Arthrology and Infections — MCQs
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A 40-year-old female patient presented to the OPD with joint pain in the wrist, MCP, PIP and DIP joints B/L. The involved joints were tender and swollen. Patient also gave a history of certain skin lesions which occurred before the joints were involved along with certain nail changes were also seen. Lab findings revealed HLA-B27 positivity. Which of the following x-ray findings most commonly correlates with the above condition?
Gradual painful limitation of shoulder movements in an elderly suggest that the most probable diagnosis is:
Recurrent dislocation is least common in
Menisci calcification is seen with
Tardy ulnar neuritis may be due to
Circumduction test is used for:
12 years male came with swelling of lower end tibia which is surrounded by rim of reactive bone. What is most likely diagnosis?
A 25-year-old male presents with chronic leg pain and a draining sinus. What is the most likely diagnosis?
What clinical finding is critical for identifying chronic osteomyelitis after sequestrectomy?
In chronic osteomyelitis, which complication may result in a non-healing sinus?
Arthrology and Infections Indian Medical PG Practice Questions and MCQs
Question 201: A 40-year-old female patient presented to the OPD with joint pain in the wrist, MCP, PIP and DIP joints B/L. The involved joints were tender and swollen. Patient also gave a history of certain skin lesions which occurred before the joints were involved along with certain nail changes were also seen. Lab findings revealed HLA-B27 positivity. Which of the following x-ray findings most commonly correlates with the above condition?
- A. Option B shows Z-deformity - seen in RA
- B. Option C shows spade phalanx - seen in acromegaly
- C. Option A shows pencil in cup deformity- seen in psoriatic arthritis (Correct Answer)
- D. All of the options are seen.
Explanation: ***Option A shows pencil in cup deformity- seen in psoriatic arthritis*** - The patient's presentation with **polyarticular joint pain** involving the MCP, PIP, and DIP joints, along with **skin lesions** and **nail changes**, strongly suggests **psoriatic arthritis**. The **pencil-in-cup deformity** is a classic radiographic sign of psoriatic arthritis, resulting from bone erosion and new bone formation. - While **HLA-B27** is positive, this marker indicates a predisposition to spondyloarthropathies, which includes psoriatic arthritis in a subset of patients, especially those with axial involvement. However, the prominent peripheral joint and skin/nail findings point towards psoriatic arthritis as the primary diagnosis. *Option B shows Z-deformity - seen in RA* - The **Z-deformity of the thumb** (flexion of the MCP joint and hyperextension of the IP joint) is characteristic of **rheumatoid arthritis (RA)**, not psoriatic arthritis. - Although RA can affect similar joints, the presence of **skin lesions** and **nail changes** makes psoriatic arthritis a much more likely diagnosis than RA in this patient. *Option C shows spade phalanx - seen in acromegaly* - **Spade phalanx** refers to the widening and tufting of the distal phalanges, which is a hallmark radiographic finding in **acromegaly** due to excessive growth hormone. - This finding is unrelated to the inflammatory polyarthritis and skin/nail changes described in the patient, making it an incorrect association for this clinical picture. *All of the options are seen.* - Each of the other options points to distinct conditions with specific radiographic findings. Given the classic presentation of **psoriatic arthritis** with polyarthritis, skin lesions, nail changes, and the specific radiographic finding of **pencil-in-cup deformity**, it is highly unlikely that all these disparate conditions would be simultaneously present or equally relevant.
Question 202: Gradual painful limitation of shoulder movements in an elderly suggest that the most probable diagnosis is:
- A. Periarthritis (Correct Answer)
- B. Myositis ossificans
- C. Osteoarthritis
- D. Arthritis
Explanation: ***Periarthritis*** - This term encompasses conditions like **adhesive capsulitis (frozen shoulder)**, which commonly presents as gradual, painful limitation of shoulder movement, particularly in the elderly. - It involves **inflammation and thickening of the joint capsule**, leading to stiffness and pain with both active and passive range of motion. *Myositis ossificans* - This condition involves the **formation of bone in muscle tissue** after trauma, presenting as a firm, tender mass. - It does not primarily cause gradual, painful limitation of joint movement in the way described for the shoulder. *Osteoarthritis* - While common in the elderly, **osteoarthritis** primarily affects articular cartilage, leading to pain and stiffness that is often worse with activity and relieved by rest. - It typically affects weight-bearing joints or those with repetitive stress, and while it can affect the shoulder, the description of "gradual painful limitation of movement" is more characteristic of periarthritis/frozen shoulder. *Arthritis* - This is a **general term for joint inflammation** and does not specify the particular cause or presentation. - While periarthritis is a type of arthritis (inflammation of tissues around a joint), "arthritis" alone is too broad to be the most probable specific diagnosis for this clinical picture.
Question 203: Recurrent dislocation is least common in
- A. Patella
- B. Shoulder
- C. Knee (Correct Answer)
- D. Hip
Explanation: ***Knee*** - While knee dislocations are **severe injuries**, they are relatively **rare** in terms of recurrent dislocation compared to other joints listed. - The knee joint's strong ligamentous support and bony configuration make primary dislocation difficult, and recurrent dislocation usually implies significant underlying pathology or trauma. *Patella* - **Patellar dislocation** is quite common, especially in young active individuals, and has a high rate of recurrence due to factors like **patella alta** or **trochlear dysplasia**. - The **medial patellofemoral ligament (MPFL)** plays a crucial role in patellar stability, and its injury often leads to recurrent episodes. *Shoulder* - The **shoulder joint** is the **most commonly dislocated major joint** in the body, largely due to its wide range of motion and relatively shallow glenoid fossa. - Recurrent shoulder dislocations are frequent, particularly in younger patients, often necessitating surgical stabilization to prevent further episodes and progression to **osteoarthritis**. *Hip* - **Hip dislocations** are typically high-energy injuries and are generally **less common** than shoulder or patellar dislocations. - However, once a hip has dislocated, there is an increased risk of **recurrent instability**, especially in cases with associated labral tears or bony defects, though the absolute frequency remains lower than for the shoulder or patella.
Question 204: Menisci calcification is seen with
- A. Pseudogout (Correct Answer)
- B. Hypothyroidism
- C. Gout
- D. Hyperparathyroidism
Explanation: ***Pseudogout*** - **Pseudogout**, also known as calcium pyrophosphate deposition (CPPD) disease, characteristically involves the deposition of **calcium pyrophosphate crystals** in articular cartilage, leading to its calcification, including the menisci. - This calcification, visible on X-ray, is known as **chondrocalcinosis** and is a hallmark of pseudogout. *Hypothyroidism* - While hypothyroidism can cause various musculoskeletal symptoms, it is not typically associated with **meniscal calcification** or chondrocalcinosis. - It more commonly presents with **arthralgia**, myalgia, and effusions due to metabolic imbalances. *Gout* - **Gout** is caused by the deposition of **monosodium urate crystals** in joints, leading to inflammation and pain, often in the big toe. - It does not cause **meniscal calcification** or chondrocalcinosis; instead, it can cause erosions and tophi but not calcified cartilage. *Hyperparathyroidism* - **Hyperparathyroidism** causes increased bone turnover and **hypercalcemia**, which can lead to various bone and joint problems. - While it can be associated with soft tissue calcifications and is a risk factor for **CPPD** (pseudogout), directly causing menisci calcification is not its primary or characteristic feature.
Question 205: Tardy ulnar neuritis may be due to
- A. Cubitus valgus deformity (Correct Answer)
- B. Advanced osteoarthritis of elbow
- C. Both of the options
- D. None of the options
Explanation: ***Cubitus valgus deformity*** - A cubitus valgus deformity increases the carrying angle of the elbow, which places abnormal **tensile stress** on the **ulnar nerve** behind the medial epicondyle. - This chronic stretching and pressure can lead to delayed onset (tardy) neuropathy, presenting as ulnar neuritis. *Advanced osteoarthritis of elbow* - While osteoarthritis can affect the elbow, it primarily involves the **articular cartilage** and bony changes within the joint, not typically directly compressing or stretching the ulnar nerve in a chronic, "tardy" fashion unless severe osteophytes directly impinge it. - The direct link to stretching and chronic irritation of the ulnar nerve as a primary cause of **tardy ulnar neuritis** is more strongly associated with structural deformities like cubitus valgus. *Both of the options* - While severe osteoarthritis could theoretically contribute to ulnar nerve compression through osteophyte formation, **cubitus valgus deformity** is a much more classic and direct cause of **tardy ulnar neuritis** due to the chronic mechanical stretch it places on the nerve. - This option is incorrect because cubitus valgus is the primary and most common long-term cause of tardy ulnar neuritis, making the inclusion of advanced osteoarthritis as equally causative less accurate in this context without further specifying direct nerve involvement. *None of the options* - This option is incorrect because **cubitus valgus deformity** is a recognized and common cause of tardy ulnar neuritis. - The valgus angulation creates a sustained tension and potential irritation of the ulnar nerve, leading to delayed onset symptoms.
Question 206: Circumduction test is used for:
- A. Inferior shoulder instability
- B. Posterior shoulder instability (Correct Answer)
- C. Anterior shoulder instability
- D. Either of above
Explanation: ***Posterior shoulder instability*** - The **circumduction test** involves circumducting the arm while applying a **posteriorly directed force** to the humeral head. - A positive test, indicated by a **clunk** or patient apprehension, suggests **posterior glenohumeral instability**. *Inferior shoulder instability* - Inferior instability is often tested using the **sulcus sign**, which assesses for a gap between the acromion and the humeral head when traction is applied. - The circumduction test primarily focuses on posterior translation, not inferior laxity. *Anterior shoulder instability* - **Anterior instability** is typically evaluated by tests like the **apprehension test** or **relocation test**, where the arm is abducted and externally rotated. - These tests provoke a sense of apprehension or pain in patients with anterior instability, which differs from the mechanism of the circumduction test. *Either of above* - Each type of shoulder instability (anterior, posterior, inferior) has specific physical examination maneuvers designed to identify it. - The circumduction test has a particular diagnostic utility for **posterior instability** and is not broadly applicable to all forms of instability.
Question 207: 12 years male came with swelling of lower end tibia which is surrounded by rim of reactive bone. What is most likely diagnosis?
- A. GCT
- B. Hyper PTH
- C. Brodie's Abscess (Correct Answer)
- D. Osteomyelitis
Explanation: ***Brodie's Abscess*** - A **Brodie's abscess** is a subacute or chronic osteomyelitis characterized by a localized bone abscess, typically with a surrounding **sclerotic rim of reactive bone**. - It often occurs in the **metaphysis of long bones** (like the lower end of the tibia) in children and adolescents, presenting with localized pain and swelling. *GCT* - **Giant cell tumor (GCT)** typically occurs in **skeletally mature adults** (20-40 years old) and is a lytic lesion often found in the **epiphysis** of long bones, rarely with a distinct sclerotic rim. - GCTs are generally more aggressive and demonstrate a **soap-bubble appearance** with cortical expansion rather than a thick reactive bone rim. *Hyper PTH* - **Hyperparathyroidism** causes bone changes such as **osteopenia**, **subperiosteal bone resorption**, especially in the phalanges, and **brown tumors** (lytic lesions). - It does not typically present as a localized lesion with a **sclerotic rim of reactive bone** in a child. *Osteomyelitis* - While chronic osteomyelitis can involve local bone destruction and reactive bone formation, a **Brodie's abscess** is a specific, well-circumscribed form of **subacute osteomyelitis**. - Acute osteomyelitis presents with more diffuse systemic symptoms (fever, malaise) and less defined reactive bone in its early stages compared to the distinct **sclerotic rim** seen in a Brodie's abscess.
Question 208: A 25-year-old male presents with chronic leg pain and a draining sinus. What is the most likely diagnosis?
- A. Ewing's sarcoma
- B. Chronic osteomyelitis (Correct Answer)
- C. Osteosarcoma
- D. Cellulitis
Explanation: ***Chronic osteomyelitis*** - **Chronic leg pain** combined with a **draining sinus** is highly suggestive of chronic osteomyelitis, indicating persistent bone infection with a tract to the skin. - The draining sinus allows for the discharge of pus and necrotic debris from the infected bone, a classic sign of this condition. *Ewing's sarcoma* - While it can present with bone pain and swelling, a **draining sinus** is not a typical feature of Ewing's sarcoma. - This tumor is often characterized by a rapidly growing mass and systemic symptoms like fever, which are not mentioned. *Osteosarcoma* - This malignant bone tumor typically presents with localized **bone pain and swelling**, often around the knee. - A **draining sinus** is not a hallmark characteristic of osteosarcoma; it is more associated with infection than primary bone malignancy. *Cellulitis* - **Cellulitis** is a superficial soft tissue infection that causes redness, warmth, and tenderness of the skin. - It does not involve the bone and therefore would not present with **chronic bone pain** or a **draining sinus from bone**.
Question 209: What clinical finding is critical for identifying chronic osteomyelitis after sequestrectomy?
- A. Codman's triangle
- B. Sunburst appearance
- C. Paprika sign
- D. Rim sign (Correct Answer)
Explanation: ***Rim sign*** - The **rim sign** refers to the presence of a persistent radiolucent 'halo' or rim around the bone post-sequestrectomy, indicating **residual infection** or a cavity that has not obliterated, which is characteristic of ongoing chronic osteomyelitis. - This finding suggests that despite the removal of the necrotic bone (sequestrum), the infection has not been fully eradicated, necessitating further intervention. *Paprika sign* - The **paprika sign** is a diffuse, speckled pattern of increased uptake seen on bone scintigraphy, often associated with **reflex sympathetic dystrophy** or **complex regional pain syndrome**, not chronic osteomyelitis. - It reflects increased peripheral blood flow and bone turnover in the affected limb, a different pathological process from bacterial infection. *Codman's triangle* - **Codman's triangle** is an elevated periosteal reaction seen on radiographs, typically associated with **aggressive bone lesions** such as osteosarcoma or Ewing's sarcoma, or sometimes with rapidly progressing infections. - While it indicates periosteal new bone formation, it is not a direct sign of chronic osteomyelitis itself, nor is it specific to post-sequestrectomy findings. *Sunburst appearance* - The **sunburst appearance** is a classic radiographic finding characterized by radiating spicules of new bone formation perpendicular to the bone cortex, almost exclusively seen in **osteosarcoma**. - This pattern is indicative of a highly aggressive bone tumor and has no relevance to the diagnosis or persistence of chronic osteomyelitis.
Question 210: In chronic osteomyelitis, which complication may result in a non-healing sinus?
- A. Brodie's abscess (localized bone infection)
- B. Cloaca (drainage opening in bone)
- C. Sequestrum (dead bone fragment) (Correct Answer)
- D. Involucrum (bone surrounding necrosis)
Explanation: ***Sequestrum (dead bone fragment)*** - A **sequestrum** is a piece of dead, necrotic bone that has separated from the healthy bone within an infected area. - This **foreign body-like presence** acts as a persistent nidus for infection, preventing complete healing and often leading to a chronic draining sinus. *Cloaca (drainage opening in bone)* - A **cloaca** is an opening in the involucrum, formed by the body to allow the discharge of pus and necrotic debris from the infected bone. - While a cloaca is a *pathway* for drainage, it is the underlying **sequestrum** that necessitates the persistent drainage and prevents healing. *Brodie's abscess (localized bone infection)* - A **Brodie's abscess** is a subacute or chronic localized osteomyelitis, typically presenting as a sterile abscess with granulation tissue. - While it is a chronic bone infection, it is usually contained and less likely to form a persistently draining sinus, especially compared to the generalized necrosis associated with a sequestrum. *Involucrum (bone surrounding necrosis)* - The **involucrum** is a collar of new bone growth that forms around the infected or necrotic bone (sequestrum) in chronic osteomyelitis. - Its formation is a reparative response, but it often encases the sequestrum, **walling off the infection** and preventing effective antibiotic penetration or surgical debridement, thereby contributing to chronicity, but it is not the direct cause of the non-healing sinus.
Practice by Chapter
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Osteomyelitis
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Reactive Arthritis
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Management of Joint Infections
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