Musculoskeletal and trauma Flashcards

1
Q
  1. A 17 year old girl presents with pain in the distal forearm which has worsened over
    the last six to eight weeks. Plain films show an eccentric lytic radiolucency in the distal
    radius with a soap-bubble appearance. The most likely pathology is:
    a. Enchondroma
    b. Aneurysmal bone cyst
    c. Simple bone cyst
    d. Fibrous dysplasia
    e. Chondroblastoma
A
  1. b. Aneurysmal bone cyst
    Aneurysmal bone cyst is most common in females and 75% occur under 20 years of age.
    The classic presentation is of pain of relatively acute onset with a rapid increase in severity
    over 6–12 weeks. Common locations include the spine, with a slight preponderance for the
    posterior elements, and the metaphysis of long bones – femur, tibia, humerus and fibula.
    The lesion is usually expansile with thin internal trabeculations giving it the characteristic
    soap-bubble appearance.
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2
Q
  1. A 35 year old man presents with increasing stiffness in his knee and soft-tissue swelling
    around the joint. Plain films show multiple areas of irregular cyst-like radiolucencies
    in the distal femur. There are no areas of abnormal calcification and there is no evidence
    of periarticular osteoporosis. MR shows a low signal joint effusion on both T1 and T2
    sequences. The most likely diagnosis is:
    a. Synovial osteochondromatosis
    b. Pigmented villonodular synovitis
    c. Osteoarthritis
    d. Reiter’s syndrome
    e. Osteomyelitis
A
  1. b. Pigmented villonodular synovitis
    Pigmented villonodular synovitis is a relatively rare condition which usually presents in the
    third or fourth decade. It is a monoarticular, painful disease which causes a decreased range
    of movement at the affected joint. It is most common at the knee (80%) followed by the hip,
    ankle, shoulder and elbow. Haemorrhagic ‘chocolate’ effusion is characteristic. Low signal
    effusion on all sequences at MR is characteristic. There is no calcification or osteoporosis,
    and joint space narrowing is a late feature.
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3
Q
  1. A 56 year old motorcyclist has a trauma series of plain films following a road traffic
    accident. On evaluation of the lateral cervical spine film, which of the following softtissue
    parameters would be a concerning feature?
    a. Predental space of 3mm
    b. Nasopharyngeal space of 7mm
    c. Retropharyngeal space of 10mm
    d. Retrotracheal space of 20mm
    e. Decreased disc space at the C5/6 level
A
  1. c. Retropharyngeal space of 10mm
    This is too wide for the retropharyngeal space. The correct acceptable limits for soft-tissue
    measurements are as follows:
    Predental space 3mm in adults, 5mm in children.
    Nasopharyngeal space (anterior to C1) 10 mm.
    Retropharyngeal space (C2–C4) 5–7 mm.
    Retrotracheal space (C5–C7) 22 mm.
    Disc spaces should be roughly equal throughout the cervical spine. Narrowing of a disc
    space is usually due to degenerative change, but widening would be a more concerning
    feature.
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4
Q
  1. A 20 year old man presents with an increasingly painful right thigh which is worse at
    night. Plain films of the area show a lucent area measuring approximately 8–9mm in
    the distal femur surrounded by extensive sclerosis. The most likely diagnosis is:
    a. Osteoblastoma
    b. Giant cell tumour
    c. Brodie’s abscess
    d. Osteoid osteoma
    e. Chondroblastoma
A
  1. d. Osteoid osteoma
    This most commonly presents in the second and third decades. The male:female ratio is
    2.5:1. Classically it presents with increasing pain which is worse at night and often relieved
    with aspirin. Spinal lesions often lead to painful scoliosis. Almost any site in the body may
    be affected but the most common regions are the lower limb and spine.
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5
Q
  1. In a 65 year old woman with a fracture of the neck of the humerus, which of the
    following classification systems to describe the fracture would be useful in guiding the
    surgical management?
    a. Garden classification
    b. Neer classification
    c. Weber classification
    d. Fryman system
    e. Crosby–Fitzgibbon system
A
  1. b. Neer classification
    The Neer classification system is used to grade humeral neck fractures. This system
    describes four parts – greater tuberosity, lesser tuberosity, humeral head and shaft of
    humerus. According to Neer, a fracture is displaced if there is more than 1 cm of displacement
    and 45 angulation between any two segments. Two-part fractures involve any of the
    four parts and include one fragment that is displaced. Three-part fractures include a
    displaced fracture of the surgical neck in addition to either a displaced greater tuberosity
    or lesser tuberosity fracture. Four-part fractures include displaced fractures of the surgical
    neck and both tuberosities.
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6
Q
  1. A 60 year old woman presents to her GP with renal colic and hypercalcaemia. She has
    the following findings on plain film: subperiosteal bone resorption of the proximal
    phalanges of the hands, chondrocalcinosis of the articular cartilage at the knee joints,
    and a well-defined lytic lesion in the body of the mandible. The most likely unifying
    diagnosis is:
    a. Parathyroid adenoma
    b. Parathyroid carcinoma
    c. Renal osteodystrophy
    d. Osteomalacia
    e. Myeloma
A
  1. a. Parathyroid adenoma
    Parathyroid adenoma would be the most likely cause of primary hyperparathyroidism.
    Parathyroid carcinoma would produce a similar radiographic picture but is much less
    common. Brown tumours are seen in both primary and secondary hyperparathyroidism
    and are most common in the mandible, ribs and pelvis; they have a variable appearance on
    MRI and may simulate primary or secondary neoplasms
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7
Q
  1. In a 21 year old man with symptoms of chronic back pain, pain in his feet, particularly
    the great toe and metatarsophalangeal joints, and bilateral sacroiliitis on plain films, the
    most likely diagnosis is:
    a. Ankylosing spondylitis
    b. Gout
    c. Inflammatory bowel disease-related arthropathy
    d. Reiter’s syndrome
    e. Psoriatic arthritis
A
  1. d. Reiter’s syndrome
    Reiter’s syndrome is the association of urethritis, conjunctivitis and mucocutaneous
    lesions. Sacroiliitis is usually bilateral but often persists asymmetrically. There is an
    association with the HLA B27 antigen. Reiter’s has a predeliction for the great toe and
    metatarsophalangeal joints.
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8
Q
  1. A 45 year old woman falls onto her outstretched hand. The following findings on PA
    and lateral wrist plain films indicate which pathology? A scapholunate angle of 70,
    a capitolunate angle of less than 20, and a 4mm gap between scaphoid and lunate
    on PA view.
    a. Normal appearances
    b. Scapholunate dissociation
    c. Volar intercalated segment instability (VISI)
    d. Dorsal intercalated segment instability (DISI)
    e. Perilunate dislocation
A
  1. b. Scapholunate dissociation
    In scapholunate dissociation the scapholunate angle is >60 and there is a >3mm gap
    between the scaphoid and lunate on AP view of the wrist. In VISI, capitolunate angle is
    increased and there is volar angulation of the lunate. In DISI, both scapholunate and
    capitolunate angles are increased and there is dorsal angulation of the lunate.
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9
Q
  1. A young man presents to A&E following a fall onto his outstretched right arm. Plain
    films of the right forearm show a fracture of the distal forearm with volar angulation
    of the distal fragment with no intra-articular component. The carpal bones remain
    well aligned. Which of the following injuries has he sustained?
    a. Smith’s fracture
    b. Barton’s fracture
    c. Monteggia fracture
    d. Galeazzi fracture
    e. Colles fracture
A
  1. a. Smith’s fracture
    This description is of a Smith’s fracture. More common is a Colles fracture, which is
    a fracture of the distal radius with dorsal angulation of the distal fragment. A Monteggia
    fracture is fracture of the ulnar with dislocation of the radial head. A Galeazzi fracture is
    a fracture of the radius with dislocation of the distal ulnar. Barton’s fracture is a fracture of
    the distal radius with dislocation of the distal radiocarpal joint
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10
Q
  1. A 24 year old man injured his left knee whilst skiing. He presents with pain and
    swelling over the lateral aspect of the knee joint. AP plain radiographs demonstrate an
    avulsion fracture of the lateral aspect of the proximal tibia below the articular surface.
    A joint effusion is also seen. The most likely associated ligamentous injury is to which
    of the following structures?
    a. Posterior cruciate ligament
    b. Anterior cruciate ligament
    c. Medial collateral ligament
    d. Lateral collateral ligament
    e. Ligament of Humphry
A
  1. b. Anterior cruciate ligament
    The fracture described is a Segond fracture, originally documented by Dr Paul Segond in
    1879 after a series of cadaveric experiments. The Segond fracture occurs most commonly
    in association with anterior cruciate ligament injuries (75–100%) and medial meniscal
    injuries. Due to the high rate of associated injuries, a patient who sustains a Segond fracture will require further imaging, usually by way of MRI, in order to specifically investigate the
    ligaments and menisci.
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11
Q
  1. A 22 year old man presents to his GP with pain in his right knee which is gradually
    worsening in severity and is relatively resistant to analgesia. MRI of the knee demonstrates
    an area of geographic bone destruction in the distal femur with a wide zone of
    transition. There is marked aneurysmal dilatation of the bone and a fluid-fluid level is
    present within the lesion. The most likely diagnosis is:
    a. Plasmacytoma
    b. Simple bone cyst
    c. Giant cell tumour
    d. Telangiectatic osteosarcoma
    e. Parosteal osteosarcoma
A
  1. d. Telangiectatic osteosarcoma
    With the MRI finding described, the most likely explanation is that the lesion is a
    telangiectatic osteosarcoma. This is a rare type of osteosarcoma with a mean age at
    presentation of 20 years. The most common site is around the knee (62%). Fluid-fluid
    levels are also seen in giant cell tumours and aneurysmal bone cysts.
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12
Q
  1. A 32 year old footballer sustains an avulsion injury to the anterior superior iliac spine
    during training. Which of the following muscles is likely to be affected?
    a. Sartorius
    b. Gracilis
    c. Iliopsoas
    d. Rectus femoris
    e. Semimembranosus
A
  1. a. Sartorius
    Sartorius has its origin at the anterior superior iliac spine and inserts into the pes anserinus.
    A sartorius muscle injury can therefore cause an avulsion fracture of the anterior superior
    iliac spine. Gracilis has its origin at the inferior pubic ramus, and rectus femoris has its
    origin at the anterior inferior iliac spine
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13
Q
  1. A middle-aged woman undergoes an MRI of the lumbar spine for longstanding lower
    back pain. She has no specific neurological signs and is otherwise well. MRI shows
    some lower lumbar spine facet joint arthropathy and a 22 cm well-defined rounded
    lesion in the L3 vertebral body. This displays high signal on both the T1 and T2
    sequences. The most likely explanation for this lesion is:
    a. Discitis
    b. Lymphoma
    c. Myeloma
    d. Metastatic deposit
    e. Haemangioma
A
  1. e. Haemangioma
    This is most likely to be a benign haemangioma. These are relatively common lesions seen as
    incidental findings on spinal imaging. High signal on T1 imaging is indicative of the presence
    of fat within the lesion. All the other conditions would give a low-signal lesion on T1 imaging.
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14
Q
  1. A 21 year old long-distance runner complains of increasing right groin pain.
    Plain films show no acute bony injury, but demonstrate a pistol grip deformity
    of the femoral head, an osseous bump deforming the femoral head–neck junction
    and an alpha angle of 70. The acetabulum appears normal. The most likely
    diagnosis is:
    a. Hip dysplasia
    b. Pincer-type acetabular impingement
    c. Cam-type acetabular impingement
    d. Sportsman’s hernia
    e. Avascular necrosis
A
  1. c. Cam-type acetabular impingement
    Femoroacetabular impingement (FAI) occurs as a result of repetitive microtrauma due to
    an anatomic conflict between the proximal femur and the acetabular rim at the extremes of
    motion. An osseous bump at the femoral head–neck junction is present in 50% of cam-type
    FAI and only 33% of pincer-type FAI. An alpha angle of >55 is indicative of cam-type FAI.
    The alpha angle, drawn on the AP pelvis radiograph, is formed by a line drawn from
    the centre of the femoral head through the centre of the femoral neck, and a line from the
    centre of the femoral head to the femoral head–neck junction, found by the point by which
    the femoral neck diverges from a circle drawn around the femoral head. A normal patient’s
    alpha angle is around 45, whereas for patients with FAI it may be around 70.
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15
Q
  1. A 24 year old rugby player attends A&E following a tackle during which he felt his left
    shoulder dislocate. Initial plain radiographs confirm an anterior inferior dislocation
    of the left shoulder. Which of the following statements is true?
    a. The humeral head lies inferior and lateral to the glenoid on the AP view
    b. The presence of a Hill–Sachs defect indicates previous dislocation
    c. Hill–Sachs lesions are more common than Bankart lesions
    d. Anterior dislocation accounts for 50% of shoulder dislocations
    e. A Hill–Sachs lesion affects the inferior aspect of the humeral head
A
  1. c. Hill–Sachs lesions are more common than Bankart lesions
    A Hill–Sachs lesion affects the postero-superior aspect of the humeral head and whilst it
    does often indicate a previous dislocation, this is not necessarily the case and it can be
    present after a single episode. A Bankart lesion affects the inferior glenoid. Almost 95% of
    all shoulder dislocations are anterior.
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16
Q
  1. In a 26 year old woman with sickle cell disease, which one of the following would not
    be considered a typical musculoskeletal manifestation of the disease?
    a. Osteopaenia and trabecular thinning
    b. ‘Bone within bone’ appearance
    c. Avascular necrosis of the femoral head
    d. Posterior vertebral scalloping
    e. Fish deformity of the vertebrae
A
  1. d. Posterior vertebral scalloping
    Posterior vertebral scalloping is not a feature. The remainder are all classic features of sickle
    cell anaemia, along with ‘hair-on-end’ appearance of the skull due to coarse granular osteoporosis and widening of the diploe. Osteomyelitis is a feature and is due to salmonella in over 50% of cases.
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17
Q
  1. A 74 year old woman presents with back pain and no history of recent trauma.
    Lateral plain radiographs show partial collapse of the L2 vertebral body. Which of
    the following findings would be more suggestive of osteoporotic collapse than
    malignancy?
    a. Complete replacement of the normal marrow signal within the vertebral body
    on T1 imaging
    b. Bilateral pedicular involvement with expansion of the right pedicle
    c. Bulging and convex appearance to the vertebral body
    d. Nodular irregular epidural mass
    e. Intervertebral vacuum phenomenon
A
  1. e. Intervertebral vacuum phenomenon
    Intervertebral vacuum phenomenon is highly specific for osteoporotic collapse, although it
    is not common. The other features are all more suggestive of malignancy than osteoporotic
    collapse. Pedicular destruction occurs in 50% of cases of malignant collapse but in less than
    1% of osteoporotic collapse.
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18
Q
  1. A 23 year old man sustains a Jefferson fracture to his cervical spine following an injury
    in which he dived into a shallow swimming pool, hitting his head on the bottom.
    Which of the following regarding his injury is incorrect?
    a. Displacement of the lateral masses of C1 relative to the dens on an odontoid view
    indicates a transverse ligament rupture
    b. Associated C2 fracture will be present in up to 30% of cases
    c. Jefferson fractures are usually associated with a neurological deficit
    d. Up to 50% are associated with a further cervical spine injury
    e. There may be associated vertebral artery injury
A
  1. c. Jefferson fractures are usually associated with a neurological deficit
    Jefferson fractures are not usually associated with neurological deficit. Although there may
    be retropulsion of fragments into the vertebral canal, spinal cord injury is rare due to the
    large dimensions of the canal at this level. Vertebral artery injury, however, must be
    considered and if there is concern either CTA or MRA imaging should be considered.
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19
Q
  1. A 50 year old woman presents with a mass on the plantar aspect of her right foot.
    Ultrasound reveals a small oval-shaped lesion between the plantar portions of the
    metatarsal heads. MRI characteristics of the lesion are low-to-intermediate signal
    on T1 and low signal intensity on T2. Which of the following is the most likely
    diagnosis?
    a. Lipoma
    b. Morton’s neuroma
    c. Plantar fibromatosis
    d. Giant cell tumour of the tendon sheath
    e. Ganglion cyst
A
  1. b. Morton’s neuroma
    The description is that of a Morton’s neuroma. This occurs most commonly in the third
    metatarsal space and less commonly in the second space. There is often an associated
    metatarsal bursitis which is a high signal on STIR imaging. Ultrasound is usually the first
    imaging modality; squeezing the metatarsal heads together during scanning will usually
    make the lesion more prominent.
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20
Q
  1. Following a traumatic left elbow fracture, a young man complains of paraesthesia in
    his left ring and little fingers. He also starts to notice weakness of his left hand.
    A diagnosis of ulnar nerve entrapment is made. Which of the following muscles will
    not be affected?
    a. Abductor digiti minimi
    b. Abductor pollicis brevis
    c. Adductor pollicis
    d. Flexor carpi ulnaris
    e. Flexor digiti minimi
A
  1. b. Abductor pollicis brevis
    Abductor pollicis brevis is supplied by the median nerve and would therefore not be affected
    in an ulnar nerve injury. Due to the anatomic location of the ulnar nerve at the elbow, it can
    often be damaged leading to denervation and paralysis of the muscles supplied by the nerve.
    This includes the intrinsic muscles of the hand, which can be very debilitating. Injury to the
    ulnar nerve at the wrist would lead to severe muscle denervation sparing only the opponens
    pollicis, the superficial head of the flexor pollicis brevis and the lateral two lumbricals
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21
Q
  1. A routine pre-operative chest X-ray in a 62 year old woman shows bilateral erosion of
    the distal clavicles. Which one of the following conditions might be responsible?
    a. Hypoparathyroidism
    b. Rheumatoid arthritis
    c. Langerhans’ cell histiocytosis
    d. Ankylosing spondylitis
    e. Sarcoidosis
A
  1. b. Rheumatoid arthritis
    Myeloma, hyperparathyroidism, metastases, cleidocranial dysplasia and Gorlin basal cell
    nevus syndrome all cause absence of the outer end of the clavicle. Destruction of the medial
    end of the clavicle is caused by metastases, infection, lymphoma, eosinophilic granuloma,
    rheumatoid arthritis and sarc
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22
Q
  1. A 74 year old woman with back pain presents to her GP. Initial plain radiographs of
    her spine show multiple sclerotic metastatic lesions. The most likely primary tumour
    would be:
    a. Renal cell carcinoma
    b. Melanoma
    c. Bronchial carcinoid
    d. Bladder
    e. Colorectal carcinoma
A
  1. c. Bronchial carcinoid
    The most likely from the above list is a bronchial carcinoid. In men the most likely cause
    would be prostate. All the other conditions are more likely to produce lytic metastases
    than sclerotic.
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23
Q
  1. An elderly gentleman complaining of generalised aching in his lower limbs is shown to
    have bilateral distal tibial periostitis. There is no underlying bone lesion identified.
    Which of the following would be the most likely explanation?
    a. Arterial insufficiency
    b. Thyroid acropachy
    c. Trauma
    d. Pachydermoperiostosis
    e. Hypertrophic pulmonary osteoarthropathy
A
  1. e. Hypertrophic pulmonary osteoarthropathy
    The most likely explanation is hypertrophic osteoarthropathy. Thyroid acropachy changes
    usually occur in the upper limb. Venous stasis is a cause of periostitis rather than arterial
    insufficiency. Trauma would be unlikely to be bilateral unless there was a specific history.
    Pachydermoperiostitis is the idiopathic form of hypertrophic osteoarthropathy, it usually
    presents around adolescence and is usually associated with clubbing.
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24
Q
  1. A 28 year old man is brought into the emergency department following an assault during
    which he was stabbed in the left flank. He has a 1.3 cm wound just below the left costal
    margin in the mid-axillary line. No information regarding the knife has been obtained.
    His renal function is within normal limits and he has no contrast allergies. The optimal CT
    protocol for scanning his abdomen would include the following contrast:
    a. IV contrast only
    b. Oral contrast and rectal contrast
    c. IV contrast and oral contrast
    d. Oral, rectal and IV contrast
    e. IV contrast and rectal contrast
A
  1. d. Oral, rectal and IV contrast
    A triple contrast technique has been advocated in penetrating trauma where there may be
    concern regarding small bowel or colon trauma. If no oral or rectal contrast are given then
    a small bowel or colon injury can easily be missed.
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25
Q
  1. A 75 year old man who is on warfarin for atrial fibrillation is involved in a high-speed
    road traffic accident in which he sustains a head injury. He lost consciousness at the
    scene. On arrival at the A&E department his GCS is 15. He has no other obvious
    injuries. According to NICE guidelines, his management should include the following:
    a. Skull radiograph
    b. No immediate imaging but admission for regular neurological observations
    c. CT head
    d. Skull radiograph followed by CT head
    e. MRI head
A
  1. c. CT head
    According to NICE guidance he should undergo CT head and the investigation should be
    performed within the hour following referral. The fact he is anticoagulated, over 65 and
    experienced a loss of consciousness would all be factors in warranting an urgent CT head.
26
Q
  1. A young man with limited range of movement at the shoulder joint, a webbed neck and
    plain film findings of a hypoplastic scapula which is elevated and medially rotated
    with an associated omovertebral bone is likely to have which associated syndrome?
    a. Turner’s syndrome
    b. Down’s syndrome
    c. Klippel–Feil syndrome
    d. Neurofibromatosis
    e. Cleidocranial dysostosis
A
  1. c. Klippel–Feil syndrome
    The collective findings described are of a Sprengel deformity of the shoulder. This occurs
    as a result of failure of descent of the scapula secondary leading to both cosmetic and
    functional impairment. The male:female ratio is 3:1 and it is associated with Klippel–Feil
    syndrome, a condition in which there is fusion of vertebral bodies, and renal anomalies
27
Q
  1. A 52 year old woman presents to her GP with a longstanding history of lower back pain
    which has suddenly worsened in severity over the past few days. An urgent MRI scan of
    the lumbar spine shows a right paracentral disc protrusion at the L4/L5 level. The disc
    impinges on the lateral recess at this level. The most likely nerve to be affected is the:
    a. Cauda equina
    b. Lumbar plexus
    c. Right L4
    d. Right L5
    e. Right S1
A
  1. d. Right L5
    The right L5 nerve root is the most likely to be affected as it will be sitting in the right lateral
    recess at the L4/5 level. The L4 nerve root will be at the exit foramen and therefore if the
    protrusion affects only the lateral recess then this nerve will already have exited and
    therefore not be affected
28
Q
  1. An 18 year old student who fell down two stairs and landed on her left knee attends
    A&E complaining of generalised knee pain but is able to weight bear. No acute bony
    injury is demonstrated on plain film, however a pedunculated lesion arising from the
    femoral metaphysis and extending away from the knee joint is seen. The lesion
    shows continuity with both the marrow and the cortex. The most likely diagnosis is:
    a. Osteochondroma
    b. Osteoblastoma
    c. Osteoid osteoma
    d. Chondroblastoma
    e. Chondromyxoid fibroma
A
  1. a. Osteochondroma
    The description is classic for an osteochondroma or osteocartilagenous exostosis. These
    lesions are the most common benign growths of the skeleton, are usually found incidentally
    and are usually asymptomatic unless complications arise. Complications include
    fracture, vascular compromise, bursa formation and malignant transformation into
    chondrosarcoma.
29
Q
  1. A 70 year old male presents with increasing pain in his right hip over the past month.
    There is no specific history of trauma. A plain radiograph demonstrates the presence
    of an incomplete fracture of the femoral neck arising from the lateral (convex) side.
    What is the most likely underlying abnormality of the femoral neck?
    a. Osteomalacia
    b. Metastasis
    c. Osteoid osteoma
    d. Infection
    e. Paget’s disease
A
  1. e. Paget’s disease
    Incremental fractures (banana fracture) along the convex side of the bone are classically
    associated with Paget’s disease. These most commonly occur in the femur where they cause
    lateral bowing, and the tibia where they cause anterior bowing. Compression fractures of
    the vertebrae are also associated with Paget’s
30
Q
  1. A 75 year old woman presents with increasing pain in her left hip. She had a total hip
    replacement eight years ago on this side which has been asymptomatic ever since. Plain
    radiographs demonstrate a lucent line at the bone cement interface of the femoral
    component. The likely cause for this is:
    a. Infection
    b. Metastasis
    c. Loosening
    d. Myeloma
    e. Trauma
A
  1. c. Loosening
    Early changes (less than six months) are almost always due to infection. Up to four years,
    infection remains the most likely cause, but after this point loosening becomes more
    common. Every year, 38 000 hips are replaced in the UK. A routine postoperative film is
    usually performed; an excessively varus stem may lead to loosening.
31
Q
  1. A 17 year old patient complains of lower thoracic back pain. Plain radiographs of the
    thoraco-lumbar spine show wedging of multiple vertebrae at the thoraco-lumbar
    junction, multiple limbus vertebrae, an increase in the AP diameter with a reduction
    in the sagittal height of multiple vertebrae, and multiple endplate defects. What is the
    unifying diagnosis?
    a. Scheuermann’s disease
    b. Ankylosing spondylitis
    c. Mycobacterium tuberculosis
    d. Hyperparathyroidism
    e. DISH
A
  1. a. Scheuermann’s disease
    These are the classical appearances of Scheuermann’s disease. This condition usually
    presents at puberty and consists of vertebral wedging, endplate irregularity and narrowing
    of the intervertebral disc spaces. The most common location is in the lower thoracic and
    upper lumbar spine. Schmorl’s nodes are often present.
32
Q
  1. A 70 year old patient complains of back pain and leg pain after walking 50 metres.
    Plain radiographs show an anterior slip of L4 relative to L5. The spinous process of
    L4 is also noted to have moved anterior to the L5 spinous process. What type of
    spondylolisthesis does this represent?
    a. Traumatic
    b. Degenerative
    c. Spondylolytic
    d. Dysplastic
    e. Pathological
A
  1. b. Degenerative
    This is the classical description of the symptoms and radiology of a degenerative spondylolisthesis.
    Degenerative spondylolisthesis is usually symptomatic due to spinal stenosis and
    narrowing of neural foramen. This most commonly occurs at the L4/5 level. Spondylolisis
    is a defect in the pars interarticularis between superior and inferior articulating processes
33
Q
  1. A 56 year old male is admitted under the orthopaedic team with increasingly severe
    lower back pain which started three weeks ago. MRI demonstrates an oedematous L4/5
    intervertebral disc, marked loss of disc material and oedematous adjacent endplate
    changes. There is associated paravertebral inflammatory tissue and a small amount of
    pus within the residual disc space. The findings are consistent with infective discitis.
    What is the most likely causative organism?
    a. Mycobacterium tuberculosis
    b. Streptococcus pyogenes
    c. Staphylococcus aureus
    d. Escherichia coli
    e. Salmonella
A
  1. c. Staphylococcus aureus
    The most common cause of infective discitis is Staphylococcus aureus, which gives the above
    typical findings. The only other relatively common cause is Mycobacterium tuberculosis,
    which typically spares the disc until late and usually has a large amount of associated pus
34
Q
  1. A 25 year old male is involved in a 60 mph road traffic accident with a head-on
    collision. He was wearing a seat-belt but his car did not have an air-bag.
    A screening lateral radiograph of the cervical spine shows the following findings:
    an angular kyphosis centred at C4/C5, a 1mm anterior slip of C4 on C5, and
    widening of the interspinous space posteriorly. What is the likely mechanism for this
    injury?
    a. Lateral compression
    b. Flexion
    c. Extension
    d. Combination
    e. Rotation
A
  1. b. Flexion
    This describes the typical appearance for a flexion injury as well as the typical mechanism.
    This would represent a potentially unstable fracture and immobilisation would be essential
    until further management decisions are made. Flexion teardrop injuries are more common
    in the lower cervical spine and extension teardrop injuries are more common in the upper
    cervical spine.
35
Q
  1. A young man presents to his GP complaining of longstanding back pain. He says he
    has been diagnosed with a ‘syndrome’ in the past but cannot remember the details.
    Which of the following signs is more likely to suggest a diagnosis of homocystinura
    than Marfan’s syndrome?
    a. Arachnodactyly
    b. Osteoporosis
    c. Scoliosis of the spine
    d. Autosomal dominant inheritance
    e. Upward lens dislocation
A
  1. b. Osteoporosis
    Osteoporosis is a feature of homocystinuria and occurs in 75% of cases, often causing
    bowing and fracture of the long bones. The other features are all more suggestive
    of Marfan’s syndrome. Although arachnodactyly does occur in homocystinuria (in 30% of cases), it occurs in 100% of people with Marfan’s syndrome. Homocystinuria has an
    autosomal recessive mode of inheritance.
36
Q
  1. A 56 year old woman slips off the pavement onto the road and her outstretched foot is
    run over by a passing car. She has immediate severe midfoot pain. Plain radiographs
    taken on arrival at the emergency department confirm a Lisfranc fracture dislocation of
    the midfoot. Which two bones does the Lisfranc ligament attach to?
    a. First metatarsal and intermediate cuneiform
    b. First metatarsal and medial cuneiform
    c. Second metatarsal and medial cuneiform
    d. Second metatarsal and intermediate cuneiform
    e. First and second metatarsals to the medial and intermediate cuneiforms
A
  1. c. Second metatarsal and medial cuneiform
    The Lisfranc ligament attaches between the second metatarsal and medial cuneiform, which
    is why an injury to this ligament allows the second to fifth metatarsals to drift laterally once
    they have lost this stabilisation. This is therefore an unstable injury and requires rapid
    immobilisation. This is a vital injury to detect as long-term sequelae will often result from a
    delayed diagnosis.
37
Q
  1. A 24 year old man suffers a short oblique fracture of his distal tibia from a direct blow
    during a football game. He is treated with an intramedullary nail with a good reduction
    being achieved. Fourteen days later the foot becomes very tender, red and swollen
    but all haematological and biochemical parameters remain normal. Plain radiographs
    show spotty osteoporosis and subchondral erosions. Which of the following is the most
    likely diagnosis?
    a. Disuse osteoporosis
    b. Charcot joints
    c. Infection
    d. Regional sympathetic dystrophy
    e. Rheumatoid arthritis
A
  1. d. Regional sympathetic dystrophy
    This is the typical appearance, history and imaging findings for regional sympathetic
    dystrophy. This may occur following fractures or secondary to other pathologies such as
    primary or secondary bone tumours. There is overactivity of the sympathetic nervous
    system causing pain, swelling and hyperaemia with excessive bone resorption. This is
    usually in a periarticular distribution and may simulate other disease processes
38
Q
  1. A 25 year old woman attends A&E after falling onto her right hand. A plain film of her
    hand is taken in order to exclude fracture. No bony injury is seen. On examination,
    however, there is painless swelling of the right index finger which she says has been
    present for a few weeks. Incidental note is made of a small central lesion within the
    medullary cavity of the middle phalanx of the index finger. There is no cortical
    breakthrough or periosteal reaction but there is bulbous expansion of the bone with
    thinning of the cortex. The lesion contains dystrophic calcifications. This is most likely
    to represent:
    a. Giant cell tumour of the tendon sheath
    b. Unicameral bone cyst
    c. Brown tumour
    d. Enchondroma
    e. Epidermal inclusion cyst
A
  1. d. Enchondroma
    This lesion is most likely to be an enchondroma. This is a benign cartilaginous growth in
    the medullary cavity and is usually asymptomatic. It most commonly occurs in the small
    bones of the hands and wrist but may also occur in the proximal humerus and proximal
    femur. Epidermoid inclusion cysts are usually in the distal phalangeal tuft and there is often
    a history of trauma. A bone cyst would be unusual in the phalanges
39
Q
  1. A 72 year old woman presents to her GP with pain in her right shoulder which is worse
    on movement. Plain films of the right shoulder show loss of subacromial space and
    superior subluxation of the humeral head. She is referred for an ultrasound with a
    suspected supraspinatus tear. Which is the best position of the arm for visualisation
    of the free edge of the supraspinatous tendon?
    a. Adduction and internal rotation
    b. Abduction and internal rotation
    c. Adduction and external rotation
    d. Abduction and external rotation
    e. Flexion and internal rotation
A
  1. a. Adduction and internal rotation
    The best position for visualising the supraspinatous tendon is with the patient’s arm in
    adduction and internal rotation. Often the patient may be asked to place the back of their
    hand onto their back, or alternatively asking them to simulate putting the hand into the
    back pocket of their trousers. The most medial part of the tendon when imaged transversely
    is the free edge – this is where the majority of supraspinatous tears occur.
40
Q
  1. A 57 year old man with increasing pain and stiffness in his hands and feet and
    worsening back pain presents to his GP. Plain films of his hands show sclerosis of
    the terminal phalanges and several ‘pencil-in-cup’ erosions. There is destruction of
    the interphalangeal joint of his right great toe with exuberant periosteal reaction.
    There is also erosion of the posterior margin of the calcaneus. The most likely
    diagnosis is:
    a. Reiter’s syndrome
    b. Ankylosing spondylitis
    c. Rheumatoid arthritis
    d. Psoriatic arthritis
    e. Osteoarthritis
A
  1. d. Psoriatic arthritis
    This is usually HLA B27 positive and is associated with skin and nail changes in the
    majority of cases. The hands are often described as having sausage digits, and erosions
    with ill-defined margins are characteristic. Sacroiliitis is often present and most often
    bilateral. Within the axial skeleton, there is often large bulky vertically orientated soft-tissue
    ossification giving a ‘floating’ osteophyte appearance
41
Q
  1. A 20 year old student complains of a six-week history of pain and tenderness in his
    right thigh associated with a soft-tissue mass. There is no definite history of trauma.
    CT of the region shows a mass in the right distal femur with well-defined mineralisation
    at the periphery and a less distinct lucent centre. On plain film, there is faint
    calcification within the lesion and a radiolucent zone separating the lesion from bone.
    The most likely cause is:
    a. Tumoural calcinosis
    b. Osteomyelitis
    c. Myositis ossificans
    d. Parosteal sarcoma
    e. Osteosarcoma
A
  1. c. Myositis ossificans
    Often there is no distinct history of trauma, although this is the most common cause.
    It usually occurs in the large muscles of the extremities and in the early stages it can be
    difficult to distinguish from soft-tissue sarcomas. It is, however, separate from bone, unlike
    parosteal sarcoma and post-traumatic periostitis. This is a self-limiting condition, most
    commonly occurring in young athletic adults, with resorption occurring in approximately
    one year
42
Q
  1. A 60 year old man is referred for an MRI of his left upper leg after noticing a slowly
    enlarging firm mass measuring approximately 7–8 cm in maximum diameter.
    The mass is located in the quadriceps muscle group and is causing cortical erosion
    of adjacent bone. There are poorly defined calcifications within it and MR shows a
    poorly defined lesion which is isointense to muscle on T1-weighted imaging and
    hyperintense on T2-weighted imaging. The most likely diagnosis is:
    a. Malignant fibrous histiocytoma
    b. Benign fibrous histiocytoma
    c. Liposarcoma
    d. Fibrosarcoma
    e. Elastofibroma
A
  1. a. Malignant fibrous histiocytoma
    Soft-tissue malignant fibrous histiocytoma is the most common primary malignant softtissue
    tumour of later adulthood. It is most commonly seen in the lower extremities. It has a
    metastatic rate of 42% and most commonly metastasises to the lung. Osseous malignant
    fibrous histiocytoma presents as a painful, tender, rapidly enlarging mass and most
    commonly arises in the metaphysis of long bones.
43
Q
  1. A 27 year old man who attends A&E following an alleged assault is shown to have
    a left-sided longitudinal temporal bone fracture. Which of the following is a correct
    association?
    a. Facial nerve palsy in 50% of cases
    b. Incudostapedial joint dislocation
    c. Sensorineural hearing loss
    d. Ophthalmoplegia
    e. Rhinorrhoea
A
  1. b. Incudostapedial joint dislocation
    Longitudinal fractures of the temporal bone are more common than transverse fractures
    and account for over 85% of temporal bone fractures. They are associated with otorrhea,
    conductive hearing loss, pneumocephalus, herniation of the temporal lobe and incudostapedial
    dislocation. Transverse fractures are associated with sensorineural hearing loss, and a
    higher percentage of facial nerve palsies
44
Q
  1. A 24 year old woman presents with a painless mass on the dorsal aspect of the right
    index finger measuring approximately 11 cm. MRI shows a lobulated lesion which
    has low signal intensity on both T1- and T2-weighted imaging. Which of the following
    is the most likely diagnosis?
    a. Haemangioma
    b. Lipoma
    c. Ganglion cyst
    d. Giant cell tumour of the tendon sheath
    e. Neurilemmoma
A
  1. d. Giant cell tumour of the tendon sheath
    This is a benign lesion thought to represent an extra-articular form of pigmented villonodular
    hyperplasia. This is low signal on both T1- and T2-weighted imaging due to
    haemosiderin deposition. It most commonly affects the fingers and characteristically lies
    along a tendon sheath
45
Q
  1. A dental radiograph of a 47 year old woman shows loss of the lamina dura of the
    majority of the teeth. Which of the following would be a possible cause?
    a. Osteopetrosis
    b. Hypoparathyroidism
    c. Scleroderma
    d. Sickle cell anaemia
    e. Myeloma
A
  1. c. Scleroderma
    The other causes of loss of the lamina dura include Cushing’s disease, Paget’s, hyperparathyroidism,
    osteoporosis, osteomalacia, leukaemia, metastases and Langerhans’ cell histiocytosis.
    Both osteopetrosis and hypoparathyroidism cause thickening of the lamina dura of
    the teeth.
46
Q
  1. A 28 year old long-distance runner is to undergo MR arthrography of the hip joint
    for a suspected labral tear. Which of the following statements is correct regarding
    MR arthrography?
    a. A solution of 20mmol/L gadopentetate dimeglumine is injected into the hip joint
    under fluoroscopic guidance
    b. Patients with developmental dysplasia of the hip are at increased risk of labral tears
    c. A communication between the joint capsule and the iliopsoas bursa is always
    pathological
    d. T2-weighted imaging is used to visualise the high signal of the gadopentetate
    dimeglumine solution
    e. The normal labrum has uniformly high signal on T1-weighted imaging
A
  1. b. Patients with developmental dysplasia of the hip are at increased risk of labral
    tears
    The increased risk of labral tears in developmental dysplasia is due to the increased stress
    placed upon the acetabular rim and labrum. A communication between the joint capsule
    and iliopsoas bursa has been described as a normal finding in 10–15% of patients. A dilute
    solution of 0.2mmol/L gadopentetate dimeglumine solution would usually be used for
    arthrography. A normal labrum has uniformly low signal on T1-weighted imaging with slightly increased signal on gradient echo imaging. Appearances on T2-weighted imaging
    can be more variable.
47
Q
  1. A 24 year old woman presents with worsening frontal headaches and a sixth nerve
    palsy. A non-enhanced CT shows a lesion situated within the clivus with associated
    bony destruction; there is soft-tissue extension into the nasopharynx. MRI shows a
    large inter-osseous mass which is isointense to brain T1-weighted imaging and hyperintense
    on T2. The most likely diagnosis is:
    a. Sphenoid sinus cyst
    b. Meningioma
    c. Nasopharyngeal carcinoma
    d. Metastasis
    e. Spheno-occipital chordoma
A
  1. e. Spheno-occipital chordoma
    The most likely cause is a spheno-occipital chordoma. This is associated with bony
    destruction in 90% of cases and is most usually within the clivus. Other sites include the
    sella, petrous temporal bone, floor of middle cranial fossa and jugular fossa. Sacrococcygeal
    chordoma is the most common subtype of chordoma and is usually located with the fourth
    or fifth sacral segments. Vertebral/spinal chordoma accounts for only 15–20% of all
    chordomas and is most often situated in the cervical spine.
48
Q
  1. Regarding scaphoid fractures, which of the following statements is correct?
    a. 80% of scaphoid fractures occur at the waist
    b. Approximately 5% of scaphoid fractures are complicated by avascular necrosis
    c. Injury is typically due to hyperextension
    d. Up to 60% of scaphoid fractures cannot be seen on initial radiograph
    e. The specificity of CT in diagnosing scaphoid fractures is 60–70%
A
  1. c. Injury is typically due to hyperextension
    The scaphoid bone is the most commonly fractured carpal bone and the mechanism is
    usually a fall onto the outstretched hand – ie. hyperextension of the wrist. The reported
    sensitivities and specificities of CT are 89–97% and 85–100%, respectively. The high
    negative predictive value of CT (96.8–99%) makes it very useful for ruling out a fracture.
    Scaphoid fractures are missed on initial radiographs in up to 30% of cases.
    (Ref: Kaewlai R et al. Multidetector CT of carpal injuries: anatomy, fractures, and fracturedislocations.
49
Q
  1. A 24 year old man is involved in a road traffic accident. On arrival in A&E he is
    haemodynamically unstable and there is concern regarding pelvic fracture and associated
    active extravasation. On multidetector CT, which of the following features is more
    suggestive of pseudoaneurysm than active extravasation?
    a. Ill-defined area of high attenaution on arterial phase imaging
    b. Presence of a haemoperitoneum
    c. Washout of the high-attenuation area on delayed imaging
    d. Layering appearance on delayed imaging
    e. Haemodynamically unstable patient
A
  1. c. Washout of the high-attenuation area on delayed imaging
    Washout of the high-attenuation area is one of the features of a pseudoaneurysm.
    A pseudoaneurysm is likely to be adjacent to a vessel and whilst there will be a relatively
    well-defined area of high attenuation on arterial phase imaging, this will diminish in
    intensity on five-minute delayed imaging. In contrast to this, an area of active extravasation
    will often appear as a jet of high attenuation which continues to collect and enlarge on
    delayed phase imaging
50
Q
  1. A 27 year old woman is brought into A&E following a road traffic accident in which
    she was knocked down by a car. On arrival she has a GCS of 15 but is haemodynamically
    unstable and on examination she has abdominal bruising. The A&E consultant
    has performed a FAST (focused assessment with sonography in trauma) scan in resus
    and cannot see evidence of free fluid. What is the approximate minimal detectable fluid
    volume by FAST scanning?
    a. 10 ml
    b. 50 ml
    c. 100 ml
    d. 200 ml
    e. 500 ml
A
  1. d. 200 ml
    The approximate minimal detectable fluid volume is 200 ml. The distribution of free fluid
    will be determined by both anatomical and physiologic factors and therefore the sensitivity
    of the scan will depend upon the areas scanned. Ultrasound is often used in conjunction
    with multidetector CT, particularly in the management of patients who have been involved
    in trauma.
51
Q
  1. An A&E SHO has asked you to review a paediatric cervical spine plain film which has
    been performed on a child who has been involved in a road traffic accident. He is
    unsure as to whether or not the appearances are normal for a paediatric cervical spine
    film. Which of the following findings is more likely to represent a true cervical spine
    injury than a normal variant?
    a. Absence of usual cervical lordosis
    b. Widening of the prevertebral soft tissues in expiration
    c. Increased distance between the tips of the C1 and C2 spinous processes in flexion
    d. Wedging of the anterior aspect of the C3 vertebral body
    e. A 7mm gap between the occipital condyles and the condylar surface of the atlas
A
  1. e. A 7mm gap between the occipital condyles and the condylar surface of the atlas
    This is highly suggestive of craniocervical injury; these injuries are often fatal and are often
    caused by sudden deceleration. Radiologic evaluation of this injury can be difficult but is
    crucial in determining further management. The remainder of the findings above can all be normal variants in the paediatric cervical spine and therefore should be interpreted
    with care.
52
Q
  1. A 24 year old man has injured his right ankle playing football. The A&E SHO has
    asked your opinion on the plain radiographs. These show a widening of the medial
    joint space on the AP ankle view but no evidence of fracture, and an oblique fracture
    of the proximal shaft of the fibula. This is the typical appearance for which of the
    following fractures?
    a. Weber B
    b. Maisonneuve
    c. Pilon
    d. Dupuytren’s
    e. Fibula stress fracture
A
  1. b. Maisonneuve
    This is the description of a Maisonneuve fracture (sometimes classified as Weber C3). This
    injury is often overlooked as the patient may complain only of ankle pain and hence a full
    tibia/fibula plain film is not taken. This fracture is often associated with ligamentous injury
    at the ankle, most usually of the anterior talofibular ligament and the postero-inferior
    talofibular ligament.
53
Q
  1. An 18 year old man undergoes a Tc MDP bone scan to investigate pain in the right hip.
    A ‘hot’ lesion is seen in the right proximal femur. No other lesions are seen. Which
    of the following lesions would appear as ‘hot’ on a Tc MDP bone scan?
    a. Osteopoikilosis
    b. Fibrous cortical defect
    c. Acute fracture within 12 hours of injury
    d. Fibrous dysplasia
    e. Haemangioma
A
  1. d. Fibrous dysplasia
    The most common site of monostotic fibrous dysplasia is the ribs, followed by proximal
    femur and craniofacial bones. Three-quarters of cases present before age 30. Other benign
    lesions causing a ‘hot’ on bone scan include Paget’s disease, brown tumours, aneurysmal
    bone cysts, osteoid osteoma and chondroblastoma.
    Acute fractures are not usually ‘hot’ until after the first 24–48 hours.
54
Q
  1. A three month old boy presents with several small painful soft-tissue swellings which
    have developed over the mandibular region and the right clavicle. Plain films show
    marked periosteal new bone formation and localised soft-tissue swelling. There is also
    bone expansion with remodelling of old cortex. The most likely diagnosis is:
    a. Caffey disease
    b. Hypervitaminosis A
    c. Infantile myofibromatosis
    d. Scurvy
    e. Kinky hair syndrome
A
  1. a. Caffey disease
    The most likely diagnosis is Caffey disease. This is a relatively rare self-limiting condition
    which usually presents before six months of age. The mandible is the most common site and
    accounts for 80% of cases, followed by the clavicle and the upper limb bones.
55
Q
  1. A 29 year old woman presents with a painful right knee which has been worsening over
    the previous few weeks. A plain film of the right knee shows an oval expansile lesion
    with a radiolucent centre in the metaphyseal region of the proximal tibia. There is a
    sclerotic margin and geographic bone destruction. There are internal septations and
    stippled calcification. There is no periosteal reaction. The most likely diagnosis is:
    a. Non-ossifying fibroma
    b. Chondroblastoma
    c. Giant cell tumour
    d. Chondromyxoid fibroma
    e. Chondrosarcoma
A
  1. d. Chondromyxoid fibroma
    This is most commonly seen in the second and third decades and the most common site is
    the long bones, most often the proximal tibia and distal femur. Non-ossifying fibroma is
    usually asymptomatic. The appearances of a chondroblastoma would be similar but this
    would most likely be epiphyseal in location and usually presents in a slightly younger age
    group.
56
Q
  1. A 56 year old woman who has had chronic wrist pain since a fall several months
    previously is referred for an MR arthrogram of her wrist with a suspected triangular
    fibrocartilage complex (TFCC) tear. Which of the following would be the best
    sequence for visualising a TFCC tear?
    a. T1 axial
    b. T2 coronal
    c. Gradient echo sagittal
    d. T2 sagittal
    e. T1 sagittal
A
  1. b. T2 coronal
    The best sequence would be a T2 or T2* image for detecting a tear. This is also a useful
    plane in which to assess for ulnar variance; positive ulnar variance has an association with
    perforations. The central portion of the articular disc is not well vascularised and therefore
    a tear in this portion will heal poorly. The peripheral portion, however, has been
    vascularised.
57
Q
  1. A 64 year old woman undergoes MRI of her left knee for investigation of chronic knee
    pain. Which of the following would be considered an abnormal finding on MR?
    a. Bowing of the posterior collateral ligament on sagittal imaging
    b. Low signal ACL on T1-weighted imaging
    c. High signal around the MCL on T2* on coronal imaging
    d. Low signal of the menisci on both T1- and T2-weighted imaging
    e. Medial patellar plica
A
  1. c. High signal around the MCL on T2* on coronal imaging
    The only abnormal finding is the presence of high signal around the MCL on T2* imaging.
    This would represent oedema or haemorrhage around the MCL and may be associated with
    a tear. Bowing of the PCL occurs when the knee is extended. A medial patellar plica is a normal finding in approximately 50% of the population. This is an embryological
    remnant from when the knee was divided into three compartments
58
Q
  1. A 53 year old woman attends A&E with a short history of dull right heel pain. She is
    otherwise fit and well and there is no history of trauma. Plain radiographs of the right
    foot and ankle reveal a 2 cm expansile non-aggressive lesion in the calcaneum. It has
    a thin, well-defined sclerotic border. There is no periosteal reaction but there is a
    small calcified central nidus. The most likely cause of the lesion is:
    a. Aneurysmal bone cyst
    b. Intra-osseous lipoma
    c. Lipoblastoma
    d. Fibrous dysplasia
    e. Desmoplastic fibroma
A
  1. b. Intra-osseous lipoma
    The calcaneum is a common location for an intra-osseous lipoma. They do, however, also
    occur in the extremities, skull and mandible. There is no periosteal reaction unless there is
    an associated fracture. Imaging features would be similar to those of a unicameral bone cyst.
    They are often asymptomatic but can present with localised bone pain
59
Q
  1. A three-year-old boy attends A&E with a history of a seizure. He has known congenital
    cardiomyopathy. A chest radiograph shows sclerosis and expansion of several ribs.
    Previous plain films have shown bone islands within the vertebrae and long bones and
    bone cysts within the phalanges. Which of the following conditions would be likely to
    underly these findings?
    a. Down’s syndrome
    b. Tuberous sclerosis
    c. Sturge–Weber syndrome
    d. Neurofibromatosis
    e. Sarcoidosis
A
  1. b. Tuberous sclerosis
    This is a multi-system autosomal dominant disorder affecting the central nervous system,
    kidneys, lung and heart. The classic triad of facial angiofibroma, epileptic seizures and
    mental retardation is only seen in approximately 30% of patients. Skeletal abnormalities
    include sclerotic calvarial patches or ‘bone islands’, thickening of diploe, expansion and
    sclerosis of ribs and periosteal thickening of long bones. Gracile ribs are often seen in
    association with Down’s syndrome
60
Q
  1. A 27 year old man falls onto his right hand during a game of rugby. He attends the
    A&E department and a plain film of the right hand shows a comminuted fracture
    through the base of the thumb metacarpal with an intra-articular component.
    This is the description of which of the following fractures?
    a. Rolando’s fracture
    b. Bennett’s fracture
    c. Gamekeeper’s thumb
    d. Boxer’s fracture
    e. Barton’s fracture
A
  1. a. Rolando’s fracture
    This is the classic description of a Rolando’s fracture. A Bennett’s fracture is also a fracture
    of the base of the first metacarpal but with no comminution; this fracture is often less stable
    than a Rolando’s fracture and more often requires surgical fixation. A ‘gamekeeper’s thumb’
    often occurs as the result of forced abduction of the thumb and results in disruption of the
    ulnar collateral ligament.