Hip Arthroscopy — MCQs
What is the most common complication after total hip replacement?
In deep transverse arrest with adequate pelvis, what is the best mode of delivery?
Which is the safest site for intramuscular (IM) injection to avoid injury to vessels and nerves?
A 70-year-old physiologically fit male presents with severe hip pain after a fall. X-ray reveals a displaced femoral neck fracture. What is the most appropriate management option?
An athlete sustained an injury around the knee joint with suspected cartilage damage. Which of the following is the investigation of choice?
The joint cavity can be examined in detail with minimal surgical exposure by which procedure?
Triple deformity of the knee is present in which condition?
Boutonniere deformity involves which of the following joint alterations?
Which of the following is a characteristic feature of osteoarthritis?
In which of the following conditions is the proximal interphalangeal joint involved while the distal interphalangeal joint is spared?
Hip Arthroscopy Indian Medical PG Practice Questions and MCQs
Question 1: What is the most common complication after total hip replacement?
- A. Dislocation
- B. DVT (Correct Answer)
- C. Infection
- D. Aseptic Loosening
Explanation: ***DVT*** - Deep vein thrombosis (DVT) is the **most common overall complication** following total hip replacement, with reported incidences as high as 40-60% without prophylaxis. - The risk of DVT is significant due to **venous stasis during surgery**, immobilization, and the inflammatory response to tissue injury. *Dislocation* - While a serious complication, **dislocation** of the prosthetic hip joint is less common than DVT, occurring in about 1-5% of primary total hip replacements. - It typically results from **improper joint positioning** or patient activities that push the hip beyond its normal range of motion. *Infection* - **Infection** is a severe but relatively rare complication, with rates for periprosthetic joint infection in total hip replacement typically ranging from 0.5% to 2%. - It can lead to significant morbidity and usually requires **further surgical intervention** for eradication. *Aseptic Loosening* - **Aseptic loosening** is a long-term complication, occurring years after the surgery, rather than an immediate post-operative complication. - This complication involves the **failure of the implant-bone interface** without evidence of infection, often due to particle disease or mechanical stress.
Question 2: In deep transverse arrest with adequate pelvis, what is the best mode of delivery?
- A. Cesarean section
- B. Kielland forceps (Correct Answer)
- C. Ventouse
- D. Manual rotation followed by forceps
Explanation: ***Kielland forceps*** - **Kielland forceps** are the **classical instrument of choice** for deep transverse arrest with an adequate pelvis, as they were specifically designed for **rotational delivery**. - They have a **minimal pelvic curve** and a **sliding lock mechanism** that allows for controlled rotation of the fetal head from transverse to occipito-anterior position. - When the pelvis is adequate and the operator is skilled, Kielland forceps provide the **most direct and effective method** for managing deep transverse arrest. - This is the **standard answer** taught in most obstetric textbooks including Williams Obstetrics and Dutta's Textbook of Obstetrics. *Manual rotation followed by forceps* - This is an acceptable alternative approach, especially when **expertise with rotational forceps is limited**. - Manual rotation (using the hand to rotate the fetal head to occipito-anterior) followed by standard forceps or traction is a valid method. - However, it requires **two separate maneuvers** rather than the single-instrument approach with Kielland forceps. *Ventouse* - While ventouse can achieve rotation and traction, it has a **higher failure rate** in cases of deep transverse arrest, particularly at the mid-pelvis level. - Rotation with ventouse is **less controlled** and has higher **cup detachment rates** compared to rotational forceps. - It may be considered when rotational forceps expertise is not available or when minimal rotation is needed. *Cesarean section* - Cesarean section would be indicated if the pelvis were **inadequate** (cephalopelvic disproportion), if there is **fetal distress**, or if **assisted vaginal delivery fails**. - Since the question specifies an **adequate pelvis**, operative vaginal delivery is preferred over the more invasive cesarean section when feasible.
Question 3: Which is the safest site for intramuscular (IM) injection to avoid injury to vessels and nerves?
- A. Upper inner quadrant of buttock
- B. Upper outer quadrant of buttock (Correct Answer)
- C. Lower part of insertion of deltoid
- D. Lower inner quadrant of buttock
Explanation: ***Upper outer quadrant of buttock*** - This site, specifically the **ventrogluteal** or **dorsogluteal** region in the upper outer quadrant, avoids major nerves and blood vessels. - The **gluteus medius** and **gluteus minimus** muscles here are thick enough for medication absorption without risk of injury. *Upper inner quadrant of buttock* - This area is close to the **sciatic nerve** and major **blood vessels** like the superior gluteal artery and vein, increasing the risk of injury. - Injecting here can lead to nerve damage, pain, or hematoma formation. *Lower part of insertion of deltoid* - While deltoid injections are common, the **lower part of the deltoid** near its insertion can be inadequate for larger volumes and is closer to the **radial nerve**, increasing nerve injury risk. - The **mid-deltoid** is usually preferred for smaller volume injections. *Lower inner quadrant of buttock* - This quadrant is in close proximity to the **sciatic nerve** and the **pudendal nerve**, making it highly susceptible to nerve injury. - It also has a thinner muscle mass compared to the upper outer quadrant, increasing the risk of hitting bone or blood vessels.
Question 4: A 70-year-old physiologically fit male presents with severe hip pain after a fall. X-ray reveals a displaced femoral neck fracture. What is the most appropriate management option?
- A. Hemiarthroplasty (Correct Answer)
- B. Total hip replacement
- C. Conservative management with physical therapy
- D. Corticosteroid injection
Explanation: ***Hemiarthroplasty*** - For an **elderly patient** (70-year-old) with a **femoral neck fracture** and good physiological status, hemiarthroplasty is often the preferred choice. - It involves replacing the **femoral head and neck** with a prosthesis, allowing for early mobilization and reducing the risk of avascular necrosis. *Conservative management with physical therapy* - This approach is generally **not suitable for displaced femoral neck fractures** in the elderly due to high risks of **non-union** and **avascular necrosis**. - Prolonged bed rest associated with conservative management can lead to complications such as **pneumonia**, **deep vein thrombosis**, and **pressure ulcers** in elderly patients. *Total hip replacement* - While an option for femoral neck fractures, **total hip replacement** is typically reserved for **younger patients**, those with **pre-existing arthritis**, or those with **better bone quality**. - It involves replacing both the **femoral head and the acetabular cup**, a more complex procedure than hemiarthroplasty. *Corticosteroid injection* - **Corticosteroid injections** are used for **inflammatory joint conditions** and pain relief, **not for fracture management**. - They have **no role in stabilizing a fractured femoral neck** and would not address the mechanical instability or bone healing required.
Question 5: An athlete sustained an injury around the knee joint with suspected cartilage damage. Which of the following is the investigation of choice?
- A. X-ray
- B. Clinical examination
- C. Arthroscopy (Correct Answer)
- D. Arthrotomy
Explanation: **Explanation:** The investigation of choice for suspected intra-articular cartilage damage is **Arthroscopy**. It is considered the **"Gold Standard"** because it allows for direct visualization of the articular surfaces, menisci, and ligaments under magnification. Unlike imaging, it provides a dynamic assessment of the tissue's integrity and allows the surgeon to perform immediate therapeutic interventions (e.g., debridement or chondroplasty). **Analysis of Options:** * **X-ray (Option A):** X-rays are excellent for visualizing bony injuries or fractures but are poor at showing soft tissues like cartilage or menisci. They are usually the first-line screening tool but are not definitive for cartilage damage. * **Clinical Examination (Option B):** While essential for initial diagnosis (e.g., McMurray’s or Lachman tests), clinical exams are subjective and can be limited by pain, swelling, or muscle guarding in an acute athlete injury. * **Arthrotomy (Option D):** This involves a large surgical incision to open the joint. It is highly invasive and has been largely replaced by arthroscopy due to higher morbidity and longer recovery times. **Clinical Pearls for NEET-PG:** * **MRI vs. Arthroscopy:** While MRI is the investigation of choice for *non-invasive* screening of soft tissue injuries, **Arthroscopy** remains the overall "Gold Standard" for definitive diagnosis and treatment. * **Triad of O'Donoghue:** Often seen in athletes, involving injury to the ACL, MCL, and Medial Meniscus. * **Arthroscopy Media:** Normal saline or Ringer’s Lactate is used to distend the joint during the procedure. * **Common Portals:** The anterolateral portal is the most common primary portal used in knee arthroscopy.
Question 6: The joint cavity can be examined in detail with minimal surgical exposure by which procedure?
- A. Sialography
- B. Arthroscopy (Correct Answer)
- C. Biopsy
- D. Endoscopy
Explanation: **Explanation:** **Arthroscopy** is the correct answer because it is a minimally invasive surgical procedure used to visualize, diagnose, and treat problems inside a joint. It involves inserting a fiber-optic camera (arthroscope) through a small "portal" or stab incision. This allows for a detailed examination of the joint cavity (articular cartilage, ligaments, and synovium) with significantly less morbidity, faster recovery, and minimal surgical exposure compared to traditional open arthrotomy. **Analysis of Incorrect Options:** * **Sialography (A):** This is a radiographic examination of the salivary glands and ducts using a contrast medium. It is unrelated to joint pathology. * **Biopsy (C):** While a biopsy can be performed *during* an arthroscopy, the term refers to the removal of tissue for histological examination. It is a diagnostic technique, not a procedure designed for the comprehensive visualization of a joint cavity. * **Endoscopy (D):** This is a broad umbrella term for looking inside the body using an endoscope. While arthroscopy is technically a type of endoscopy, "Arthroscopy" is the specific and most appropriate clinical term for joint visualization. **High-Yield Clinical Pearls for NEET-PG:** * **Triangulation:** The fundamental skill in arthroscopy where the scope and the surgical instrument meet at a specific point within the joint to perform a task. * **Distension Media:** Normal saline or Ringer’s Lactate is used to expand the joint space for better visualization. * **Common Sites:** The **knee** is the most common joint examined via arthroscopy, followed by the shoulder and ankle. * **Complications:** Although rare, the most common complication of arthroscopy is **hemarthrosis** (bleeding into the joint).
Question 7: Triple deformity of the knee is present in which condition?
- A. Tuberculosis of the knee (Correct Answer)
- B. Pyogenic arthritis of the knee
- C. Osteoarthritis of the knee
- D. None of the above
Explanation: **Explanation:** The **Triple Deformity of the Knee** is a classic clinical feature of advanced **Tuberculosis (TB) of the knee joint**. It occurs due to the progressive destruction of the joint surfaces and the weakening of the cruciate and collateral ligaments, combined with the powerful pull of the hamstring muscles. The "Triple Deformity" consists of: 1. **Flexion:** Due to the spasm and contracture of the hamstrings. 2. **Posterior Subluxation of the Tibia:** The ACL and PCL are destroyed, allowing the tibia to slip backward on the femur. 3. **External Rotation of the Tibia:** The biceps femoris pulls the tibia laterally. **Why other options are incorrect:** * **Pyogenic Arthritis:** While it causes rapid joint destruction and flexion deformity due to pain, it typically presents as an acute emergency. It does not usually progress to the specific "triple" chronic malalignment seen in the indolent, long-standing course of TB. * **Osteoarthritis (OA):** OA typically presents with a **Varus (bow-leg)** deformity due to the collapse of the medial compartment. Posterior subluxation and significant external rotation are not characteristic features of OA. **Clinical Pearls for NEET-PG:** * **Stages of TB Knee:** Stage 1 (Synovitis), Stage 2 (Arthritis/Early destruction), Stage 3 (Erosion/Triple deformity), Stage 4 (Ankylosis - usually fibrous). * **Phemister’s Triad (Radiology):** Juxta-articular osteopenia, peripheral osseous erosions, and gradual narrowing of the joint space. * **Treatment:** TB of the knee is primarily managed with **AKT (Antitubercular Therapy)** and splinting. Surgery (Synovectomy or Arthrodesis) is reserved for specific indications.
Question 8: Boutonniere deformity involves which of the following joint alterations?
- A. Flexion at the proximal interphalangeal (PIP) joint and distal interphalangeal (DIP) joint
- B. Extension at the proximal interphalangeal (PIP) joint and distal interphalangeal (DIP) joint
- C. Flexion at the proximal interphalangeal (PIP) joint and extension at the distal interphalangeal (DIP) joint (Correct Answer)
- D. Extension at the proximal interphalangeal (PIP) joint and flexion at the distal interphalangeal (DIP) joint
Explanation: **Explanation:** **Boutonniere deformity** is a classic hand deformity characterized by **flexion of the PIP joint** and **hyperextension of the DIP joint**. **Pathophysiology:** The primary pathology is the **rupture or avulsion of the central slip** of the extensor tendon from its insertion at the base of the middle phalanx. This allows the lateral bands to slip volarly (towards the palm) past the axis of the PIP joint. Once displaced, these lateral bands act as flexors of the PIP joint. Simultaneously, the increased tension on the lateral bands is transmitted distally, leading to compensatory hyperextension at the DIP joint. **Analysis of Options:** * **Option C (Correct):** Accurately describes the PIP flexion and DIP extension (hyperextension) resulting from central slip injury. * **Option A & B:** These do not match the reciprocal nature of the deformity caused by the displacement of lateral bands. * **Option D:** This describes a **Swan-neck deformity** (PIP hyperextension and DIP flexion), which is essentially the "opposite" of a Boutonniere deformity. **High-Yield NEET-PG Pearls:** * **Etiology:** Most commonly seen in **Rheumatoid Arthritis** (due to synovitis) and trauma (jammed finger). * **Elson’s Test:** The gold standard clinical test to diagnose early central slip injury before the deformity becomes fixed. * **Treatment:** Initial management involves splinting the PIP joint in full extension for 6–8 weeks while allowing active DIP motion. * **Pseudo-Boutonniere:** Involves PIP flexion but lacks DIP hyperextension; it is usually caused by a volar plate injury.
Question 9: Which of the following is a characteristic feature of osteoarthritis?
- A. Heberden node (Correct Answer)
- B. Increased ESR
- C. Onycholysis
- D. Z deformity
Explanation: **Explanation:** **Osteoarthritis (OA)** is a degenerative joint disease characterized by the loss of articular cartilage and the formation of new bone at the joint margins (osteophytes). **1. Why Heberden Nodes are correct:** Heberden nodes are palpable osteophytes (bony overgrowths) occurring at the **Distal Interphalangeal (DIP) joints**. They are a hallmark clinical feature of nodal osteoarthritis, more common in women, and often have a strong genetic predisposition. Similar swellings at the **Proximal Interphalangeal (PIP) joints** are known as **Bouchard nodes**. **2. Analysis of Incorrect Options:** * **Increased ESR:** OA is a non-inflammatory "wear and tear" condition; therefore, systemic inflammatory markers like ESR and CRP remain **normal**. An elevated ESR typically suggests inflammatory arthritides like Rheumatoid Arthritis (RA) or infection. * **Onycholysis:** This refers to the painless separation of the nail from the nail bed. It is a classic feature of **Psoriatic Arthritis**, not OA. * **Z-deformity:** This refers to a specific deformity of the thumb (hyperextension of the IP joint and flexion of the MCP joint) or ulnar deviation of the hand, which is characteristic of **Rheumatoid Arthritis**. **High-Yield Clinical Pearls for NEET-PG:** * **Joint Involvement:** OA characteristically **involves the DIP joints** but **spares the MCP joints** (unlike RA, which involves MCP and PIP but spares the DIP). * **Radiological Hallmarks (LOSS):** **L**oss of joint space (asymmetrical), **O**steophytes, **S**ubchondral sclerosis, and **S**ubchondral cysts. * **First-line Treatment:** Acetaminophen (Paracetamol) is traditionally the initial drug, though topical/oral NSAIDs are most effective for symptomatic relief. * **Kellgren-Lawrence Grading:** The standard radiological classification system used to assess the severity of OA.
Question 10: In which of the following conditions is the proximal interphalangeal joint involved while the distal interphalangeal joint is spared?
- A. Osteoarthritis
- B. Psoriatic arthritis
- C. Rheumatoid arthritis (Correct Answer)
- D. Ankylosing spondylitis
Explanation: **Explanation:** **Rheumatoid Arthritis (RA)** is a chronic inflammatory systemic disease that primarily targets the **synovium**. The hallmark of RA in the hands is the involvement of the **Proximal Interphalangeal (PIP)** and **Metacarpophalangeal (MCP)** joints, while characteristically **sparing the Distal Interphalangeal (DIP) joints**. This sparing occurs because the DIP joints have minimal synovial tissue compared to the more proximal joints. **Analysis of Options:** * **Osteoarthritis (OA):** Typically involves the **DIP joints** (forming Heberden’s nodes) and the PIP joints (forming Bouchard’s nodes). The involvement of the DIP joint is a classic differentiating feature from RA. * **Psoriatic Arthritis:** This seronegative spondyloarthropathy is notorious for involving the **DIP joints**. It often presents with "dactylitis" (sausage digits) and nail pitting. * **Ankylosing Spondylitis:** Primarily affects the axial skeleton (sacroiliac joints and spine). While it can involve peripheral joints, it usually affects large girdle joints (hips/shoulders) rather than the small joints of the hand in the pattern described. **High-Yield Clinical Pearls for NEET-PG:** * **RA Hand Deformities:** Swan-neck deformity (PIP hyperextension, DIP flexion), Boutonniere deformity (PIP flexion, DIP hyperextension), and Z-deformity of the thumb. * **Joint Sparing:** If the DIP is involved, think OA or Psoriatic Arthritis. If the DIP is spared, think RA. * **Radiological Signs of RA:** Periarticular osteopenia, symmetrical joint space narrowing, and marginal erosions. * **Mnemonic:** **R**heumatoid **A**rthritis **R**ejects the **D**IP.
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