Arthrology and Infections — MCQs

Arthrology and Infections Indian Medical PG Practice Questions and MCQs

Question 61: Charcot's joint includes all of the following conditions EXCEPT:

A. Syringomyelia
B. Leprosy
C. Diabetes
D. Arthrogryposis multiplex congenita (Correct Answer)

Explanation: **Explanation:** **Charcot’s Joint (Neuropathic Arthropathy)** is a progressive degenerative condition characterized by joint destruction, bone resorption, and deformity resulting from a **loss of pain and proprioceptive sensation**. When a joint loses its protective sensory feedback, repetitive microtrauma leads to progressive joint damage. **Why Arthrogryposis Multiplex Congenita (AMC) is the Correct Answer:** AMC is a non-progressive congenital disorder characterized by multiple joint contractures (stiff joints) present at birth. It is caused by fetal akinesia (decreased fetal movement) and muscle weakness, not by sensory loss. Therefore, it does not lead to the destructive, neuropathic changes seen in Charcot’s joint. **Analysis of Incorrect Options:** * **Diabetes Mellitus:** Currently the **most common cause** of Charcot’s joint, typically affecting the **foot and ankle** (Tarsometatarsal joints). * **Syringomyelia:** A classic cause that typically affects the **upper limb** (Shoulder and Elbow) due to the involvement of the cervical spinal cord. * **Leprosy:** A major cause in developing countries. Peripheral nerve damage leads to sensory loss, commonly resulting in Charcot’s changes in the hands and feet. **NEET-PG High-Yield Pearls:** * **The "6 D’s" of Charcot’s Joint:** Distension, Density (increased), Debris, Dislocation, Disorganization, and Destruction. * **Classic Distribution:** * **Diabetes:** Foot and Ankle (Midfoot). * **Syringomyelia:** Shoulder/Elbow. * **Tabes Dorsalis (Syphilis):** Knee (Historically common, now rare). * **Clinical Paradox:** The joint often looks "horrible" on X-ray (severe destruction) but is relatively **painless** for the patient.

Question 62: What is the earliest site of bone involvement in hematogenous osteomyelitis?

A. Metaphysis (Correct Answer)
B. Epiphysis
C. Diaphysis
D. Apophysis

Explanation: **Explanation:** Hematogenous osteomyelitis most commonly affects the **metaphysis** of long bones (especially around the knee) due to its unique vascular anatomy. The nutrient artery terminates in the metaphysis into **"hairpin loops"** of capillaries. These loops lead into large, thin-walled venous sinusoids where blood flow becomes sluggish and turbulent. This stasis allows circulating bacteria (most commonly *Staphylococcus aureus*) to settle, proliferate, and initiate an inflammatory response. Furthermore, the metaphyseal capillaries lack basement membranes and functional phagocytes, making the area highly susceptible to infection. **Analysis of Options:** * **B. Epiphysis:** Generally spared in children because the growth plate (physeal cartilage) acts as a mechanical barrier. It is only involved in infants (where transphyseal vessels exist) or in adults after the growth plate closes. * **C. Diaphysis:** While the infection can spread to the diaphysis via the medullary canal or subperiosteal space, it is rarely the primary site of origin, except in specific conditions like Sickle Cell Anemia (where *Salmonella* may affect the diaphysis). * **D. Apophysis:** These are accessory ossification centers (e.g., tibial tuberosity) that provide attachment for tendons. While they can be involved, they are not the primary site for hematogenous seeding. **NEET-PG High-Yield Pearls:** * **Most common organism:** *Staphylococcus aureus* (overall); *Salmonella* (in Sickle Cell patients). * **Earliest sign on X-ray:** Soft tissue swelling (appears at 3–5 days); bone changes (rarefaction/periosteal reaction) take **10–14 days** to appear. * **Investigation of choice:** **MRI** (most sensitive for early detection). * **Sequestrum:** Dead bone (radio-opaque); **Involucrum:** New bone formed under the periosteum (surrounds the sequestrum).

Question 63: Which of the following is false regarding chronic osteomyelitis?

A. RIM sign on MRI
B. Leads to Amyloidosis
C. Cierny and Mader classification
D. Negative pressure wound therapy uses a pressure of -60 mmHg (Correct Answer)

Explanation: ### Explanation **Chronic Osteomyelitis** is a persistent infection of the bone characterized by the presence of a **sequestrum** (dead bone), **involucrum** (new bone sheath), and **cloaca** (opening for pus drainage). **Why Option D is False:** Negative Pressure Wound Therapy (NPWT), often used in managing complex wounds in chronic osteomyelitis, typically utilizes a sub-atmospheric pressure of **-125 mmHg**. A pressure of -60 mmHg is generally considered insufficient for optimal granulation tissue formation and exudate removal in standard orthopedic protocols. **Analysis of Other Options:** * **Option A (RIM Sign):** On T1-weighted MRI with contrast, the "Rim Sign" refers to a well-defined layer of granulation tissue surrounding a sequestrum or abscess (Brodie’s abscess). It is highly suggestive of chronic osteomyelitis. * **Option B (Amyloidosis):** Chronic osteomyelitis is a classic cause of **Secondary (AA) Amyloidosis** due to prolonged systemic inflammation. This can eventually lead to renal failure. * **Option C (Cierny and Mader Classification):** This is the gold-standard clinical classification for chronic osteomyelitis. It stages the disease based on **Anatomic type** (medullary, superficial, localized, or diffuse) and **Host status** (systemic/local factors affecting healing). **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Bone Biopsy and Culture. * **X-ray Findings:** Sequestrum (most dense/radio-opaque) and Involucrum (least dense). * **Most Common Organism:** *Staphylococcus aureus*. * **Malignant Transformation:** Long-standing discharging sinuses can lead to **Squamous Cell Carcinoma** (Marjolin’s Ulcer). * **Treatment:** Radical debridement (Sequestrectomy and Saucerization) is the mainstay of treatment.

Question 64: What is the earliest radiological manifestation of TB of the hip joint?

A. Loss of joint space
B. Femoral head loss
C. Periosteal thickening
D. Osteopenia (Correct Answer)

Explanation: **Explanation:** The earliest radiological manifestation of Tuberculosis (TB) of the hip joint is **Osteopenia** (juxta-articular osteoporosis). This occurs due to increased vascularity and hyperemia associated with the chronic inflammatory process, which leads to the leaching of calcium from the bones surrounding the joint. On an X-ray, this appears as a "ground-glass" appearance or decreased bone density. **Analysis of Options:** * **A. Loss of joint space:** This is a later finding. In TB, joint space is initially **preserved** for a long time because the mycobacteria lack proteolytic enzymes (unlike pyogenic arthritis). Narrowing only occurs once the articular cartilage is destroyed by subchondral granulation tissue. * **B. Femoral head loss:** This represents advanced destruction (Stage of Arthritis/Erosion). It occurs much later in the disease progression as the infection leads to "wandering acetabulum" or pathological dislocation. * **C. Periosteal thickening:** While seen in some bone infections, it is not a hallmark or the earliest sign of TB hip. TB is primarily a "cold" and "lytic" process rather than a bone-forming one. **Clinical Pearls for NEET-PG:** * **Phemister’s Triad:** Characterizes TB of joints: (1) Juxta-articular osteopenia, (2) Peripheral osseous erosions, and (3) Gradual narrowing of the joint space. * **Earliest Sign:** The very first sign is often **soft tissue swelling**, but among bony radiological changes, **Osteopenia** is the earliest. * **Key Distinction:** In **Pyogenic Arthritis**, joint space loss is rapid and early; in **Tubercular Arthritis**, joint space loss is a late feature.

Question 65: What is chronic periostitis in children called?

A. Cherubism
B. Garre's osteomyelitis (Correct Answer)
C. Histiocytosis X
D. Tuberculous osteomyelitis

Explanation: **Explanation:** **Garre’s Osteomyelitis** (also known as Chronic Osteomyelitis with Proliferative Periostitis) is a specific type of chronic osteomyelitis characterized by a prominent **periosteal reaction** that leads to the formation of new bone. It typically occurs in children and young adults. The underlying medical concept is a low-grade, persistent infection (often staphylococcal) where the body’s immune response is robust enough to prevent suppuration (pus formation) but triggers the periosteum to lay down concentric layers of new bone, giving it a characteristic **"onion-skin" appearance** on X-ray. It most commonly affects the mandible or the tibia. **Analysis of Incorrect Options:** * **Cherubism:** A rare genetic disorder (not infectious) characterized by bilateral, painless, cystic expansion of the jaws, giving the child a "cherubic" facial appearance. * **Histiocytosis X (Langerhans Cell Histiocytosis):** A group of disorders involving abnormal proliferation of Langerhans cells. While it can cause "punched-out" bone lesions, it is a neoplastic/proliferative process, not chronic periostitis. * **Tuberculous Osteomyelitis:** Caused by *Mycobacterium tuberculosis*, it typically presents with "cold abscesses" and bone destruction (caries) rather than the reactive periosteal thickening seen in Garre’s. **NEET-PG High-Yield Pearls:** * **Classic X-ray finding:** "Onion-skin" appearance (concentric laminations of periosteal new bone). * **Common Site:** The Mandible (often associated with dental infections/caries). * **Key Feature:** It is a **non-suppurative** process; there is no drainage or sequestrum formation. * **Treatment:** Primarily involves removing the source of infection (e.g., tooth extraction or antibiotics); surgical resection is rarely needed.

Question 66: Clutton's joints are associated with which of the following?

A. Syphilitic joints (Correct Answer)
B. End stage Tuberculous joints
C. Joints associated with trauma
D. Usually painful joints

Explanation: **Explanation:** **Clutton’s joints** are a classic manifestation of **Late Congenital Syphilis**. The condition is characterized by symmetrical, painless swelling of the joints, most commonly involving the **knees**. 1. **Why the correct answer is right:** Clutton’s joints represent a chronic hydrarthrosis (fluid accumulation) caused by a localized inflammatory response to *Treponema pallidum*. It typically appears between the ages of 8 and 15 years. The hallmark is a **painless, bilateral effusion** with a full range of motion and no significant bony destruction on X-ray. 2. **Why the incorrect options are wrong:** * **Option B (Tuberculous joints):** TB of the joints (like Pott’s spine or TB hip) is typically "cold" but destructive, leading to joint space narrowing, bony erosion, and eventually fibrous ankylosis (the "end stage"). It is rarely symmetrical or purely effusive like Clutton's. * **Option C (Trauma):** Traumatic effusions (hemarthrosis) are usually unilateral, acute in onset, and associated with significant pain and a history of injury. * **Option D (Painful joints):** This is a key distractor. Clutton’s joints are characteristically **painless** despite the marked swelling, which helps differentiate them from septic or rheumatoid arthritis. **High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Triad:** Often associated with Clutton's joints; includes Interstitial keratitis, Sensorineural deafness (8th nerve), and Hutchinson’s teeth (notched incisors). * **Synovial Fluid:** In Clutton’s joints, the fluid shows a predominance of lymphocytes. * **Treatment:** While the effusion is often self-limiting and does not respond significantly to penicillin, systemic treatment is required to manage the underlying syphilis.

Question 67: Garre's osteomyelitis is:

A. Chronic
B. Usually seen in the mandible
C. Associated with sclerosis of the diaphysis of long bones
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Garre’s Osteomyelitis** (also known as Chronic Sclerosing Non-suppurative Osteomyelitis) is a specific type of chronic bone infection characterized by a low-grade inflammatory process that triggers intense periosteal reaction and bone formation rather than pus production or sequestration. 1. **Why Option D is Correct:** * **Chronic (Option A):** It is a chronic condition resulting from a low-grade, persistent infection (often *Staphylococcus aureus*). Unlike acute osteomyelitis, it lacks systemic symptoms like high fever or abscess formation. * **Mandibular Involvement (Option B):** In the head and neck region, the **mandible** is the most common site, often associated with periapical dental infections or caries in children and young adults. * **Sclerosis of Diaphysis (Option C):** In long bones (like the tibia or femur), it typically affects the **diaphysis**. It presents with significant subperiosteal new bone formation and cortical thickening (sclerosis), which gives the bone a dense, "swollen" appearance on X-ray. 2. **Clinical Pearls for NEET-PG:** * **Key Radiographic Feature:** The "Onion-skin" appearance (concentric layers of subperiosteal new bone) is a classic finding, which must be differentiated from Ewing’s Sarcoma. * **Distinguishing Feature:** Unlike typical chronic osteomyelitis, Garre’s **does not** show sequestrum (dead bone), involucrum, or sinus tract formation. * **Treatment:** Primarily involves addressing the source of infection (e.g., tooth extraction or long-term antibiotics). Surgery is rarely needed unless to rule out malignancy. * **Age Group:** Most commonly seen in children and adolescents.

Question 68: What is the most common cause of fracture in hemophilic arthropathy?

A. Osteoporosis and restrictive joint movement (Correct Answer)
B. Cartilage destruction
C. Inflammatory arthropathy
D. Osteosclerosis

Explanation: **Explanation:** In Hemophilic Arthropathy, the primary mechanism leading to fractures is the combination of **Osteoporosis and restrictive joint movement**. Recurrent hemarthrosis (bleeding into joints) leads to chronic synovitis. The iron (hemosiderin) deposition and inflammatory cytokines cause hyperemia of the epiphysis, which results in **disuse atrophy** and juxta-articular osteoporosis. Furthermore, repeated bleeds lead to fibrous ankylosis and muscle contractures, causing restrictive joint movement. This combination makes the bone brittle and increases the mechanical stress on the bone during minor trauma, leading to fractures. **Analysis of Incorrect Options:** * **B. Cartilage destruction:** While cartilage destruction is a hallmark of late-stage hemophilic arthropathy (due to proteolytic enzymes), it leads to joint space narrowing and deformity rather than being the direct cause of a bone fracture. * **C. Inflammatory arthropathy:** Although the process involves inflammation (synovitis), the term is too broad. The specific sequelae of inflammation—osteoporosis—is what directly predisposes the bone to fracture. * **D. Osteosclerosis:** This refers to increased bone density. In hemophilia, the bone density actually decreases (osteoporosis), making this option the physiological opposite of what occurs. **NEET-PG High-Yield Pearls:** * **Earliest sign of Hemophilic Arthropathy:** Soft tissue swelling. * **Most common joint involved:** Knee > Elbow > Ankle. * **Radiological Signs:** Widening of the intercondylar notch of the femur and "squaring" of the inferior pole of the patella (Jordan’s Sign). * **Classification:** The **Arnold-Hilgartner classification** is used to stage hemophilic arthropathy.

Question 69: Which of the following are common sites of tuberculous bursitis?

A. Prepatellar (Correct Answer)
B. Subacromial
C. Subdeltoid
D. Trochanteric

Explanation: **Explanation:** Tuberculous bursitis is a chronic granulomatous inflammation of the bursa caused by *Mycobacterium tuberculosis*. It usually occurs secondary to an underlying bone or joint focus or via hematogenous spread. **Why Prepatellar is the Correct Answer:** The **prepatellar bursa** is the most common site for tuberculous bursitis. This is primarily because of its superficial location, making it more susceptible to repeated minor trauma, which can localize a hematogenous infection. Clinically, it presents as a "cold swelling" over the patella with minimal pain, often mimicking a chronic non-specific bursitis (Housemaid’s knee) but with thicker walls and potentially "rice bodies" (fibrin masses) within the fluid. **Analysis of Other Options:** * **Subacromial and Subdeltoid (B & C):** While tuberculosis can affect these bursae, it is significantly less common than the prepatellar site. When it occurs here, it is often associated with tuberculosis of the shoulder joint or the greater tuberosity of the humerus. * **Trochanteric (D):** Trochanteric tuberculous bursitis is a well-known entity but is less frequent than prepatellar involvement. It typically presents with pain over the lateral aspect of the hip and may be associated with underlying trochanteric bone erosion. **High-Yield Clinical Pearls for NEET-PG:** * **Rice Bodies:** These are pathognomonic macroscopic findings in TB bursitis/tenosynovitis, representing organized fibrin. * **Compound Palmar Ganglion:** This is a classic presentation of TB tenosynovitis involving the common flexor sheath of the wrist, characterized by a cross-fluctuant swelling above and below the flexor retinaculum. * **Diagnosis:** Gold standard is a biopsy of the bursa wall showing caseating granulomas and AFB (Acid Fast Bacilli) culture. * **Treatment:** Standard anti-tubercular therapy (ATT) for 6–9 months; surgical excision is reserved for persistent or recurrent cases.

Question 70: What is true about frozen shoulder?

A. May occur after myocardial infarction.
B. Seen following Colles' fracture.
C. Less commonly seen in diabetes.
D. Improves after intraarticular steroid injection. (Correct Answer)

Explanation: **Explanation:** Frozen shoulder, or **Adhesive Capsulitis**, is a clinical syndrome characterized by spontaneous onset of progressive pain and a significant loss of both active and passive range of motion (especially external rotation) due to chronic inflammation and fibrosis of the glenohumeral joint capsule. **Why Option D is correct:** Intra-articular corticosteroid injections are a mainstay of treatment, particularly in the early "freezing" (painful) stage. They work by reducing the inflammatory response and synovitis, thereby providing rapid pain relief and facilitating physical therapy to restore joint mobility. **Analysis of Incorrect Options:** * **Options A & B:** While the question marks Option D as the "most" true or intended answer in many traditional question banks, it is important to note that **Frozen Shoulder can indeed occur after Myocardial Infarction (MI) and Colles' fracture.** These are known triggers due to prolonged immobilization of the limb. However, in the context of competitive exams like NEET-PG, if a question asks for a definitive clinical characteristic or treatment outcome, the efficacy of steroids (Option D) is often prioritized as the "best" answer regarding management. * **Option C:** This is factually incorrect. Diabetes Mellitus is the **most common predisposing factor** for frozen shoulder. Diabetics have a higher incidence (up to 20%), often experience bilateral involvement, and are generally more resistant to conservative treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Stages:** 1. Freezing (Painful), 2. Frozen (Stiff/Adhesive), 3. Thawing (Recovery). * **Pathology:** Characterized by a thickened, fibrotic capsule and a **diminished joint volume** (pathognomonic finding on arthrography). * **Clinical Sign:** Loss of **External Rotation** is typically the first and most severe restriction. * **Associations:** Diabetes (most common), Hypothyroidism, Post-cardiac surgery, and Parkinson’s disease.

Practice by Chapter

Septic Arthritis

Practice Questions

Osteomyelitis

Practice Questions

Tuberculosis of Bones and Joints

Practice Questions

Fungal and Parasitic Infections

Practice Questions

Diabetic Foot Infections

Practice Questions

Prosthetic Joint Infections

Practice Questions

Reactive Arthritis

Practice Questions

Management of Joint Infections

Practice Questions

Prevention of Orthopaedic Infections

Practice Questions

Biofilms in Orthopaedic Infections

Practice Questions

Antibiotic Prophylaxis

Practice Questions

Implant-Related Infections

Practice Questions

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