VIQ - MSK Flashcards
@# 14) In the spectrum of perilunate ligamentous injuries and instability, volar tilt of the lunate, seen as a triangular or ‘pie-shaped’ lunate on the AP projection of the wrist, is most commonly a feature of which of the following?
a. scapholunate dissociation
b. perilunate dislocation
c. lunate dislocation
d. volar intercalated segmental instability
e. dorsal intercalated segmental instability
c. lunate dislocation
The lesser arc refers to the arc of ligamentous attachments around the lunate.
These ligaments become disrupted in a stepwise four-stage fashion.
Stage I injury is to the scapholunate ligament, leading to dissociation with rotary subluxation of the scaphoid.
Stage II is radiographically characterized by perilunate dislocation, caused by additional injury to the capitolunate joint. The carpus migrates dorsally and the lunate maintains a normal relationship with the radius.
Stage III involves the triquetrolunate ligaments,
and stage IV is complete disruption of the perilunate ligaments, allowing dislocation and rotation of the lunate. It is this rotation that creates the triangular outline on AP radiographs. Segmental instabilities relate to the spectrum of dynamic scaphoid instability.
@# 33) A 23-year-old man falls onto his outstretched right hand with his elbow flexed. AP and lateral radiographs of the mid-forearm reveal a fracture of the middle third of the radius. Which additional radiograph should be performed?
a. clavicle
b. shoulder
c. elbow
d. oblique forearm
e. wrist
e. wrist
A Galeazzi fracture–dislocation is a pattern of injury sustained by falling on an outstretched hand with a flexed elbow. It most commonly consists of a fracture of the radial diaphysis with dislocation or subluxation of the distal radioulnar joint. It is associated with a high rate of non-union, and one or both components are usually treated with surgical fixation.
It is important therefore that the radiologist can recognize potential patterns of injury and radiographically demonstrate their full extent. As a general rule, fractures should be viewed in two orthogonal planes, as should the joint above and below any fracture.
The opposite pattern, of an ulnar shaft fracture with dislocation of the proximal radial head, is termed a Monteggia fracture–dislocation.
A mnemonic for remembering the two is Glasgow Rangers (Galeazzi, radius) and Manchester United (Monteggia, ulna), which indicates for each injury which of the forearm bones is fractured.
@# 48) A young male patient sustains an external rotational injury to his left ankle and is unable to bear weight. A plain radiograph of the ankle performed in accident and emergency shows no fracture but does show soft-tissue swelling over the medial malleolus and widening of the ankle joint space medially (lateral talar shift). Which of the following additional view(s) should be performed?
a. mortise view
b. calcaneus
c. foot
d. knee
e. contralateral ankle
d. knee
The Maisonneuve fracture is a spiral fracture of the upper third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane.
The medial component of the injury may be an associated fracture of the medial malleolus or rupture of the deep deltoid ligament.
The ankle joint is effectively a bony ring that extends up to the knee.
Interruption of the ring in this way allows lateral displacement of the fibula and so disruption of the congruence of the ankle mortise, resulting in an unstable ankle injury that requires surgical fixation.
@# 51) At which of the following skeletal locations does avascular osteonecrosis typically only occur in the presence of an associated fracture?
a. medial tibial condyle
b. second metatarsal head
c. lunate
d. femoral head
e. proximal scaphoid pole
e. proximal scaphoid pole
Osteonecrosis may be caused by two mechanisms: interruption of arterial supply, and intra- or extra-osseous venous insufficiency.
Interruption of vascular supply is usually associated with a fracture, as seen in the proximal scaphoid following waist fractures.
Femoral head osteonecrosis can occur with subcapital fractures, or without fracture as in Legg–Calve´ –Perthes disease.
Other common locations that may develop osteonecrosis without overt fracture include the medial tibial condyle (Blount’s disease), metatarsal head (Freiberg’s infraction) and the lunate (Kienbock’s disease).
Radiographic findings often lag several months behind the injury or onset of symptoms, and MR is the most sensitive imaging modality.
Radiographic signs include focal radiolucencies, sclerosis, bone collapse and loss of joint space.
@#e2 57) Of the following eponyms associated with fractures, which relates to a fracture–dislocation?
a. Segond
b. Jones
c. Smith
d. Barton
e. Hutchinson
d. Barton
The use of eponymous names for fractures allows quick and accurate identification and communication of bone injuries while simultaneously alerting clinicians to the potential complications associated with a given fracture pattern. This is also particularly useful when describing complex radiographic appearances to someone remote from the images. The full value of such eponyms depends on accurate use and understanding of their meaning:
Barton’s fracture–dislocation is an intra-articular fracture of the dorsal margin of the distal radius with dorsal dislocation of the radiocarpal joint;
Segond’s fracture is an avulsion fracture of the proximal lateral tibia;
Jones’ fracture is a transverse fracture of the base of the fifth metatarsal, at the junction of the diaphysis and metaphysis;
Smith’s fracture is a distal radial fracture with ventral displacement;
and Hutchinson’s fracture is a triangular fracture of the radial styloid.
@#e2 62) A middle-aged woman falls on an outstretched hand, which becomes immediately painful and swollen. A lateral radiograph shows a small fracture fragment dorsal to the carpus, and the AP radiograph appears normal. Which carpal bone is most likely to be fractured?
a. scaphoid
b. lunate
c. triquetrum
d. capitate
e. hamate
c. triquetrum
Carpal fractures in general are much less common than fractures to the distal radius. The two bones most commonly injured are the scaphoid (75%) followed by the triquetrum (14%), and these provide a greater diagnostic challenge radiographically than distal radial fractures.
Triquetrum fractures generally occur on the dorsal surface due to avulsion of the dorsal radiocarpal ligament, or shearing forces from impaction with the ulnar styloid or hamate in hyperextension.
Less commonly, the body of the bone can fracture in a transverse pattern.
A posterior chip fragment can often be seen with dorsal surface fractures, but is only visualized on the lateral view.
Such an injury may be a primary triquetrum injury (such as avulsion) or related to a perilunate fracture–dislocation.
@#e2 24 A 32 year old man falls on his outstretched right wrist whilst playing football. Wrist X-ray reveals a displaced, oblique intraarticular fracture of the dorsal lip of the distal radius. What is the fracture type described?
(a) Barton’s
(b) Chauffeur’s
(c) Calles’
(d) Smith’s
(e) Salter Harris Type II
(a) Barton’s
A Barton’s fracture refers to an intra-articular fracture through the distal radius. The conventional Barton fracture involves the dorsal rim of the radius, the reverse Barton involves the volar rim.
Salter-Hanis fractures involve the growth plate before closure;
the other types described are not intra-articular.
Calles’ and Smith’s are fractures of the distal radius with dorsal and volar displacement of the distal fragments, respectively.
A chauffeur fracture is a triangular fracture of the radial styloid process.
@#e2 36 A patient has injured his right shoulder. An AP view demonstrates an acromio-clavicular distance of 12 mm and a coraco-clavicular distance of 10 mm. The clavicle is not otherwise grossly displaced. What is the grade of the acromio-clavicular joint injury?
(a) Grade I
(b) Grade II
(c) Grade Ill
(d) Grade IV
(e) Grade V
(b) Grade II
@# 53 A 15 year old boy presents with a history of right knee clicking, locking and intermittent swelling. There is no clear history of trauma. MRI shows a focus of abnormal signal in the subarticular marrow, a defect in the overlying cartilage, a loose intra-articular body and a small effusion.
What is the likeliest site of the cartilaginous defect?
(a) Medial aspect of the lateral condyle
(b) Lateral aspect of the lateral condyle
(c) Medial aspect of the medial condyle
(d) Lateral aspect of the medial condyle
(e) Posterior surface of the patella
(d) Lateral aspect of the medial condyle
Osteochondritis dissecans is the fragmentation and sometimes separation of a portion of the articular surface usually seen in adolescent males. It is most commonly related to repetitive
microtrauma although associations with other conditions such as Osgood-Schlatter’s and Scheuerman’s disease have been reported. It is most common in the medial femoral condyle although the humerus, capitellum and talus may be involved. It is bilateral in 10-20%.
@# 17 A young man avulses his anterior inferior iliac spine whilst kicking a football. The origin of which muscle will be affected?
(a) Adductor magnus
(b) lliopsoas
(c) Rectus femoris
(d) Sartorius
(e) Tensor fasciae latae
(c) Rectus femoris
The anterior inferior iliac spine is the origin of rectus femoris.
@#e2 51 A patient presents with wrist pain subsequent to a fall. Carpal instability is suspected and a lateral radiograph is taken of the wrist in neutral alignment. The scapholunate angle is 70° and the capitolunate angle is 10°. What is the most appropriate description?
(a) Normal
(b) Scapholunate dissociation
(c) Volar intercalated segment instability
(d) Dorsal intercalated segment instability
(e) Scapholunate advanced collapse
(b) Scapholunate dissociation
@#e2 6. A 60-year-old woman undergoing follow-up CT under the care of the oncologist develops a new expansile lytic lesion. Which of the following primary tumours usually causes an expansile lytic metastasis?
A. Cervix
B. Uterus
C. Ovary
D. Thyroid
E. Rectum
D. Thyroid
Renal cell carcinoma also causes expansile lytic metastases.
@# 24. Plain film, CT and MRI are performed for the investigation of suspected chordoma. Which is the best answer?
A. Radiographic appearances show sacral osteosclerosis
B. Coarse calcification often present with associated soft tissue
C. Areas of low attenuation within a mass on CT
D. Intermediate SI on T2
E. Arise from the spinal canal
C. Areas of low attenuation within a mass on CT
Chordoma usually appears as a low attenuation mass on CT.
@# 12) A female adult patient with right shoulder pain is shown to have multiple markedly expansile lytic lesions within the scapula and clavicle secondary to metastatic malignant spread. Which of thefollowing is most likely to be the primary site of malignancy?
a. renal
b. breast
c. cervical
d. colon
e. bronchus
a. renal
The common cancers that typically metastasize to bone are breast, lung, thyroid, renal and prostate. Due to the high prevalence of colon cancer, even though only a relatively small proportion metastasizes to bone, it forms a significant proportion of bone metastases.
Prostatic metastases are typically sclerotic, whereas breast deposits are mixed.
Colonic bone metastases are usually lytic, with renal metastases typically lytic and expansile due to their highly vascular nature.
Other less frequent sources of lytic expansile metastases include thyroid, melanoma andphaeochromocytoma.
@# 13) A ‘fallen fragment’ seen within a lytic bone lesion is most commonly associated with which of the following?
a. aneurysmal bone cyst
b. unicameral (simple) bone cyst
c. giant cell tumour
d. eosinophilic granuloma
e. chondroblastoma
b. unicameral (simple) bone cyst
The fallen fragment is virtually pathognomonic for a simple bone cyst. It represents a fragment from a pathological fracture through the lesion, which has fallen to lie in a dependent location in the cyst matrix.
@#e2 (Ped) 22) A 4-year-old boy is investigated for abnormal gait, with swelling and deformity of the right lower leg. Radiographs reveal epiphyseal irregularity and multiple abnormal ossifications around the medial portions of the distal femoral, and proximal and distal tibial epiphyses of the affected leg, with normal appearances of the lateral epiphyses and the whole of the contralateral lower limb. MRI demonstrates that the ossifications lie within the epiphyseal cartilage. What is the described condition?
a. hereditary multiple exostoses
b. Trevor’s disease
c. Ollier’s disease
d. Morquio’s syndrome
e. warfarin embryopathy
b. Trevor’s disease
Trevor’s disease (also called dysplasia epiphysealis hemimelica) is a rare developmental bone dysplasia.
It primarily occurs in children aged 2–4 years and affects boys more commonly than girls.
It shows a preponderance for the lower limbs, most commonly affecting the knee and ankle, and demonstrates single or multiple osteocartilaginous tumours arising from epiphyses.
The lesion is characteristically hemimelic, involving either the medial (two-thirds of cases) or lateral aspect of the ossification centres. Cases can be classified as localized, classic or generalized.
