Osteoarthritis — MCQs
Which of the following is difference between Rheumatoid arthritis and osteoarthritis -
Heberdens nodes are the clinical manifestations seen in -
Osteoarthritis is associated with all of the following except -
A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?
A middle aged female presents with polyarthritis with elevated rheumatoid factor and ANA levels, which among the following will help you to differentiate rheumatoid arthritis from SLE?
Primary osteoarthritis affects all except:
A 68-year-old man presents with pain and swelling of the right knee. Investigations reveal Ahlbäck grade 2 osteoarthritic changes. What is the further management?
A 70-year-old woman with chronic osteoarthritis of the hip presents with worsening pain and limited mobility despite conservative management. What is the next appropriate step?
A 65-year-old lady presented with a swollen and painful knee. On examination, she was found to have grade III osteoarthritic changes. What is the best course of action?
According to American College of Rheumatology, all of the following are clinical criteria for the diagnosis of osteoarthritis, EXCEPT:
Osteoarthritis Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is difference between Rheumatoid arthritis and osteoarthritis -
- A. Osteophytes are seen in osteoarthritis (Correct Answer)
- B. Rheumatoid arthritis commonly affects the hands and feet
- C. Osteoarthritis is a degenerative joint disease
- D. Systemic symptoms are seen in rheumatoid arthritis
Explanation: ***Osteophytes are seen in osteoarthritis*** - **Osteophytes** (bone spurs) are characteristic bony outgrowths that develop in **osteoarthritis** due to cartilage degradation and an attempt at bone repair, differentiating it from rheumatoid arthritis [1]. - Their presence indicates a **degenerative process** involving cartilage loss and reactive bone formation [2]. *Rheumatoid arthritis commonly affects the hands and feet* - While rheumatoid arthritis (RA) commonly affects the small joints of the hands and feet (e.g., **MCPs and PIPs**), this is a commonality, not a difference, as osteoarthritis (OA) can also affect these joints (e.g., DIPs and PIPs), just with different patterns [1]. - RA typically causes **symmetrical polyarthritis** in these joints, often with associated inflammation. *Osteoarthritis is a degenerative joint disease* - This statement is true but describes a characteristic of osteoarthritis, not a direct differentiating factor in the way osteophytes are. Both conditions can involve joint damage, but OA is primarily **degenerative** while RA is **inflammatory** [2]. - Its **degenerative nature** means joint damage is primarily due to wear and tear and cartilage breakdown [2]. *Systemic symptoms are seen in rheumatoid arthritis* - This is a true characteristic of rheumatoid arthritis (e.g., **fatigue, fever, weight loss**) but is not a difference in the same context as osteophytes [2]. OA is generally not associated with systemic symptoms. - The presence of systemic symptoms highlights the **autoimmune and inflammatory** nature of RA, contrasting with the localized mechanical breakdown in OA [2].
Question 2: Heberdens nodes are the clinical manifestations seen in -
- A. Reactive arthritis
- B. Rheumatoid arthritis
- C. Ankylosing spondylitis
- D. Osteoarthritis (Correct Answer)
Explanation: Explanation: ***Osteoarthritis*** - **Heberden's nodes** are characteristic bony enlargements of the **distal interphalangeal (DIP) joints** of the fingers, resulting from osteophyte formation due to osteoarthritis [1]. - They are a common sign of **degenerative joint disease**, particularly in older adults and are often associated with genetic predisposition and trauma [1]. *Reactive arthritis* - This condition typically affects larger joints in the lower extremities, often following a genitourinary or gastrointestinal infection. - It does not characteristically involve the formation of **Heberden's nodes** on the DIP joints. *Rheumatoid arthritis* - **Rheumatoid arthritis** primarily affects the small joints of the hands and feet, but it causes **inflammatory synovial hypertrophy** and erosions, not bony nodes like Heberden's [2]. - This condition is characterized by **symmetric polyarthritis** and often spares the DIP joints, while affecting the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints [2]. *Ankylosing spondylitis* - **Ankylosing spondylitis** is a chronic inflammatory disease primarily affecting the **axial skeleton**, particularly the sacroiliac joints and spine. - It does not typically cause peripheral joint involvement leading to symptoms like **Heberden's nodes**.
Question 3: Osteoarthritis is associated with all of the following except -
- A. Subchondral sclerosis
- B. Ca++deposition in joint space (Correct Answer)
- C. Osteophyte formation
- D. Decreased joint space
Explanation: ***Ca++deposition in joint space*** - **Calcium pyrophosphate dihydrate (CPPD) crystal deposition** in the joint space is characteristic of **pseudogout**, not osteoarthritis [1]. - While some **calcification** may occur in osteophytes, direct **calcium crystal deposition** in the synovial fluid is not a primary feature of osteoarthritis [1]. *Subchondral sclerosis* - **Subchondral sclerosis** refers to the increased bone density that occurs beneath the cartilage in areas of stress in osteoarthritis. - This is a common radiological finding in osteoarthritis, reflecting the bone's response to increased mechanical load. *Osteophyte formation* - **Osteophytes** (bone spurs) are bony projections that form along the joint margins in osteoarthritis [2]. - They are a hallmark feature of the disease, resulting from the body's attempt to repair and stabilize the damaged joint [2]. *Decreased joint space* - **Decreased joint space** on radiographs is a classic sign of osteoarthritis, indicating loss of articular cartilage thickness [2]. - As the cartilage erodes, the distance between the bones within the joint decreases. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 683-684. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1210-1212.
Question 4: A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?
- A. CT Scan
- B. MRI with contrast (Correct Answer)
- C. Bone Scan
- D. Plain Radiograph
Explanation: ***MRI with contrast*** - An **MRI with contrast** is the most sensitive and specific imaging modality for detecting early changes in **osteomyelitis** or **septic arthritis**, which are serious conditions given the child's symptoms and elevated inflammatory markers. - It can visualize soft tissue and bone marrow edema, joint effusions, and abscesses, guiding immediate treatment. *CT Scan* - While useful for bony detail, a CT scan is **less sensitive than MRI** for detecting early bone marrow changes or soft tissue inflammation in the hip joint. - It also involves **radiation exposure**, which should be limited in children when other effective modalities are available. *Bone Scan* - A bone scan using **technetium-99m** is sensitive for detecting increased bone turnover, but it is **not specific for infection** and cannot differentiate between inflammatory processes, tumors, or fractures. - It provides less anatomical detail compared to MRI, making precise localization of an infection more challenging. *Plain Radiograph* - Plain radiographs are typically the **initial imaging study** for orthopedic complaints but are often **normal in early stages** of septic arthritis or osteomyelitis. - Significant radiographic changes, such as bone erosion or joint space widening, usually appear much later in the disease process.
Question 5: A middle aged female presents with polyarthritis with elevated rheumatoid factor and ANA levels, which among the following will help you to differentiate rheumatoid arthritis from SLE?
- A. Soft tissue swelling at the proximal interphalangeal joint
- B. Articular erosions on X-ray (Correct Answer)
- C. Elevated ESR
- D. Juxta articular osteoporosis on X-ray
Explanation: ***Articular erosions on X-ray*** - Articular erosions are classic radiographic hallmarks of **rheumatoid arthritis (RA)**, indicating destructive changes to cartilage and bone [1]. - While both RA and **Systemic Lupus Erythematosus (SLE)** can cause polyarthritis, erosive disease is characteristic of RA and generally absent in SLE [1]. *Soft tissue swelling at the proximal interphalangeal joint* - **Soft tissue swelling** can occur in both RA and SLE due to inflammation, making it a non-specific finding for differentiation [2]. - Both conditions frequently affect the **proximal interphalangeal (PIP) joints**, causing swelling and tenderness [2]. *Elevated ESR* - An **elevated Erythrocyte Sedimentation Rate (ESR)** is a general marker of inflammation and can be high in both RA and SLE [3]. - It reflects ongoing disease activity but does not help to distinguish between these two specific autoimmune conditions. *Juxta articular osteoporosis on X-ray* - **Juxta-articular osteoporosis** can be seen in both RA due to regional bone loss from inflammation and in SLE, often as a side effect of corticosteroid use. - This finding is therefore not specific enough to definitively differentiate between RA and SLE.
Question 6: Primary osteoarthritis affects all except:
- A. Metacarpophalangeal joint (Correct Answer)
- B. Hip Joint
- C. Distal interphalangeal joint
- D. Knee joint
Explanation: ***Metacarpophalangeal joint*** - The **metacarpophalangeal (MCP) joints** are typically spared in primary osteoarthritis, making their involvement a less common presentation. - Involvement of the MCP joints, particularly with significant inflammation, might suggest other conditions like **rheumatoid arthritis**. *Hip Joint* - The hip joint is a common site for primary osteoarthritis due to its **weight-bearing function** and susceptibility to mechanical stress. - Patients often experience **groin pain** and reduced range of motion, particularly internal rotation. *Distal interphalangeal joint* - The **distal interphalangeal (DIP) joints** are very commonly affected in primary osteoarthritis, leading to the formation of **Heberden's nodes**. - These nodes are bony enlargements that indicate osteophyte formation and cartilage loss. *Knee joint* - The knee joint is another frequently affected large joint in primary osteoarthritis, often presenting with **pain**, **stiffness**, and **crepitus**. - Its **weight-bearing role** contributes significantly to its vulnerability to degenerative changes.
Question 7: A 68-year-old man presents with pain and swelling of the right knee. Investigations reveal Ahlbäck grade 2 osteoarthritic changes. What is the further management?
- A. High tibial osteotomy
- B. Total knee replacement
- C. Conservative (Correct Answer)
- D. Arthroscopic washout
Explanation: ***Conservative care*** - **Ahlbäck grade 2** is considered mild to moderate **osteoarthritis**; therefore, initial management should focus on non-surgical interventions. - This includes **pain management** (NSAIDs, analgesics), **physiotherapy**, **weight loss**, and **activity modification**. *High tibial osteotomy* - This procedure is typically reserved for **younger patients** with **varus deformity** and **unicompartmental osteoarthritis** to realign the knee, which is not indicated in this case for a 68-year-old. - It aims to shift the weight-bearing axis away from the damaged compartment to an healthier area, often considered when **total knee replacement** is being delayed. *Total knee replacement* - This is a definitive surgical option for **severe, end-stage osteoarthritis** that has failed conservative management. - Given the patient's **Ahlbäck grade 2**, less invasive treatments should be tried first as this grade does not typically warrant immediate total knee replacement. *Arthroscopic washout* - While it can provide temporary relief of symptoms by removing debris, its **long-term efficacy** in managing **osteoarthritis** has been extensively debated and is generally not recommended as a primary treatment for knee osteoarthritis. - There is little evidence to suggest that it alters the progression of the disease or provides sustained pain relief in **mild to moderate osteoarthritis**.
Question 8: A 70-year-old woman with chronic osteoarthritis of the hip presents with worsening pain and limited mobility despite conservative management. What is the next appropriate step?
- A. NSAIDs
- B. Physical therapy
- C. Intra-articular corticosteroid injections
- D. Total hip replacement (Correct Answer)
Explanation: ***Total hip replacement*** - For **severe osteoarthritis (OA)** causing significant pain and **functional impairment** despite failed conservative management, **total hip replacement** is the most definitive and effective treatment. - This procedure alleviates pain and restores **mobility**, dramatically improving the patient's quality of life. *NSAIDs* - **NSAIDs** are typically part of **initial conservative management** for symptomatic relief in mild to moderate OA, but they have already failed in this patient. - Continued use in elderly patients carries risks of **gastrointestinal, renal, and cardiovascular side effects**, making it a less desirable long-term solution. *Physical therapy* - **Physical therapy** is a crucial component of conservative management to improve **strength, flexibility, and function**, but it often becomes insufficient in advanced OA. - Since this patient has worsening symptoms despite conservative measures, physical therapy alone is unlikely to provide adequate relief. *Intra-articular corticosteroid injections* - **Corticosteroid injections** can provide temporary pain relief by reducing inflammation but do not address the underlying **structural damage** of severe OA. - Their effectiveness diminishes over time, and repeated injections are discouraged due to potential cartilage damage.
Question 9: A 65-year-old lady presented with a swollen and painful knee. On examination, she was found to have grade III osteoarthritic changes. What is the best course of action?
- A. Conservative management
- B. Total knee replacement (Correct Answer)
- C. Arthroscopic washing
- D. Partial knee replacement
Explanation: ***Total knee replacement*** - For **grade III osteoarthritis** in a 65-year-old, a total knee replacement is the most definitive and effective treatment to relieve pain and restore function in a severely damaged joint. - This procedure addresses widespread cartilage loss and structural changes typical of advanced osteoarthritis. *Conservative management* - This approach is typically favored for **mild to moderate osteoarthritis**, involving physical therapy, NSAIDs, and lifestyle modifications. - For **grade III changes** with significant pain and swelling, conservative measures are unlikely to provide sufficient relief or halt disease progression effectively. *Arthroscopic washing* - **Arthroscopic lavage** and debridement are rarely recommended for osteoarthritis as they have not shown sustained benefits for pain or function. - It is sometimes used for specific mechanical symptoms, but it does not address the underlying cartilage loss and structural damage in severe osteoarthritis. *Partial knee replacement* - A **partial knee replacement** is suitable when osteoarthritis is confined to a single compartment of the knee, and the other compartments are healthy. - Given the indication of "grade III osteoarthritic changes" without specifying a single compartment, a total knee replacement is generally more appropriate for widespread disease.
Question 10: According to American College of Rheumatology, all of the following are clinical criteria for the diagnosis of osteoarthritis, EXCEPT:
- A. Lack of warmth
- B. Crepitus
- C. Atrophy of quadriceps muscles (Correct Answer)
- D. Age > 50 years
Explanation: ### Atrophy of quadriceps muscles - While muscle weakness can be a consequence of **osteoarthritis (OA)** due to pain and disuse, **quadriceps atrophy** is not a primary diagnostic criterion according to the American College of Rheumatology (ACR) criteria for OA. Local examination of the knee in OA may frequently reveal weakness and wasting of the quadriceps muscle [1]. - The ACR criteria primarily focus on patient symptoms, physical exam findings, and radiographic evidence to define OA. ### Lack of warmth - This is a typical physical finding in osteoarthritis, as **inflammation** is generally mild or absent compared to inflammatory arthropathies, thus joints are usually **not warm** to the touch. - It helps differentiate OA from conditions like septic arthritis or gout, where warmth is a prominent feature. ### Crepitus - **Crepitus**, or crackling/grating sounds during joint movement, is a classic clinical finding in osteoarthritis, indicating a roughened articular surface. Examination often reveals restricted flexion/extension accompanied by coarse crepitus [1]. - It is one of the key clinical signs used in the ACR criteria for OA, especially when combined with other symptoms like pain and stiffness. ### Age > 50 years - **Age over 50 years** is a significant risk factor and a clinical criterion for diagnosing osteoarthritis, as the prevalence of OA increases with age. While typical symptoms usually present after age 45-50, early-onset OA is rare and often linked to trauma [1]. - The ACR criteria often incorporate age as a factor when considering symptomatic OA.
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