucis longus
• B ) Fibularis longus
• C ) Soleus
• D ) Tibialis anterior
• E ) Tibialis posterior

Answer 12

= B) Fibularis longus

Fibularis (peroneus) longus, brevis, and tertius comprise the everters of the foot.

Question 13

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

Answer 13

= G) Posterior cutaneous nerve of thigh

Question 14

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

Answer 14

= 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.

Question 15

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

Answer 15

= 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:

1. Bone fractures
2. Anaemia, thrombocytopaenia, and leukopaenia with extramedullary hematopoiesis due to the bony replacement of the marrow
3. Vision and hearing impairment, secondary to bony impingement on cranial nerves
4. Hydrocephalus from narrowing of the foramen magnum
5. Renal tubular acidosis, as seen with carbonic anhydrase II mutation

Question 16

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

Answer 16

= 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.

Question 17

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

Answer 17

E ) Paget’s disease

Question 18

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

Answer 18

= B) Lateral collateral ligament

Question 19

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

Answer 19

= 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

Question 20

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

Answer 20

= D) Supraglenoid tubercle of the scapula

Question 21

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

Answer 21

= D ) Osteoblastoma

Question 22

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

Answer 22

= E ) Tibial nerve

Question 23

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

Answer 23

= E ) Ulnar

Question 24

At what level does the inferior vena cava cross the diaphragm?

• A ) L1
• B ) T10
• C ) T12
• D ) T6
• E ) T8

Answer 24

= E ) T8

Question 25

**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

Answer 25

**= B) Polymyalgia rheumatica associated with giant cell arteritis**

Question 26

**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

Answer 26

**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.

Question 27

**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

Answer 27

= A ) Extensor digitorum longus

Question 28

**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

Answer 28

= D) Radial nerve

Question 29

**Tenderness on palpation of the anatomical snuffbox can suggest fracture of which bone?** * A ) Hamate * B ) Lunate * C ) Pisiform * D ) Scaphoid * E ) Trapezium

Answer 29

= 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.

Question 30

**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

Answer 30

**= G ) Osteosarcoma** Imaging reveals a destructive mass with a 'sunburst' appearance and lifting of the periosteum, typical in osteosarcoma.

Question 31

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

Answer 31

**= 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.

Question 32

**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

Answer 32

= E ) patellar ligament ## Footnote The prominence shown is the tibial tuberosity.

Question 33

**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

Answer 33

**= 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.

Question 34

**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

Answer 34

= E) The medial compartment of the thigh is supplied by the **profunda femoris artery and obturator artery** and innervated by the **obturator nerve.**

Question 35

* 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

Answer 35

**= D ) Osteoporosis**

Question 36

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

Answer 36

**= D) Supraspinatus**

Question 37

**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

Answer 37

= **A) It can be complicated by osteosarcoma**

Question 38

**What kind of fracture is shown?** * A ) Compound * B ) Greenstick fracture * C ) Impacted * D ) Oblique * E ) Spiral

Answer 38

**= B) Greenstick fracture** A greenstick fracture is a partial fracture in which only one side of the bone is broken.

Question 39

* A ) Ankylosing spondylitis * B ) Osteoarthritis * C ) Psoriatic arthritis * D ) Reiter syndrome * E ) Rheumatoid arthritis

Answer 39

**= B) Osteoarthritis**

Question 40

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

Answer 40

**= D) Osteochondroma**

Question 41

* A ) decreased serum prostate specific antigen * B ) Hyperparathyroidism * C ) Hypocalcemia * D ) Hypoparathyroidism * E ) Increased serum prostate specific antigen

Answer 41

**= E ) Increased serum prostate-specific antigen**

Question 42

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

Answer 42

**= 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](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3761820/)). * An ACL repair can be done with an allograft tendon.

Question 43

* A ) Metastatic adenocarcinoma * B ) Osteoporosis * C ) Paget's disease of the bone * D ) Renal failure with renal osteodystrophy * E ) Vitamin D deficiency

Answer 43

**= C) Paget's disease of the bone**

Question 44

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

Answer 44

**= 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.

Question 45

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

Answer 45

**= B) Ewing's sarcoma**

Question 46

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

Answer 46

**= C) Osteoarthritis**

Question 47

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

Answer 47

= B ) Osteomyelitis

Question 48

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

Answer 48

= C) Fasting glucose of 217mg/dL

Question 49

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')

Answer 49

= B ) Osteogenesis imperfecta

Question 50

* 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

Answer 50

**= 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.

Question 51

* A ) Fibroblasts * B ) Giant cells * C ) Metastatic renal carcinoma cells * D ) Osteoblasts * E ) Plasma cells

Answer 51

= E ) Plasma cells

Question 52

**What kind of fracture is shown?** * A ) Comminuted * B ) Greenstick * C ) Impacted * D ) Oblique * E ) Open

Answer 52

= A ) Comminuted A comminuted fracture occurs when several breaks result in many small pieces between two large segments.

Question 53

**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

Answer 53

**= E ) Palmaris longus longus**

Question 54

**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

Answer 54

**= C) Sciatic nerve** The sciatic nerve is derived from spinal nerves L4 to S3.

Question 55

A 38-year-old woman has severe systemic lupus erythematosus with renal complications. She is treated with long-term corticosteroid therapy. Which of the following bone diseases is she most likely to develop? * A ) Osteochondritis * B ) Osteomalacia * C ) Osteoporosis * D ) Paget's disease of bone * E ) Rickets

Answer 55

= C) Osteoporosis

Question 56

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

Answer 56

= A ) Anti-citrullinated peptide

Question 57

**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

Answer 57

**= A)** The anterior compartment of the lower leg is supplied by the **anterior tibial artery** and innervated by the **deep peroneal nerve**.

Question 58

**What pathology is shown in this X-ray?** * A ) Osteoarthritis * B ) Osteomalacia * C ) Osteomyelitis * D ) Osteopetrosis * E ) Osteoporosis

Answer 58

**= 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.

Question 59

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

Answer 59

= B ) Gonococcal urethritis

Question 60

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

Answer 60

= A ) Achondroplasia

Question 61

**The inguinal ligament arises from the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** * A ) external oblique aponeurosis * B ) internal oblique * C ) rectus abdominis muscle * D ) rectus sheath * E ) transversus abdominis fascia

Answer 61

= A ) external oblique aponeurosis

Question 62

**Formation of pannus occurs in which of the following diseases?** * A ) Osteoarthritis * B ) Osteochondroma * C ) Osteopetrosis * D ) Osteoporosis * E ) Rheumatoid arthritis

Answer 62

= E ) Rheumatoid arthritis

Question 63

**A 45-year-old woman with longstanding rheumatoid arthritis presents to hospital with her third chest infection this year. She complains of weight loss. On examination she has rheumatoid nodules, lymphadenopathy, splenomegaly and a purpuric rash.** **What is the most likely cause of her recurrent infections?** * A ) Angioimmunoblastic lymphadenopathy * B ) Chronic lymphocytic leukaemia * C ) Felty's syndrome * D ) Lymphoma * E ) Still’s disease

Answer 63

= C ) Felty's syndrome ## Footnote Felty's syndrome is an extra-articular manifestation of rheumatoid arthritis that presents with splenomegaly and neutropenia.

Question 64

**\_\_\_\_\_ are characterised histologically by pleomorphic and mitotically active osteoblasts associated with osteoid.** * A ) Chondrosarcomas * B ) Chordomas * C ) Giant cell tumours * D ) Osteoblastomas * E ) Osteochondromas * F ) Osteoid osteomas * G ) Osteosarcomas

Answer 64

= G ) Osteosarcomas

Question 65

**Occasionally, a diagnosis of\_\_\_\_\_\_ is secondary to result from Crohn’s disease or extensive surgical resection of the small intestine.** * A ) osteomalacia * B ) osteopenia * C ) osteopetrosis * D ) osteoporosis * E ) Paget's disease

Answer 65

= A ) osteomalacia

Question 66

**A 30-year-old man presents to his primary care physician complaining of increased swelling and pain in his hands. He has also been experiencing increased joint pain and stiffness in the mornings. On examination his fingers have a sausage-like appearance and a few of the distal interphalangeal joints of the hands are swollen, worse on the left than the right. There is some nail pitting.** **What is the most likely diagnosis?** * A ) Ankylosing spondylitis * B ) Osteoarthritis * C ) Psoriatic arthritis * D ) Reiter syndrome * E ) Rheumatoid arthritis

Answer 66

= C ) Psoriatic arthritis

Question 67

**High output cardiac failure is a manifestation of which of the following?** * A ) Osteoarthritis * B ) Paget's disease * C ) Pott's disease * D ) Renal artery stenosis * E ) Rheumatoid arthritis

Answer 67

= B ) Paget's disease

Question 68

Pin C?

Answer 68

**Answer: Palmaris longus**

Question 69

* A ) Chondrosarcoma * B ) Chordoma * C ) Giant cell tumour * D ) Osteoblastoma * E ) Osteochondroma * F ) Osteosarcoma

Answer 69

= 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

Question 70

**Seronegative spondyloarthropathies are associated with which HLA genotype?** * A ) B127 * B ) B17 * C ) B21 * D ) B27 * E ) B7

Answer 70

= D ) B27

Question 71

Which cutaneous nerve innervates the area shown by pin I?

Answer 71

**Answer: Tibial nerve**

Question 72

Answer 72

**Answer: Ankylosing spondylitis** Note the characteristic "bamboo spine" as the vertebral bodies fuse together.

Question 73

Answer 73

**Answer: Sural nerve**

Question 74

**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

Answer 74

**= E ) Symmetrical joint space narrowing** ## Footnote 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.

Question 75

**Which disease complication is shown by the white arrows?** * A ) Osteoarthritis * B ) Osteochondroma * C ) Osteopetrosis * D ) Osteoporosis * E ) Rheumatoid arthritis

Answer 75

= A ) Osteoarthritis ## Footnote An osteophyte is a bony projection associated with the degeneration of cartilage at joints, and is commonly seen in osteoarthritis.

Question 76

**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

Answer 76

= E ) RANK

Question 77

Answer 77

**Answer: Flexor carpi ulnaris**

Question 78

Answer 78

**Answer: Osteosarcoma** ## Footnote 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.

Question 79

**Lesion to what nerve causes wrist drop?** * A ) Axillary * B ) Lateral cutaneous * C ) Medial * D ) Radial * E ) Ulnar

Answer 79

= D ) Radial

Question 80

**Dr. Lee is a neurosurgeon who recently has been performing several long and difficult microsurgeries with delicate tools. He has to hold these surgical tools in cramped spaces for long periods of time. Lately, he has been waking up in the middle of the night with pins and needles in the palmar surface of his left hand, with occasional pain and paraesthesia shooting into the radial region of his antebrachium. His left hand feels ‘weak’ and the pain is not relieved by shaking it. Dr Lee believes he may have carpal tunnel syndrome. On examination you find some weakness in shoulder abduction, internal and external rotation of the shoulder, elbow flexion and wrist flexion. He has an absent brachioradialis reflex.** **Which nerve root lesion is likely to cause his symptoms?** * A ) C5 * B ) C6 * C ) C7 * D ) C8 * E ) T1

Answer 80

= B ) C6

Question 81

**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

Answer 81

**= B) Ewing's sarcoma** ## Footnote 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.

Question 82

**Reactive arthritis is defined by a triad of \_\_\_\_.** A ) arthritis, gonococcal urethritis or cervicitis, and aortic insufficiency. B ) arthritis, non-gonococcal urethritis or cervicitis, and aortic insufficiency C ) arthritis, non-gonococcal urethritis or cervicitis, and conjunctivitis. D ) arthritis, non-gonococcal urethritis or cervicitis, and posterior uveitis. E ) septic arthritis, gonococcal urethritis or cervicitis, and anterior uveitis.

Answer 82

= C ) arthritis, non-gonococcal urethritis or cervicitis, and conjunctivitis.

Question 83

**A 26-year-old woman presents with a miscarriage, and has had three previous ones. She has systemic lupus erythematosus (SLE) and has had a previous deep vein thrombosis (DVT).** **Which autoantibody is most associated with this condition?** * A ) Anti cardiolipin * B ) Anti Jo 1 * C ) Anti RH * D ) Anti RNP * E ) Anti RO

Answer 83

= A ) Anti cardiolipin

Question 84

What is highlighted on this xray?

Answer 84

Osteophyte

Question 85

**Children with haemoglobinopathies, especially sickle cell disease, have an increased risk of \_\_\_\_\_.** * A ) asthma * B ) irritable bowel disease * C ) osteodystrophy * D ) osteomyelitis * E ) osteopetrosis

Answer 85

= D ) osteomyelitis ## Footnote Hemoglobinopathy is a kind of genetic defect that results in an abnormal structure of one of the globin chains of the hemoglobin molecule. Hemoglobinopathies are inherited single-gene disorders; in most cases, they are inherited as autosomal co-dominant traits. Common hemoglobinopathies include sickle-cell disease. The most common cause of osteomyelitis is Staphylococcus aureus. However, it is well-known that in children with sickle cell disease (SCD) who develop osteomyelitis, infection is often attributable to Salmonella. Salmonella osteomyelitis tends to occur more often in children with hemoglobinopathies,

Question 86

**\_\_\_\_ is a solitary and characteristically painful lesion which usually affects the femur or tibia. The pain may be severe, worse at night, and is characteristically relieved by aspirin. Histologically, there is a central ‘nidus’ of vascular fibrous tissue containing bone trabeculae formed by benign osteoblasts.** * A ) Chondrosarcoma * B ) Chordoma * C ) Giant cell tumour * D ) Osteoblastoma * E ) Osteochondroma * F ) Osteoid osteoma * G ) Osteosarcoma

Answer 86

= F ) Osteoid osteoma

Question 87

**Which intrinsic thumb muscle is part of the thenar compartment of the hand?** * A ) Adductor pollicis * B ) First dorsal interossus * C ) Flexor digitorum superficialis * D ) Opponens pollicis * E ) Second dorsal interossus

Answer 87

= D ) Opponens pollicis ## Footnote The thenar compartment includes the **opponens pollicis**, **abductor pollicis brevis**, and **flexor pollicis brevis**.

Question 88

**A 65-year-old woman reports difficulty walking. She can walk for one block, but strong cramping pain in her calves forces her to stop and sit, which relieves the pain. She can walk for a long time in the grocery store, but the pain returns when she carries groceries into her house.** **On examination, she has limitation in range of motion in the cervical spine, marked Heberden’s nodes and Bouchard’s nodes, and knee crepitus. Her neurologic examination is unremarkable. Her distal pulses are detected with some effort. Which of the following is the most likely cause of her symptoms?** * A ) Knee osteoarthritis * B ) Lumbar radiculopathy * C ) Spinal stenosis * D ) Trochanteric bursitis * E ) Vascular claudication

Answer 88

= C ) Spinal stenosis ## Footnote The distribution of joint abnormalities in this patient suggests the diagnosis of primary osteoarthritis of the vertebral joints; a generalised process that involves the spine in a diffuse manner. Spinal stenosis most commonly results from degenerative changes of the facet joints and the vertebral discs, although a congenitally narrow spinal canal can be a factor as well.

Question 89

**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

Answer 89

= C ) Ferritin level ## Footnote 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.

Question 90

**The pattern of numbness known as "Sergeant's patch" is commonly seen due to a lesion to which nerve?** * A ) Axillary * B ) Lateral cutaneous * C ) Median * D ) Radial * E ) Ulnar

Answer 90

= A ) Axillary

Question 91

Answer 91

**Answer: Flexor carpi radialis**

Question 92

**In which joint pathology is aortic regurgitation a potential manifestation?** * A ) Ankylosing spondyloarthritis * B ) Infectious arthritis * C ) Pseudogout * D ) Psoriatic arthritis * E ) Rheumatoid arthritis

Answer 92

= A ) Ankylosing spondyloarthritis ## Footnote Ankylosing spondyloarthritis causes long-term inflammation that affects the sacroiliac joints and spine. It presents with lower back pain, typically in young males. Extraarticular manifestations include uveitis, achilles tendinitis, amyloidosis, and aortitis, which can go on to cause aortic regurgitation.

Question 93

**A 55-year-old man presents to his physician complaining of pain mostly felt in his shoulders. He states that in the morning he feels rather stiff and has general discomfort and pain in his muscles. The patient has a past medical history of diabetes and is not currently taking any medications.** **Physical exam demonstrates mild tenderness of the patient's musculature diffusely.** **The patient has 2+ reflexes and 5/5 strength in his upper and lower extremities.** **Laboratory values are notable for an elevated erythrocyte sedimentation rate.** **Which of the following is the best next step in management?** * A ) Aldolase levels * B ) Glucocorticoids * C ) Muscle biopsy * D ) Temporal artery biopsy * E ) Thyroxine

Answer 93

**= B ) Glucocorticoids** This patient is presenting with muscle stiffness without weakness and an elevated erythrocyte sedimentation rate (ESR) suggesting a diagnosis of polymyalgia rheumatica which is best treated with low-dose glucocorticoids. Polymyalgia rheumatica is an autoimmune disorder that presents in patients older than 50 with pain and morning stiffness of their proximal joints (without weakness) and an elevated ESR. When the diagnosis is suspected, the patient can be started on low-dose glucocorticoids rather than obtaining more invasive diagnostic tests like a biopsy, MRI, or EMG. Patients with polymyalgia rheumatica should be monitored closely for giant cell temporal arteritis which occurs with increased incidence in these patients. Incorrect Answers: * Aldolase levels could be appropriate if the most likely diagnosis was polymyositis/dermatomyositis, which would present with profound muscle weakness. * Muscle biopsy is the most accurate diagnostic test for diseases like inclusion body myositis and polymyositis; however, it would be unnecessary in a simple case of polymyalgia rheumatica. * Temporal artery biopsy is not necessary given the low concern for giant cell temporal arteritis in this patient. It is important to note that giant cell temporal arteritis is common in patients with polymyalgia rheumatica. * Thyroxine would be an appropriate treatment if this patient's muscular symptoms were from hypothyroidism, which would present with elevated muscle enzymes and muscle weakness. A TSH level would be ordered before administering treatment.

Question 94

**What is the most common cause of isolated elevated ALP in patients above the age of 40?** * A ) Osteomalacia * B ) Osteoporosis * C ) Paget's disease * D ) Potts disease * E ) Primary biliary cirrhosis

Answer 94

= C ) Paget's disease

Question 95

**What pathogen is the most common identifiable cause of osteomyelitis?** * A ) Mycobacterium tuberculosis * B ) Neisseria gonorrhoeae * C ) Pseudomonas aeruginosa * D ) Salmonella * E ) Staphylococcus aureus

Answer 95

= E ) Staphylococcus aureus ## Footnote *Staphyloccous aureus* is the most common cause of osteomyelitis. However, in as many as 50% of cases no pathogen can be cultured. It typically occurs in long bones and vertebral bodies via hematogenous spread.

Question 96

**Heberden nodes are nodules of the ________________ which are suggestive of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.** * A ) distal interphalangeal joint, osteoarthritis * B ) distal interphalangeal joint, septic arthritis * C ) metacarpophalangeal joint, carpal tunnel syndrome * D ) proximal interphalangeal joint, psoriatic arthritis * E ) proximal interphalangeal joint, rheumatoid arthritis

Answer 96

= A ) distal interphalangeal joint, osteoarthritis ## Footnote Heberden nodes are made up of osteophyte formations which have arisen due to the degeneration of articular cartilage that occurs in osteoarthritis. When these nodes arise in the proximal interphalangeal joints they are known as Bouchard nodes ("B" before "H").

Question 97

**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

Answer 97

= D ) Paget's disease of bone

Question 98

Answer 98

* *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.

Question 99

**Which artery supplies the quadriceps muscles?** * A ) Descending genicular * B ) Femoral * C ) Fibular * D ) Popliteal * E ) Posterior tibial

Answer 99

= B ) Femoral

Question 100

**What structure is indicated by pin 13?** * A ) Calcaneus * B ) Cuboid * C ) Lateral cuneiform * D ) Navicular * E ) Sustentaculum tali

Answer 100

= B ) Cuboid ## Footnote 1. 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**

Question 101

Answer 101

**Answer: Flexor carpi ulnaris**

Question 102

**Which HLA type is ankylosing spondylitis associated with?** * A ) HLA-B27 * B ) HLA-DQ2 * C ) HLA-DQ8 * D ) HLA-DR3 * E ) HLA-DR4

Answer 102

= A ) HLA-B27 Seronegative spondyloarthropathies (such as ankylosing spondyloarthritis) are a group of joint disorders typically involving the axial skeleton. They are associated with HLA-B27.

Question 103

**A 50-year-old Middle Eastern woman wearing a niqaab presents with pain in all her bones. Blood tests reveal a serum calcium of 2.0 mmol/L (n: 8.5-10.2 mg/dL) and phosphate of 0.4 mmol/L (n: generally 2.5 to 4.5 mg/dL). PTH and ALP are both elevated.** **X-ray of the left hip shows a linear lucency partly traversing the longitudinal axis of the femoral neck.** **What is the diagnosis?** * A ) Bony metastases * B ) Osteomalacia * C ) Osteoporosis * D ) Paget's disease * E ) Potts disease

Answer 103

= B ) Osteomalacia ## Footnote Note that osteomalacia is often asymptomatic until insufficiency fracture, and must be differentiated from osteoporosis via blood tests.

Question 104

**What hand deformity is typically associated with osteoarthritis?** * A ) Boutonniere's deformity * B ) Heberden's nodes * C ) Radial deviation at wrist * D ) Swan neck deformity * E ) Ulnar deviation at MCPJ

Answer 104

= B ) Heberden's nodes ## Footnote Osteoarthritis features: swelling of joints distal\>proximal, Heberden's nodes on DIPs, Bouchard's nodes on PIPs. The other features listed below are associated with rheumatoid arthritis.

Question 105

Answer 105

**Answer: Medial epicondyle**

Question 106

Answer 106

**Answer: Anterior femoral cutaneous**

Question 107

Answer 107

**Answer: Flexor carpi ulnaris**

Question 108

**Which dermatome corresponds to the big toe?** * A ) L1 * B ) L4 * C ) L5 * D ) S1 * E ) S2, S3

Answer 108

= B ) L4

Question 109

Answer 109

**Answer: Metatarsophalangeal joints** ## Footnote 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.

Question 110

Answer 110

**Answer: Common fibular nerve**

Question 111

**A woman comes into the ED with a dislocated right knee following a high-impact incident during basketball. You notice a high-stepping gait as she limps to the bay. She has a foot drop and she is unable dorsiflex her right foot or toes. Upon testing for sensation, she tells you that she cannot feel anything over the dorsum of her foot. Which nerve is likely to be damaged?** * A ) Common fibular nerve * B ) Genitofemoral nerve * C ) Saphenous nerve * D ) Sciatic nerve * E ) Tibial nerve

Answer 111

= A ) Common fibular nerve The sciatic nerve becomes the common fibular nerve (also known as the common peroneal nerve), and then divides into the superficial and deep fibular nerves (also known as the superficial and deep peroneal nerves). The common fibular nerve winds superficially around the neck of the fibula, and thus is vulnurable to injury, such as with neck of fibula fractures.

Question 112

Answer 112

**Answer: Ewing's sarcoma** ## Footnote 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.

Question 113

**What is the most common benign tumour of the bone?** * A ) Giant cell tumour * B ) Osteochondroma * C ) Osteoid osteoma * D ) Osteoma * E ) Osteosarcoma

Answer 113

= B ) Osteochondroma

Question 114

**Gout occurs as a result of hyperuricaemia and deposition of monosodium urate (MSU) crystals in tissues. Secondary gout can be caused by:** A ) Celiac disease B ) Diet consisting solely of cheese C ) Extramammary Paget disease D ) Idiopathic pulmonary fibrosis E ) Renal insufficiency

Answer 114

= E ) Renal insufficiency ## Footnote Gout is related to the overproduction or decreased excretion of uric acid, which is derived from purine metabolism. Renal insufficiency due to any cause can result in decreased excretion of uric acid.

Question 115

**An 80-year-old man presents to his primary care physician with left leg pain. Blood tests reveal serum calcium 2.4 mmol/L, phosphate 1.02 mmol/L and alkaline phosphatase (ALP) 500 IU/L. X-rays show a bowed tibia, bone expansion and thickening of trabeculae.** **What is the diagnosis?** ***Normal calcium*****: 2.12 - 2.65mmol/L** ***Normal phosphate*****: 1.12 - 1.45 mmol/L** ***Normal ALP*****: variable minimum, but 44 - 147 international units per litre (IU/L) is standard** * A ) Avascular necrosis * B ) Osteomalacia * C ) Osteoporosis * D ) Paget's disease * E ) Pott's disease

Answer 115

= D ) Paget's disease

Question 116

**Which joint pathology is associated with human leukocyte antigen DR4?** * A ) Osteoarthritis * B ) Rheumatoid arthritis * C ) Seronegative spondyloarthropathies * D ) Systemic lupus erythematosus * E ) X-linked muscular dystrophy

Answer 116

= B ) Rheumatoid arthritis ## Footnote The human leukocyte antigen (HLA) system is a gene complex encoding the major MHC proteins. The HLA-DR4 serotype is associated with a number of autoimmune diseases, including rheumatoid arthritis and IgA nephropathy (it is associated with SLE, but this question asks specifically about joint pathology).

Question 117

Answer 117

**Answer: Flexor digitorum profundus**

Question 118

Answer 118

**Answer: Saphenous nerve**

Question 119

Answer 119

**Answer: Olecranon fossa**

Question 120

Answer 120

**Answer: Palmaris longus**