Musculoskeletal and Trauma - Practice papers

Question 1

@# 1. Morton neuroma:
a) Is typically found in the 4th intermetatarsal space
b) Is of high signal on T2 weighted MRI
c) Is asymptomatic
d) On ultrasound, has the appearance of an ovoid hypoechoic mass orientated parallel to the
long axis of the metatarsal bones
e) Has a high malignant potential

Answer 1

1.
a) False - 3rd intermetatarsal space
a) False - low
b) False - usually presents with burning/electric forefoot pain
c) False - hyperechoic
d) False - benign lesion

Question 2

@# 2. The following are recognized associations:
a) Madelung’s deformity and Turner’s syndrome
b) Superior rib notching and osteogenesis imperfecta
c) Erosion of the outer end of the clavicle and pyknodysostosis
d) Erlenmeyer flask deformity and Noonan’s syndrome
e) Arachnodactyly and homocystinuria

Answer 2

2.
a. True - other causes include diaphyseal aclasia, post-infection, post-trauma, Leri-Weil
disease
b) True - other causes include rheumatoid arthritis, systemic lupus erythematosus,
scleroderma, Sjogren’s disease, hyperparathyroidism, neurofibromatosis, poliomyelitis,
progeria, Marfan’s syndrome
c) True - other causes include rheumatoid arthritis, multiple myeloma, metastases,
hyperparathyroidism, cleidocranial dysplasia
d) False
e) True - Marfan’s syndrome is another cause

Question 3

@# 3. Causes of acro-osteolysis include:
a) Leprosy
b) Frostbite
c) Hyperparathyroidism
d) Phenytoin toxicity
e) Syringomyelia

Answer 3

3.
a) True
b) True
c) True
d) True
e) True

Question 4

@# 4. The following statements regarding bone marrow are true:
a) Yellow marrow decreases with age
b) Red marrow is of high signal on T1 weighted MRI images
c) Yellow marrow is of high signal on T2 weighted MRI images
d) Radiotherapy causes marked reduction in yellow marrow
e) Osteopetrosis is characterised by reduced signal on T2 weighted MRI images

Answer 4

4.
a) False - yellow marrow increases with age
b) False - red marrow is of low signal on T1 and high signal on T2 weighted MRI images
c) True - yellow marrow is of high signal on T1 and T2 weighted MRI images
d) False
e) True - osteopetrosis is characterised by reduced signal on T1 and T2 weighted MRI images

Question 5

@# 5. Concerning aneurysmal bone cysts:
a) 60-80% of aneurysmal bone cysts are found in under 20-year-olds
b) Periosteal reaction is a pathognomonic feature
c) Hypervascularity is usually seen in the periphery of the lesion
d) They demonstrate a fluid-fluid level on CT
e) They have a recurrence rate of 20-30% after surgical treatment

Answer 5

5.
a) True
b) False - no periosteal reaction unless there is a fracture
c) True - peripheral hypervascularity is seen in 75% of lesions
d) True
e) True - recurrence rate of 20-30%

Question 6

@# 6. Regarding blunt trauma to the pancreas:
a) Injury to the pancreas occurs in 25-30% of blunt abdominal trauma patients
b) The majority of injuries occur in the pancreatic tail
c) Isolated pancreatic injuries occur in 85-90% of cases
d) A pancreatic laceration appears as a high attenuation lesion on contrast-enhanced CT
e) Integrity of the pancreatic duct is an important factor in determining outcome following
pancreatic injury

Answer 6

6.
a) False - pancreatic injury occurs in 2%
b) False - two thirds of injuries occur in the pancreatic body
c) False - 90% of cases have associated injuries, especially to the liver, spleen, duodenum and
stomach
d) False - low attenuation lesion
e) True - pancreatic duct disruption is associated with increased fistula and abscess formation,
and increased mortality

Question 7

@# 7. Shoulder anatomy:
a) In an intact rotator cuff there is communication between the glenohumeral joint and the
subacromial-subdeltoid bursae
b) Subscapularis, infraspinatus and teres minor insert onto the greater tuberosity
c) Rotator cuff tears most commonly involve the supraspinatus portion of the cuff
d) Long head of biceps runs in the bicipital groove to insert into the infraglenoid tubercle
e) Normal glenoid labrum is of high signal on a T2 weighted fat- saturated MRI image

Answer 7

7.
a) False - no communication
b) False - supraspinatus, infraspinatus and teres minor attach to the greater trochanter,
subscapularis attaches to the lesser tuberosity
c) True
d) False - supraglenoid tubercle
e) False - low signal

Question 8

@# 8. Desirable properties of a radionuclide for imaging are:
a) Decay to a stable daughter
b) A physical half-life of a few minutes
c) Decay by electron capture
d) Decay by isomeric transition
e) Emit gamma rays of energy 350-550 kiloelectron volts (keV)

Answer 8

8.
a) True
b) False - if too short, much more activity must be prepared than is actually injected.
Therefore, a half-life of a few hours is preferred
c) True
d) True
e) False - 50-300 keV

Question 9

@# 9. Regarding diffuse idiopathic skeletal hyperostosis:
a) Highest incidence in the 3rd to 5th decades
b) Most commonly involves the cervical spine
c) Sacroiliac joints are usually involved when the lumbar spine is
d) Extraspinal ligamentous hyperostosis is a feature
e) In the thoracic spine the hyperostotic changes are more prominent on the right

Answer 9

9.
a) False - >50 years. Males. Females
b) False - lower thoracic spine
c) False - no sacroiliac joint involvement though sometimes appearances in the spine are
similar to ankylosing spondylitis
d) True - most often seen at the pelvis, patella, calcaneum, olecranon
e) True - pulsating aorta on left side reduces ossification

Question 10

@# 10. Vertebroplasty:
a) Has no role in patients with osteolytic vertebral metastases
b) Use of percutaneous vertebroplasty in patients with multiple myeloma prevents subsequent
radiation therapy
c) Extensive vertebral destruction is a contraindication to vertebroplasty
d) For the lumbar spine, a 12-15-gauge needle is used
e) Methyl methacrylate polymer cement is used

Answer 10

10.
a) False - common indications are metastases, osteoporotic collapse, vertebral haemangiomas
b) False - radiation has no effect on the constitution of cement
c) False - significant destruction/collapse makes the procedure difficult but not a
contraindication. Contraindications include infection, coagulation disorders, if facilities for
emergency decompression surgery are not available
d) False - lumbar and lower thoracic - 10-11-gauge, cervical and upper thoracic - 12-15-gauge
e) True

Question 11

@#e 11. The following descriptions of the fractures are correct:
a) Monteggia fracture - ulnar fracture with dislocation of the radial head
b) Galleazi fracture - distal radial fracture with dislocation of distal radioulnar joint
c) Segond fracture - cortical avulsion fracture of proximal lateral tibia
d) Chauffer’s fracture - triangular fracture of radial styloid process
e) Pott’s fracture - tibia fracture above an intact tibiofibular ligament

Answer 11

11.
a) True
b) True
c) True
d) True
e) False - fibula fracture

Question 12

@# 12. Trauma to the spleen:
a) In blunt abdominal trauma the spleen is injured in 50-60% of significant abdominal injuries
b) Hypotension is a presenting symptom of splenic trauma in less than 40% of cases
c) At least 500 ml of intra-abdominal fluid is required for detection by focused abdominal
ultrasonography in trauma (FAST)
d) Splenic injury can be reliably excluded by the absence of free fluid in the peritoneal cavity
e) Acute splenic lacerations appear as hyperechoic regions on ultrasound

Answer 12

12.
a) False- 20-30%
b) True - 25-30%
c) False - about 100 mls
d) False - 12% have no free fluid
e) False - hypoechoic lesion

Question 13

@# 13. Regarding lumbar spondylolisthesis:
a) Degenerative spondylolisthesis most commonly affects L5/S1
b) Spondyloptosis is a complete slip of L5 on S1
c) Degenerative spondylolisthesis is commoner in men
d) Facet joint synovial cysts are associated with degenerative spondylolisthesis
e) Traumatic spondylolisthesis accounts for 20-30% of spondylolistheses

Answer 13

13.
a) False - L4/5
b) True
c) False - 4 times more in women
d) True
e) False - rare

Question 14

@# 14. Causes for a superscan on bone scintigraphy include:
a) Renal osteodystrophy
b) Osteomalacia
c) Hyperparathyroidism
d) Hyperthyroidism
e) Diffuse skeletal metastases

Answer 14

14.
a) True
b) True
c) True
d) True
e) True

Question 15

@# 15. The following are features of hypervitaminosis D:
a) Increased density of the skull
b) Widened zone of provisional calcification
c) Soft tissue calcification
d) Osteoporosis
e) Nephrocalcinosis

Answer 15

15.
a) True
b) True
c) True
d) True - late feature
e) True

Question 16

@# 16. Features of rheumatoid arthritis include:
a) Late involvement of the 2nd and 3rd metacarpophalangeal joints
b) Central bone erosions
c) Ulnar subluxation
d) Juxta-articular osteoporosis
e) Calcification of the triangular fibrocartilage complex

Answer 16

16.
a) False
b) True - marginal and central erosions
c) True
d) True
e) False

Question 17

@# 17. The following are skeletal features of tuberous sclerosis:
a) Multiple bone islands
b) Periosteal reactions
c) Cystic bone lesions
d) Rib expansion
e) Multiple non-ossifying fibromas

Answer 17

17.
a) True
b) True
c) True
d) True
e) False - this is a feature in neurofibromatosis

Question 18

@# 18. The following statements regarding Sudeck’s dystrophy are true:
a) It affects 5-10% of all trauma patients
b) Plain radiograph appearances are of patchy osteopaenia
c) Have increased uptake on a 3-phase bone scan
d) It is associated with Raynaud’s phenomenon
e) Atrophy of the soft tissues occurs early

Answer 18

18.
a) False - 0.01 % of all trauma patients are affected
b) True - patchy osteopaenia is seen in 50% as early as 2-3 weeks after symptom onset
c) True
d) True
e) False - this is an end-stage feature

Question 19

@# 19. The following are features of Gaucher’s disease:
a) Generalised osteopaenia
b) Marked cortical thickening
c) Endosteal scalloping
d) Biconcave ‘fish-mouth’ vertebrae
e) Madelung’s deformity

Answer 19

19.
a) True
b) False
c) True
d) True
e) False

Question 20

@# 20. Regarding stress fractures:
a) 16-detector multislice CT is more accurate than skeletal scintigraphy at identifying stress
fractures
b) Stress fractures account for less than 1 % of all significant sporting injuries
c) A stress fracture is characterised by reduced uptake at the fracture site on a 99m technetium
MDP bone scan
d) Stress fractures only occur in an osteoporotic skeleton
e) Zwas’ system consists of criteria used for diagnosing stress fractures

Answer 20

20.
a) False
b) False - account for more than 10%
c) False - increased uptake at the fracture site on 99m technetium MDP bone scan
d) False - stress fractures occur as a result of a repetitive strain on a bone that has not
accommodated itself to this. Insufficience fractures occur when a normal physiologic stress
is applied to abnormal bone
e) True

Question 21

@# 21. Features found in pigmented villonodular synovitis:
a) Predominantly polyarticular distribution
b) Haemorrhagic ‘chocolate’ effusion
c) Calcification in 50-60%
d) Joint space narrowing is early
e) MRI appearances of high signal on T1 weighted spin-echo MRI images

Answer 21

21.
a) False - monoarticular
b) True
a) False - no calcification
b) False - joint space narrowing is a late feature
c) False - characteristic appearances of low signal on T1 and T2 weighted spin-echo MRI
images due to presence of iron

Question 22

@# 22. Regarding arthrography:
a) 10 ml of air is appropriate for a double-contrast knee arthrogram in an adult
b) Perthes’ disease is an indication for hip arthrography
c) A 22-gauge lumbar puncture needle is commonly used for shoulder arthrography
d) In ankle arthrography 6-8 ml of LOCM 240 is used
e) Presence of intra-articular loose bodies are a recognized contraindication to knee
arthrography

Answer 22

22.
a) False - 40 ml of air is required
b) True - other causes include developmental dysplasia of the hip, trauma, arthropathy
c) True
d) True
e) False

Question 23

@# 23. The following statements regarding musculoskeletal MRI are true:
a) A surface coil gives an improved resolution than the body coil
b) Gradient echo sequences can differentiate articular cartilage from effusion
c) A total hip replacement is usually an absolute contraindication to MRI
d) T wave elevation on ECG is a recognized physiological change by the static magnetic field
of the MRI scanner
e) Claustrophobia may occur in as many as 20% of patients

Answer 23

23.
a) True
b) True
c) False - most orthopaedic implants are safe
d) True
e) False - 10%, 1 % of investigations are curtailed

Question 24

@# 24. Regarding imaging appearances of osteomyelitis:
a) Radiographic findings become evident approximately 3 days after onset of infection
b) Periosteal reaction is the earliest sign of acute osteomyelitis
c) Klebsiella is the commonest organism isolated in adults
d) Chronic osteomyelitis is characterised by prominent cortical thinning
e) The diaphyses are often spared in patients with sickle cell disease

Answer 24

24.
a) False - 1-2 weeks
b) False - soft tissue swelling and loss of normal fat planes
c) False
d) False - thickening
e) False - infection focus at diaphyseal infarcts

Question 25

@# 25. The following statements regarding the imaging of acute cervical spine injuries are true:
a) 10-20% of significant cervical spine injuries are not identified on plain radiographs
b) Flexion/extension views are of little use in the acute setting
c) CT is the imaging modality of choice for soft tissue injuries
d) A fall of greater than 3 metres is a high risk parameter for cervical spine injury
e) T2 fat-saturated images are useful in assessing for bone marrow oedema

Answer 25

25.
a) True - due to poor radiography, errors of image interpretation and absence of signs
b) True - delayed flexion/extension views helpful in identifying soft tissue injuries
c) False - MRI
d) True
e) True - increased signal areas

Question 26

@# 26. The following are causes of painful sclerosis of the medial end of the clavicle:
a) Osteoarthritis
b) Sternoclavicular pyoarthrosis
c) Condensing osteitis
d) Sternocostoclavicular hyperostosis
e) Freidrich’s disease

Answer 26

26.
a) True
b) True
c) True
d) True
e) True - other causes include sclerotic metastases, osteoid osteoma, osteosarcoma, Paget’s
disease and fibrous dysplasia

Question 27

@# 27. Regarding imaging of periosteal reactions:
a) Periosteal reaction becomes apparent 10-20 days following insult
b) Single layered periosteal reaction is a physiological appearance in premature infants
c) Osteomyelitis is a recognized cause of solid periosteal reaction
d) Sunburst periosteal reaction is seen in relation to aggressive tumours
e) Aggressive malignant primary bone tumours are a cause of Codman’s triangle

Answer 27

27.
a) True
b) True - physiological appearance in premature infants up to 6 months old
c) True
d) True - osteosarcoma is commonest
e) True - osteomyelitis and trauma are other causes

Question 28

@# 28. Regarding trauma:
a) Salter Harris 2 fractures involve the articular surface
b) A posterior fat pad can be a normal finding on a lateral X-ray of the elbow
c) Avulsion of the flexor tendon results in a mallet finger
d) Tracking McGregor’s line 1 will help to identify a fracture through the inferior orbital rim
e) In a fracture of the 5th metatarsal the fracture line is usually longitudinal to the long axis of
the metatarsal

Answer 28

28.
a) False - Salter Harris 3 and 4 are intra-articular
b) False
c) False - extensor tendons
d) False - line 2 passes through the zygomatic arch and inferior orbital rim
e) False - the fracture line is transverse to the long axis of the metatarsal

Question 29

@# 29. The following statements regarding a burst fracture of a vertebral body are true:
a) This is most commonly associated with a shearing injury
b) It is most commonly found from T4-T8
c) Other spinal injuries are associated in up to 10-15% of cases
d) Reduced interpedicular distance is a sign on an AP film
e) Concavity of the posterior cortical line is a sign on lateral film

Answer 29

29.
a) False - vertical compression injury
b) False -T12-L2
c) False - other spinal injuries are associated in up to 40% of cases
d) False - increased interpedicular distance is a sign on an AP film
e) False - convexity of the posterior cortical line is a sign on lateral film

Question 30

@# 30. The following are features of transient osteoporosis of the hip:
a) Usually painless
b) Joint space narrowing
c) Reduced uptake on bone scan
d) Pathological fractures are rare
e) Usually bilateral and symmetrical

Answer 30

30.
a) False
b) False
c) False - increased
d) False - common
e) False