Arthrology and Infections Practice Questions

Q: With reference to frozen shoulder, consider the following statements: 1. It is associated with diabetes and heart disease. 2. It may follow minor trauma. 3. Its differential diagnosis are infection and fractures. 4. Treatment of choice is surgery. Which of the statements given above are correct?

1, 2 and 3. ***1, 2 and 3*** - **Frozen shoulder** (adhesive capsulitis) has a higher incidence in individuals with **diabetes mellitus** and **cardiovascular diseases**, indicating systemic associations. - It can be triggered by minor trauma or surgery, but often it has **no identifiable cause** (idiopathic). - The differential diagnoses for shoulder pain and restricted motion include serious conditions like **infection (septic arthritis)** and **fractures**, which must be ruled out. *1 and 2 only* - This option correctly identifies the association with diabetes and heart disease, and the possibility of minor trauma. - However, it incorrectly excludes the importance of considering infection and fractures in the differential diagnosis. *3 and 4 only* - This option correctly identifies the importance of differential diagnosis (infection and fractures). - However, **surgery is generally not the first-line treatment for frozen shoulder**; it is reserved for severe cases unresponsive to conservative measures. - It also fails to acknowledge the associations with diabetes and heart disease, or the role of minor trauma. *2, 3 and 4* - This option correctly notes that frozen shoulder can follow minor trauma and that infection and fractures are important differential diagnoses. - However, it incorrectly states that **surgery is the treatment of choice**, when **conservative management is usually first-line**. - It also misses the crucial association with **diabetes and heart disease**.

Q: A 18-year-old boy presents with tenderness, warmth over the bone, and fever, ESR and CRP levels. The radiograph is shown below. What is the most likely diagnosis?

Osteomyelitis. ***Osteomyelitis*** - The clinical presentation of **fever, localized tenderness, and warmth** with elevated **ESR and CRP** levels in an 18-year-old is highly suggestive of **osteomyelitis**, an infection of the bone. - Radiographs in acute osteomyelitis may show soft tissue swelling, periosteal reaction, and areas of **bone destruction**, which can be subtle early in the infection. *Ewing's sarcoma* - This typically presents with local pain and swelling, and can also cause fever and elevated inflammatory markers. - However, characteristic radiographic findings such as an **"onion skin" periosteal reaction** or a **"moth-eaten" appearance** are not clearly visible here. *Osteosarcoma* - This is a primary malignant bone tumor often seen in adolescents, presenting with localized pain and swelling. - Radiographic features typically include a **Codman triangle**, **sunburst appearance**, or a **mixed lytic and blastic lesion**, which are not seen in this image. *Giant cell tumor* - Usually occurs in **young adults (20-40 years old)**, not typically in an 18-year-old, and presents with pain and swelling around the joint. - Radiographically, it is characterized by an **eccentric lytic lesion** in the **epiphysis or metaphysis** of long bones, often described as a **"soap bubble" appearance**, which is not depicted here.

Q: An 18-year-old boy presents with tenderness, warmth over the bone, and fever, ESR and CRP levels. The radiograph is shown below. What is the most likely diagnosis?

Osteomyelitis. ***Osteomyelitis*** - The presentation of **tenderness**, **warmth over the bone**, **fever**, and elevated **ESR** and **CRP** are classic signs of a bone infection, or osteomyelitis. - While not explicitly shown in the provided text, a radiograph in acute osteomyelitis might show **soft tissue swelling** or subtle **periosteal elevation**, progressing to **bone destruction** and **sclerosis** in later stages. *Ewing's sarcoma* - This is a highly malignant bone tumor that presents with **pain** and **swelling**, but is typically not associated with a pronounced **fever** and signs of systemic infection. - Radiographically, it often shows an "onion-skin" **periosteal reaction** and lytic lesions, without the strong inflammatory markers seen here. *Osteosarcoma* - This is another malignant bone tumor, primarily presenting with bone **pain** and **swelling**, but systemic inflammatory signs like **fever** are rare unless there is a pathologic fracture or infection secondary to tumor necrosis. - Radiographs typically show a "sunburst" appearance, **Codman's triangle**, or mixed lytic and blastic lesions, not indicative of acute infection. *Giant cell tumor* - This is a usually **benign aggressive bone tumor** that causes **pain** and **swelling** around joints. - It does not typically present with systemic signs of infection such as **fever** and significantly elevated **ESR** and **CRP** unless there is a secondary infection, and it usually affects the **epiphyses** of long bones in young adults.

Q: Which of the following statements about tubercular osteomyelitis is NOT true?

Periosteal reaction is characteristic. ***Periosteal reaction is characteristic*** - This statement is **NOT true** for tubercular osteomyelitis; periosteal reaction is generally **minimal or absent** due to the insidious and less florid inflammatory response. - Unlike pyogenic osteomyelitis, which causes significant periosteal new bone formation, tuberculosis typically results in **slow bone destruction** without marked reactive bone changes. *Sequestrum is uncommon* - This statement is **true** because **sequestrum** (a piece of dead bone separated from healthy bone) is less frequently observed in tubercular osteomyelitis compared to pyogenic osteomyelitis. - The **granulomatous inflammation** of tuberculosis tends to cause slow bone necrosis rather than the rapid, liquefactive necrosis that leads to large sequestra. *It is a type of secondary osteomyelitis* - This statement is **true** as tubercular osteomyelitis is almost always secondary to a **primary focus of tuberculosis** elsewhere in the body, typically the lungs [1]. - The infection spreads **hematogenously** to the bone, making it a manifestation of disseminated tuberculosis rather than a primary bone infection [1]. *Inflammation is minimal* - This statement is **true** in the sense that the **acute inflammatory response** in tubercular osteomyelitis is often less pronounced than in pyogenic infections. - While it is a chronic infectious process, the characteristic **granulomatous inflammation** develops over time, and the initial or acute inflammatory signs might be subtle or "minimal" compared to bacterial osteomyelitis [1].

Q: Tom-smith arthritis results from

Staphylococcus aureus infection. ***Staphylococcus aureus infection*** - **Tom-smith arthritis** (more commonly known as **septic arthritis** or infectious arthritis) is most frequently caused by **Staphylococcus aureus**, especially in adults and older children [1]. - The bacteria can enter the joint directly via trauma, surgery, or spread hematogenously from a distant infection, leading to rapid joint destruction if untreated [1]. *Streptococcus pyogenes infection* - While **Streptococcus pyogenes** can cause infectious arthritis, it is a less common cause than **Staphylococcus aureus** [1]. - It is more classically associated with **rheumatic fever** following pharyngitis, which involves migratory polyarthritis but is an immunologically mediated process, not direct bacterial infection of the joint in the same way. *Haemophilus influenzae infection* - **Haemophilus influenzae type b (Hib)** was once a common cause of septic arthritis in unvaccinated children but is now rare due to widespread vaccination. - In adults, other bacterial causes are more prevalent for septic arthritis. *Escherichia coli infection* - **Escherichia coli** can cause septic arthritis, particularly in neonates, immunocompromised individuals, or following genitourinary tract infections or intra-abdominal sepsis. - However, it is less common than **Staphylococcus aureus** as the primary cause of acute septic arthritis in otherwise healthy adults.

Q: Which of the following is/are established risk factor(s) for osteonecrosis of the femoral head?

All of the above. ***All of the above*** - All the listed conditions are **well-established risk factors** for osteonecrosis of the femoral head through various mechanisms including **vascular compromise**, **bone metabolism disruption**, and **direct bone damage**. - The combination of **traumatic**, **metabolic**, **inflammatory**, and **iatrogenic** factors all contribute to **femoral head ischemia** and subsequent bone cell death. *Sickle cell disease* - **Sickle cell disease** causes osteonecrosis through **vaso-occlusive crises** where abnormal red blood cells block small vessels supplying the femoral head. - The **chronic hemolysis** and repeated ischemic episodes lead to progressive bone damage, making it a significant risk factor, but it's not the only one. *Systemic lupus erythematosus and chemotherapy* - **SLE** increases risk through **vasculitis**, **antiphospholipid antibodies** causing thrombosis, and frequent corticosteroid treatment. - **Chemotherapy agents**, particularly when combined with steroids, can cause direct bone toxicity and vascular damage, but these are part of multiple risk factors. *Alcohol abuse and corticosteroid use* - **Chronic alcohol abuse** disrupts **lipid metabolism** and causes microvascular changes leading to bone ischemia. - **Corticosteroids** are among the most common causes, affecting **fat metabolism** and causing **intravascular coagulation**, but represent only some of the risk factors. *Trauma and radiation therapy* - **Femoral neck fractures** directly disrupt the **retinacular vessels** and **medullary blood supply** to the femoral head. - **Radiation therapy** causes **endothelial damage** and progressive vascular compromise, but these are additional risk factors rather than exclusive ones.

Q: Charcot's/neuropathic joint are most commonly seen in

Diabetes Mellitus. ***Diabetes Mellitus*** - **Diabetic neuropathy**, a common complication, leads to impaired sensation and autonomic dysfunction, making the joints susceptible to repeated trauma without the patient's awareness [1]. - This **unrecognized trauma**, combined with changes in bone and joint mechanics due to vascular and neurological complications, predisposes individuals to the destructive process of a Charcot joint [1]. *Rheumatic Arthritis* - **Rheumatoid arthritis** is an autoimmune inflammatory disorder primarily affecting the synovial lining of joints, causing pain, swelling, and eventual joint destruction, distinct from the neuropathic changes seen in Charcot joint. - While it causes significant joint damage, the underlying pathology involves **immune-mediated inflammation** rather than neurogenic arthropathy from sensory loss. *Leprosy* - **Leprosy** can cause peripheral neuropathy, which might lead to joint deformities and neuropathic changes in some cases due to sensory loss. - However, the overall incidence of severe **Charcot arthropathy** in leprosy is less common and less severe compared to that seen in diabetes mellitus, which affects a broader and more critical nerve supply compromising the joints. *Syringomyelia* - **Syringomyelia** involves a fluid-filled cyst within the spinal cord, leading to loss of sensation (especially pain and temperature) in the upper extremities. - While it can result in **neuropathic joint changes**, particularly affecting the shoulder and elbow, it is a less common cause of Charcot joint overall compared to diabetes mellitus, which has a much higher prevalence and systemic neuropathic effects.

Q: A patient has a history of pain and swelling at the same site for 2 years. An X-ray shows the following features. What is the most likely diagnosis?

Chronic osteomyelitis. ***Chronic osteomyelitis*** - The history of **pain and swelling at the same site for 2 years** indicates a chronic process, and an X-ray showing features consistent with bone destruction, new bone formation, and possibly a **sequestrum** or **involucrum** would point to chronic osteomyelitis. - The long duration and localized symptoms are highly characteristic of a persistent bacterial infection of the bone, as opposed to rapidly progressing malignant tumors. *Osteogenic sarcoma* - This is a **highly aggressive primary bone tumor** that typically presents with rapidly worsening pain and swelling, not a 2-year history of unchanged symptoms. - X-ray features usually include a **"sunburst" appearance** or a **Codman’s triangle**, indicating rapid periosteal elevation, which would be expected to be less organized than the features seen in chronic osteomyelitis. *Ewing's sarcoma* - Ewing's sarcoma is also a **malignant tumor**, common in children and young adults, presenting with pain, swelling, and sometimes systemic symptoms like fever. - X-ray often shows an **"onion skin" periosteal reaction** due to layers of new bone formation, but the course is generally more acute or subacute, not a stable 2-year history. *Multiple myeloma* - Multiple myeloma is a **plasma cell malignancy** primarily affecting older adults, causing widespread lytic bone lesions, - Bone pain is common, but it typically presents as **punch-out lesions** on X-ray, often in the axial skeleton, without the extensive reactive bone changes or chronic inflammation seen in osteomyelitis.

Q: All of the following are associated with frozen shoulder except

Psoriasis. ***Psoriasis*** - **Psoriasis** is an autoimmune skin condition that typically affects the skin and joints (psoriatic arthritis), but it is **not a recognized risk factor** or associated condition for frozen shoulder (adhesive capsulitis). - While it can cause joint pain and stiffness, its pathology is distinct from the inflammation and fibrosis of the glenohumeral joint capsule seen in adhesive capsulitis, and there is **no known epidemiological link**. *Hyperthyroidism* - **Thyroid disorders**, including hyperthyroidism, are well-established systemic risk factors for frozen shoulder. - The exact mechanism is unclear, but hormonal imbalances are thought to contribute to the **fibroproliferative changes** in the joint capsule. *Diabetes* - **Diabetes mellitus**, particularly type 1 and type 2, is a strong and consistently reported risk factor for frozen shoulder. - Patients with diabetes are more prone to developing adhesive capsulitis, often with **greater severity** and **prolonged recovery**, possibly due to advanced glycation end-products (AGEs) leading to collagen stiffening. *Hemiplegia* - **Neurological conditions** like stroke leading to hemiplegia (paralysis on one side of the body) are associated with an increased risk of developing frozen shoulder in the affected limb. - This is often attributed to **immobility**, **muscle weakness**, and altered proprioception and sensation in the shoulder joint.

Q: A 60-year-old man with diabetes mellitus presents with a painless, swollen right ankle joint. Radiographs of the ankle show a destroyed joint with a large number of loose bodies. The most probable diagnosis is:

Charcot's joint. ***Charcot's joint*** - The combination of **diabetes mellitus**, a **painless, swollen joint**, and radiographic evidence of a **destroyed joint with loose bodies** is highly suggestive of a Charcot joint, or neuropathic arthropathy [1]. - This condition results from **neuropathy**, leading to loss of protective sensation and repeated microtrauma, culminating in joint destruction [1]. *Clutton's joint* - This is a form of **painless arthritis** associated with **congenital syphilis**, typically affecting the knees symmetrically. - The patient's age and diabetes mellitus make syphilis an unlikely primary cause for this presentation. *Rheumatoid arthritis* - Rheumatoid arthritis typically presents with **painful, symmetrical joint inflammation**, often affecting small joints first [2]. - While it can cause joint destruction, a **painless joint** and the extensive **loose bodies** are not characteristic features of rheumatoid arthritis, especially in a patient with diabetes [2]. *Osteoarthritis* - Osteoarthritis usually leads to **painful joints** and is characterized by loss of cartilage, osteophytes, and subchondral sclerosis, not typically a **painless, severely destroyed joint with numerous loose bodies** to this extent. - Although common in the elderly, the **painless nature** and the degree of destruction in a diabetic patient point away from primary osteoarthritis.

Question 1

With reference to frozen shoulder, consider the following statements:

1. It is associated with diabetes and heart disease.

2. It may follow minor trauma.

3. Its differential diagnosis are infection and fractures.

4. Treatment of choice is surgery.
Which of the statements given above are correct?

Accepted Answer

1, 2 and 3

Answer

1 and 2 only

Answer

3 and 4 only

Answer

2, 3 and 4

Question 2

A 18-year-old boy presents with tenderness, warmth over the bone, and fever, ESR and CRP levels. The radiograph is shown below. What is the most likely diagnosis?

Accepted Answer

Osteomyelitis

Answer

Ewing's sarcoma

Answer

Osteosarcoma

Answer

Giant cell tumor

Question 3

An 18-year-old boy presents with tenderness, warmth over the bone, and fever, ESR and CRP levels. The radiograph is shown below. What is the most likely diagnosis?

Accepted Answer

Osteomyelitis

Answer

Ewing's sarcoma

Answer

Osteosarcoma

Answer

Giant cell tumor

Question 4

Which of the following statements about tubercular osteomyelitis is NOT true?

Accepted Answer

Periosteal reaction is characteristic

Answer

Sequestrum is uncommon

Answer

It is a type of secondary osteomyelitis

Answer

Inflammation is minimal

Question 5

Tom-smith arthritis results from

Accepted Answer

Staphylococcus aureus infection

Answer

Streptococcus pyogenes infection

Answer

Haemophilus influenzae infection

Answer

Escherichia coli infection

Question 6

Which of the following is/are established risk factor(s) for osteonecrosis of the femoral head?

Accepted Answer

All of the above

Answer

Sickle cell disease

Answer

Trauma and radiation therapy

Answer

Systemic lupus erythematosus and chemotherapy

Answer

Alcohol abuse and corticosteroid use

Question 7

Charcot's/neuropathic joint are most commonly seen in

Accepted Answer

Diabetes Mellitus

Answer

Rheumatic Arthritis

Answer

Leprosy

Answer

Syringomyelia

Question 8

A patient has a history of pain and swelling at the same site for 2 years. An X-ray shows the following features. What is the most likely diagnosis?

Accepted Answer

Chronic osteomyelitis

Answer

Osteogenic sarcoma

Answer

Ewing's sarcoma

Answer

Multiple myeloma

Question 9

All of the following are associated with frozen shoulder except

Accepted Answer

Psoriasis

Answer

Hyperthyroidism

Answer

Diabetes

Answer

Hemiplegia

Question 10

A 60-year-old man with diabetes mellitus presents with a painless, swollen right ankle joint. Radiographs of the ankle show a destroyed joint with a large number of loose bodies. The most probable diagnosis is:

Accepted Answer

Charcot's joint

Answer

Clutton's joint

Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Arthrology and Infections — MCQs

Arthrology and Infections — MCQs

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