FMGE 2023 - Orthopaedics PYQs Practice Questions

Q: A 60-year-old female patient complains of pain and swelling in the left wrist following a fall on an outstretched hand. On examination, dinner fork deformity can be noticed. What is the most likely displacement seen in this patient?

Distal and dorsal displacement of radius. ***Distal and dorsal displacement of radius*** This patient presents with a **Colles' fracture**, the most common distal radius fracture in elderly patients following a fall on an outstretched hand (FOOSH injury). **Key Features of Colles' Fracture:** - Fracture of the **distal radius** (within 2.5 cm of radiocarpal joint) - **Dorsal (posterior) displacement** of the distal fragment - **Dorsal angulation** of the distal fragment - **Radial displacement and shortening** - Creates the characteristic **"dinner fork deformity"** when viewed from the side - The intact proximal radius fragment remains in normal position **Why the dinner fork deformity occurs:** The dorsal displacement and angulation of the distal radius fragment causes the wrist to have a bayonet-like appearance on lateral view, resembling the curve of a dinner fork. *Incorrect - Proximal displacement options:* In Colles' fracture, it is the **distal fragment** that displaces, not the proximal fragment. The proximal radius remains attached to the elbow and stays in its normal anatomical position. *Incorrect - Ventral (volar/palmar) displacement:* Volar displacement would be seen in **Smith's fracture** (reverse Colles'), which is much less common and occurs from a fall on the back of the hand. This would produce a "garden spade deformity," not a dinner fork deformity. *Incorrect - Ulnar displacement:* The ulna is not the primary bone involved in dinner fork deformity. While ulnar styloid fractures may occur concurrently in 50-60% of cases, the characteristic deformity results from distal radius displacement. [Practice more Orthopaedics PYQs on OnCourse]

Q: A 17-year-old boy presents to the clinic complaining of a painless lump on the lateral aspect of his left knee. The radiograph of the patient is shown below. Which of the following is the most likely diagnosis?

Osteochondroma. ***Osteochondroma*** - The radiograph displays a classic **bony exostosis** with a stalk (pedunculated) arising from the metaphyseal region of the distal femur, which is the pathognomonic appearance of an osteochondroma. - These are the most common benign bone tumors, typically presenting in adolescents as a painless, slow-growing mass near the **growth plates** of long bones, especially around the knee. *Enchondroma* - An enchondroma is a benign cartilaginous tumor that develops *within* the **medullary cavity** of a bone, not as an external projection. - They are most commonly found in the small bones of the hands and feet and appear as a lytic lesion with characteristic **"rings and arcs" calcification** on radiographs. *Chondroblastoma* - This is a rare benign cartilaginous tumor that characteristically arises in the **epiphysis** of long bones in skeletally immature patients. - Radiographically, it appears as a well-defined, lytic lesion, often with a thin **sclerotic rim**, located in the end of the bone, unlike the metaphyseal outgrowth seen here. *Giant cell tumor* - This is a locally aggressive tumor that typically affects the **epiphysis** of long bones in skeletally mature adults (age 20-40). - It appears as an eccentric, lytic lesion with a **"soap bubble"** appearance that extends to the subchondral bone, which is inconsistent with the presented image. [Practice more Orthopaedics PYQs on OnCourse]

Q: An elderly patient with the following deformity was brought to the OPD. What is the most probable diagnosis? ![img-13.jpeg](img-13.jpeg)

Rheumatoid arthritis. ***Rheumatoid arthritis*** - The image displays classic deformities of advanced **rheumatoid arthritis**, including **ulnar deviation** of the fingers at the metacarpophalangeal (MCP) joints and swelling, which are characteristic of this condition. - The presence of a subcutaneous nodule over the olecranon process (elbow) is highly suggestive of a **rheumatoid nodule**, a common extra-articular manifestation of the disease. *Rickets* - Rickets is a disease of **children** caused by defective mineralization of growing bone, typically due to **vitamin D deficiency**. This patient is described as elderly. - It presents with skeletal deformities like **bowed legs (genu varum)** and **rachitic rosary**, not the specific erosive small joint arthritis seen in the image. *Osteomalacia* - Osteomalacia is the adult counterpart of rickets, characterized by softening of bones. It typically causes diffuse **bone pain**, muscle weakness, and fractures rather than joint deformities. - It does not cause the **inflammatory synovitis** and characteristic joint erosions that lead to the deformities seen in rheumatoid arthritis. *Osteoarthritis* - Osteoarthritis is a **degenerative** joint disease that typically affects the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints, leading to **Heberden's** and **Bouchard's nodes**, while characteristically sparing the MCP joints. - It lacks the systemic inflammatory features and does not cause **ulnar deviation** or **rheumatoid nodules**. [Practice more Orthopaedics PYQs on OnCourse]

Q: A 20-year-old patient presents with painful swelling in the middle finger around the proximal phalanx. An X-ray was done, and it is shown below. What is the most likely diagnosis? ![img-14.jpeg](img-14.jpeg)

Enchondroma. ***Enchondroma*** - This is the most common primary bone tumor of the hand, typically found in the **phalanges** and **metacarpals** in patients aged 10-40, consistent with this case. - The X-ray shows a classic well-defined, centrally located, **lytic lesion** causing **endosteal scalloping** (thinning of the inner cortex) and expansile remodeling, which are characteristic features of an **enchondroma**. *Osteosarcoma* - **Osteosarcoma** typically arises in the **metaphysis** of long bones like the femur and tibia, and is very rare in the small bones of the hand. - Radiographically, it presents with aggressive features like **cortical destruction**, a soft tissue mass, and a **sunburst** or **Codman's triangle** periosteal reaction, which are absent in this image. *Ewing's sarcoma* - This is a highly malignant tumor that most commonly affects the **diaphysis** (shaft) of long bones and the pelvis; its occurrence in the hand is extremely rare. - It classically shows an aggressive, permeative or **moth-eaten** lytic lesion with a large soft tissue component and a characteristic **onion-skin** periosteal reaction. *Osteoclastoma* - Also known as a Giant Cell Tumor (GCT), it characteristically occurs in the **epiphysis** of long bones in skeletally mature individuals, most commonly around the knee. - The typical radiographic appearance is an eccentric, lytic lesion extending to the subarticular bone, often described as having a **"soap bubble"** appearance, which differs from the findings here. [Practice more Orthopaedics PYQs on OnCourse]

Q: An 80-year-old female patient with a history of slip and fall in the bathroom was brought to the casualty. She is having pain in the left hip and is unable to walk. She has no history of osteoarthritis. On examination, the left lower limb is shortened and externally rotated. X-ray findings are shown below. How will you manage this patient?

Hemiarthroplasty. ***Hemiarthroplasty*** - This is the treatment of choice for a **displaced intracapsular femoral neck fracture** in an elderly patient (typically >75 years) due to the high risk of **avascular necrosis (AVN)** and **non-union** if treated with internal fixation. - It involves replacing the femoral head with a prosthesis, which allows for **early mobilization** and weight-bearing, significantly reducing the risk of complications associated with immobility in geriatric patients, such as DVT and pneumonia. *Internal fixation with cancellous screws* - This approach is reserved for **undisplaced femoral neck fractures** or for displaced fractures in younger, more physiologically fit patients (<65 years) where preserving the native femoral head is a priority. - In an 80-year-old with a displaced fracture and likely poor bone quality, the risk of fixation failure, **non-union**, or subsequent **AVN** is unacceptably high, often requiring a second surgery. *Meyer's operation* - This is a **muscle-pedicle bone graft** procedure, typically using the quadratus femoris, designed to improve the blood supply to the femoral head. - It is not a primary treatment for an acute fracture but is sometimes used as an adjunct to internal fixation in younger patients to prevent AVN, or as a treatment for early-stage AVN itself. *McMurray's osteotomy* - This is a type of **intertrochanteric osteotomy** historically used to treat **non-union** of femoral neck fractures by converting shear forces at the fracture site into compressive forces. - It is not indicated for the primary management of an acute femoral neck fracture in an elderly patient and has been largely superseded by modern arthroplasty techniques. [Practice more Orthopaedics PYQs on OnCourse]

Question 1

A 60-year-old female patient complains of pain and swelling in the left wrist following a fall on an outstretched hand. On examination, dinner fork deformity can be noticed. What is the most likely displacement seen in this patient?

Accepted Answer

Distal and dorsal displacement of radius

Answer

Proximal and dorsal displacement of ulna

Answer

Proximal and ventral displacement of ulna

Answer

Proximal and ventral displacement of radius

Question 2

A 17-year-old boy presents to the clinic complaining of a painless lump on the lateral aspect of his left knee. The radiograph of the patient is shown below. Which of the following is the most likely diagnosis?

Accepted Answer

Osteochondroma

Answer

Giant cell tumor

Answer

Enchondroma

Answer

Chondroblastoma

Question 3

An elderly patient with the following deformity was brought to the OPD. What is the most probable diagnosis? ![img-13.jpeg](img-13.jpeg)

Accepted Answer

Rheumatoid arthritis

Answer

Rickets

Answer

Osteomalacia

Answer

Osteoarthritis

Question 4

A 20-year-old patient presents with painful swelling in the middle finger around the proximal phalanx. An X-ray was done, and it is shown below. What is the most likely diagnosis? ![img-14.jpeg](img-14.jpeg)

Accepted Answer

Enchondroma

Answer

Osteosarcoma

Answer

Ewing's sarcoma

Answer

Osteoclastoma

Question 5

An 80-year-old female patient with a history of slip and fall in the bathroom was brought to the casualty. She is having pain in the left hip and is unable to walk. She has no history of osteoarthritis. On examination, the left lower limb is shortened and externally rotated. X-ray findings are shown below. How will you manage this patient?

Accepted Answer

Hemiarthroplasty

Answer

Meyer's operation

Answer

McMurray's osteotomy

Answer

Internal fixation with cancellous screws

Question 6

A patient is referred to a higher center with the diagnosis of fracture. On examination, the forearm pulses were not palpable. An upper arm X-ray was done, which is given below. Which artery is most likely to be injured in this condition?

Accepted Answer

Brachial artery

Answer

Radial artery

Answer

Anterior interosseous artery

Answer

Ulnar artery

FMGE 2023 — Orthopaedics