Arthroscopy — MCQs

Arthroscopy Indian Medical PG Practice Questions and MCQs

Question 11: A 40-year-old female presents with a history of fever, fatigue, weight loss, and symmetrical polyarthralgia predominantly involving the small joints of the hands and wrists. What is the most likely diagnosis?

A. Osteoarthritis
B. Rheumatoid arthritis (Correct Answer)
C. Gout
D. Psoriatic arthritis

Explanation: ***Rheumatoid arthritis*** - The combination of **systemic symptoms** (fever, fatigue, weight loss) with **symmetrical polyarthralgia** affecting small joints is characteristic of rheumatoid arthritis. - **Middle-aged females** are most commonly affected, and the **hands and wrists** are typical early sites of involvement in this autoimmune condition. *Osteoarthritis* - Primarily a **degenerative joint disease** without systemic features like fever, fatigue, or weight loss. - Typically affects **weight-bearing joints** and **DIP joints**, with **asymmetric** joint involvement rather than symmetrical small joint polyarthralgia. *Gout* - Usually presents as **acute monoarticular arthritis** affecting large joints, particularly the **first metatarsophalangeal joint**. - More common in **males** and lacks the systemic symptoms and symmetrical small joint involvement seen in this case. *Psoriatic arthritis* - Characteristically involves **DIP joints** and has an **asymmetric distribution**, unlike the symmetrical small joint pattern described. - Associated with **psoriatic skin lesions** and **nail changes**, which are not mentioned in this presentation.

Question 12: A 27-year-old male presents with low backache that occurs early in the morning, is associated with stiffness, and persists for more than 30 minutes. On examination, his chest expansion is also restricted. What is the most probable diagnosis?

A. Rheumatoid arthritis
B. Osteoarthritis
C. Gouty arthritis
D. Ankylosing spondylitis (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Ankylosing Spondylitis** **Concept:** Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy that primarily affects the axial skeleton (sacroiliac joints and spine). The hallmark clinical presentation includes **inflammatory back pain**, characterized by: * Onset in young males (<40 years). * **Morning stiffness** lasting >30 minutes. * Improvement with activity/exercise and worsening with rest. * **Reduced chest expansion** (due to involvement of costovertebral and costotransverse joints), which is a specific diagnostic criterion in the Modified New York Criteria. **Why other options are incorrect:** * **A. Rheumatoid Arthritis:** Typically affects small joints of the hands and feet symmetrically. While it causes morning stiffness, it rarely involves the sacroiliac joints or restricts chest expansion. * **B. Osteoarthritis:** This is a degenerative condition. Pain typically **worsens with activity** and improves with rest. Morning stiffness is brief (usually <30 minutes). * **C. Gouty Arthritis:** Presents as acute, episodic, exquisitely painful monoarthritis (most commonly the 1st metatarsophalangeal joint) associated with hyperuricemia, not chronic axial stiffness. **NEET-PG High-Yield Pearls:** * **Genetic Association:** Strongly linked with **HLA-B27** (>90% of cases). * **Radiology:** Look for **"Bamboo Spine"** (due to marginal syndesmophytes) and "Dagger Sign" on X-ray. The earliest radiographic change is **Sacroiliitis**. * **Schober’s Test:** Used to clinically assess restricted lumbar flexion. * **Extra-articular manifestation:** The most common is **Acute Anterior Uveitis**. * **Treatment:** NSAIDs are the first-line treatment; TNF-alpha inhibitors (e.g., Etanercept, Infliximab) are used for refractory cases.

Question 13: Which type of arthritis commonly involves the distal interphalangeal joint?

A. Gouty arthritis
B. Psoriatic arthritis (Correct Answer)
C. Reactive arthritis
D. Rheumatoid arthritis

Explanation: **Explanation:** The involvement of the **Distal Interphalangeal (DIP) joints** is a classic diagnostic hallmark of **Psoriatic Arthritis (PsA)**. While PsA can present in various patterns (symmetric polyarthritis, asymmetric oligoarthritis, or spondylitis), the "DIP predominant" variety is unique and often associated with characteristic **psoriatic nail changes** (pitting, onycholysis). **Analysis of Options:** * **Psoriatic Arthritis (Correct):** It is the most common inflammatory arthritis to involve the DIP joints. Radiologically, it may show the "Pencil-in-cup" deformity due to periarticular erosions and bone resorption. * **Rheumatoid Arthritis (Incorrect):** RA characteristically **spares the DIP joints**. It primarily involves the MCP, PIP, and wrist joints. If a small joint of the hand is involved and it’s the DIP, RA is highly unlikely. * **Gouty Arthritis (Incorrect):** While gout can affect any joint, it most commonly presents as podagra (1st MTP joint). DIP involvement is rare and usually occurs in chronic tophaceous gout, often mimicking Osteoarthritis (Heberden's nodes). * **Reactive Arthritis (Incorrect):** This typically presents as an asymmetric large-joint oligoarthritis, predominantly affecting the lower limbs (knees and ankles). **NEET-PG High-Yield Pearls:** * **DIP Joint Involvement:** Think **Psoriatic Arthritis** or **Osteoarthritis** (Heberden’s nodes). * **Nail-Joint Link:** In PsA, DIP joint involvement is strongly correlated with psoriatic nail dystrophy. * **Dactylitis:** The "Sausage digit" appearance is a classic feature of PsA and other Seronegative Spondyloarthropathies. * **Radiology:** Look for "Pencil-in-cup" deformity and "Telescoping" of digits (Arthritis Mutilans) in PsA cases.

Question 14: Which joint is rarely affected by ankylosing spondylitis?

A. Ankle (Correct Answer)
B. Hip
C. Shoulder
D. Sacroiliac

Explanation: **Explanation:** Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy that primarily targets the axial skeleton and large proximal joints. **Why Ankle is the Correct Answer:** In AS, peripheral joint involvement typically follows a **centripetal pattern**, meaning it predominantly affects the "root" joints (proximal joints) like the hips and shoulders. Distal joints, such as the **ankle**, wrist, and small joints of the hands and feet, are **rarely involved**. When peripheral involvement does occur in the lower limbs, it more commonly manifests as enthesitis (e.g., Achilles tendonitis or plantar fasciitis) rather than true joint synovitis. **Analysis of Incorrect Options:** * **Sacroiliac Joint:** This is the **hallmark** of AS. Symmetrical sacroiliitis is usually the earliest radiographic finding and is essential for diagnosis according to the Modified New York Criteria. * **Hip Joint:** The hip is the most commonly involved extra-axial joint (up to 30-50% of cases). Hip involvement is often bilateral and is a major predictor of functional disability and the need for future surgery. * **Shoulder Joint:** Along with the hip, the shoulder is a "root" joint frequently affected in AS, leading to a significant reduction in the range of motion (the "proximal" pattern). **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign:** Symmetrical Sacroiliitis. * **Genetic Association:** HLA-B27 (found in >90% of white patients). * **Radiological Signs:** "Bamboo spine" (due to marginal syndesmophytes), Dagger sign, and Andersson lesion. * **Schober’s Test:** Used to clinically assess the restriction of lumbar spine flexion. * **Extra-articular Manifestation:** Acute anterior uveitis is the most common.

Question 15: Large bilateral painless effusions of the knees occurring in late congenital syphilis in patients between ages 8 to 18 are designated as?

A. Clutton's joints (Correct Answer)
B. Ramsey's joints
C. Charcot's joints
D. Mercer's joints

Explanation: ### Explanation **Correct Answer: A. Clutton's joints** **Clutton’s joints** are a classic manifestation of **late congenital syphilis**, typically appearing between the ages of 8 and 18 years. The condition is characterized by **symmetrical, painless, chronic hydrarthrosis** (fluid accumulation) primarily affecting the knee joints, though other joints can occasionally be involved. * **Pathophysiology:** It represents a chronic inflammatory response (synovitis) rather than an active infection of the joint space. * **Clinical Presentation:** Despite the large size of the effusions, there is minimal pain, no local heat, and the range of motion is usually preserved. It often resolves spontaneously without permanent joint damage. **Why other options are incorrect:** * **B. Ramsey’s joints:** This is a distractor. There is no recognized orthopedic condition by this name. (Note: Ramsay Hunt syndrome refers to herpes zoster oticus). * **C. Charcot’s joints (Neuropathic Arthropathy):** This involves progressive joint destruction due to loss of pain and proprioception. While associated with *acquired* syphilis (Tabes Dorsalis), it is characterized by "6 Ds" (Destruction, Debris, Disorganization, etc.) and is typically seen in adults, not as painless effusions in children. * **D. Mercer’s joints:** This is a distractor. Walter Mercer was a famous orthopedic surgeon (author of *Mercer’s Orthopaedic Surgery*), but no specific joint pathology bears his name. **High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Triad (Late Congenital Syphilis):** 1. Interstitial keratitis, 2. Sensorineural deafness (8th nerve), 3. Hutchinson’s teeth (notched incisors). * **Saber Shin:** Anterior bowing of the tibia due to periostitis in congenital syphilis. * **Wimberger’s Sign:** Focal erosion of the medial proximal tibial metaphysis (seen in early congenital syphilis). * **Clutton’s joints** do not require surgical intervention; they are usually treated with systemic penicillin and resolve over several months.

Question 16: Arthroscopy of the temporomandibular joint (TMJ) is useful in which of the following conditions?

A. Internal derangement (Correct Answer)
B. Fracture of condyle
C. Ankylosis
D. Hyperplasia

Explanation: **Explanation:** **1. Why Internal Derangement is Correct:** Internal derangement (ID) of the TMJ refers to a localized mechanical fault where the articular disc is displaced from its normal functional relationship with the mandibular condyle and the articular eminence. Arthroscopy is considered the **gold standard** for both diagnosing and treating ID (Stages II-IV). It allows direct visualization of the joint space, lysis of adhesions, and lavage of inflammatory mediators (arthrocentesis), which significantly improves joint mobility and reduces pain. **2. Why Other Options are Incorrect:** * **Fracture of Condyle:** These are structural bone injuries. While arthroscopically-assisted reduction exists, the standard of care remains closed reduction or Open Reduction and Internal Fixation (ORIF) to ensure anatomical alignment. * **Ankylosis:** This involves extensive bony or fibrous fusion of the joint. Arthroscopy is ineffective here because the joint space is obliterated, making it impossible to insert the scope or visualize structures. Treatment requires aggressive surgery like gap arthroplasty. * **Hyperplasia:** Mandibular or condylar hyperplasia is a growth deformity resulting in facial asymmetry. This is a macro-structural bone issue requiring orthognathic surgery or condylectomy, not intra-articular endoscopic visualization. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common indication:** TMJ arthroscopy is most frequently performed for **Internal Derangement with closed lock** (disc displacement without reduction). * **Anatomy:** The TMJ is a **Ginglymoarthrodial joint**. Arthroscopy is primarily performed in the **superior joint space**. * **Complication:** The most common nerve injury during TMJ arthroscopy is to the **auriculotemporal nerve** or branches of the **facial nerve**. * **Diagnostic Gold Standard:** While MRI is the best non-invasive imaging for the disc, arthroscopy is the definitive diagnostic tool.

Question 17: What crystal is characteristic of pseudogout?

A. Calcium pyrophosphate dihydrate (CPPD) (Correct Answer)
B. Urate
C. Calcium carbonate
D. Xanthine

Explanation: **Explanation:** **Pseudogout**, clinically known as **Calcium Pyrophosphate Deposition (CPPD) disease**, is a crystal-induced arthropathy. The correct answer is **Calcium pyrophosphate dihydrate (CPPD)** because these crystals deposit in the articular cartilage and fibrocartilage (chondrocalcinosis), leading to acute inflammatory episodes that mimic gout. **Analysis of Options:** * **Option A (Correct):** CPPD crystals are the hallmark of pseudogout. Under polarized microscopy, they appear as **rhomboid-shaped** crystals with **weak positive birefringence**. * **Option B (Incorrect):** **Monosodium Urate (MSU)** crystals are characteristic of **Gout**. These are needle-shaped and show strong negative birefringence. * **Option C (Incorrect):** Calcium carbonate is not typically associated with crystal arthropathies; it is more relevant to renal stones or physiological buffering. * **Option D (Incorrect):** Xanthine crystals are rare and usually associated with hereditary xanthinuria or the use of xanthine oxidase inhibitors (like Allopurinol), but they do not cause pseudogout. **High-Yield NEET-PG Pearls:** 1. **Radiology:** The classic finding is **Chondrocalcinosis** (linear calcification of the meniscus or articular cartilage), most commonly seen in the **Knee** (most common site), wrist, and symphysis pubis. 2. **Microscopy:** Remember the "P's": **P**seudogout = **P**ositively birefringent = **P**yrophosphate = **P**olygonal/Rhomboid. 3. **Associations:** Often associated with metabolic conditions like **Hyperparathyroidism, Hemochromatosis, and Hypomagnesemia**. 4. **Treatment:** Acute attacks are managed with NSAIDs, Colchicine, or intra-articular steroids.

Question 18: Which of the following is a differential diagnosis for tuberculous arthritis of the hip joint?

A. Rheumatoid arthritis
B. Perthes disease
C. Septic arthritis
D. All of the above (Correct Answer)

Explanation: **Explanation:** Tuberculous (TB) arthritis of the hip is a chronic, granulomatous infection characterized by an insidious onset, pain, limp, and a gradual reduction in the range of motion. Because its presentation can mimic various inflammatory, degenerative, and infectious conditions, a broad differential diagnosis is essential. **Why "All of the Above" is Correct:** * **Rheumatoid Arthritis (RA):** Like TB, RA causes chronic synovial hypertrophy and joint space narrowing. While RA is typically polyarticular and symmetrical, monoarticular RA of the hip can closely resemble the "Pannus" formation and marginal erosions seen in TB. * **Perthes Disease:** In the early stages (Stage 1: Synovitis), Perthes disease presents with a limp and hip pain in children. TB hip in children often presents similarly with "night cries" and muscle spasms, making it a crucial differential in the pediatric age group. * **Septic Arthritis:** Although septic arthritis is usually acute and pyogenic, subacute or partially treated septic arthritis can present with a more indolent course, overlapping with the clinical picture of TB hip. **High-Yield Clinical Pearls for NEET-PG:** * **Phemister’s Triad:** Characteristic of TB arthritis—1. Juxta-articular osteopenia, 2. Peripherally located osseous erosions, and 3. Gradual narrowing of the joint space. * **Stages of TB Hip:** 1. *Stage of Synovitis:* Apparent lengthening (Abduction, External Rotation). 2. *Stage of Arthritis:* Apparent shortening (Adduction, Internal Rotation). 3. *Stage of Erosion:* True shortening (Wandering Acetabulum). * **Cold Abscess:** Unlike pyogenic infections, TB abscesses lack classical signs of inflammation (heat, redness). * **Gold Standard Diagnosis:** Synovial biopsy and culture (Lowenstein-Jensen medium) or GeneXpert.

Question 19: Which of the following best describes a toe deformity where there is hyperextension at the metatarsophalangeal joint, flexion at the proximal interphalangeal joint, and flexion at the distal interphalangeal joint?

A. Claw toe (Correct Answer)
B. Hammer toe
C. Mallet toe
D. Curly toe

Explanation: To master toe deformities for NEET-PG, it is essential to focus on the specific position of the three joints: the Metatarsophalangeal (MTP), Proximal Interphalangeal (PIP), and Distal Interphalangeal (DIP) joints. ### **Explanation of the Correct Answer** **A. Claw Toe:** This deformity is characterized by **MTP hyperextension**, **PIP flexion**, and **DIP flexion**. It typically involves all the lesser toes and is often associated with neuromuscular disorders (like Charcot-Marie-Tooth disease) or inflammatory conditions (like Rheumatoid Arthritis). The underlying pathology involves an imbalance between the extrinsic and intrinsic muscles of the foot. ### **Analysis of Incorrect Options** * **B. Hammer Toe:** This involves **MTP hyperextension**, **PIP flexion**, but the **DIP joint is neutral or hyperextended**. It most commonly affects the second toe and is often associated with a long second metatarsal or hallux valgus. * **C. Mallet Toe:** This is an isolated flexion deformity of the **DIP joint** only. The MTP and PIP joints remain in a neutral position. It is often caused by pressure from ill-fitting shoes. * **D. Curly Toe:** A congenital condition, usually affecting the 3rd, 4th, or 5th toes, characterized by flexion and medial rotation of the PIP and DIP joints. ### **High-Yield Clinical Pearls for NEET-PG** * **Mnemonic for Claw vs. Hammer:** In **Claw** toe, the tip of the toe digs into the sole (DIP flexion), whereas in **Hammer** toe, the tip usually points straight or up (DIP neutral/extension). * **Friedreich’s Ataxia:** Frequently presents with bilateral claw toes and high-arched feet (Pes Cavus). * **Girdlestone-Taylor Procedure:** A high-yield surgical fix for flexible claw/hammer toes involving the transfer of the Flexor Digitorum Longus (FDL) tendon to the extensor expansion.

Question 20: Double contrast arthrography is used for the analysis of which anatomical structure?

A. Intervertebral discs
B. Joint spaces (Correct Answer)
C. Treatment of dislocations
D. None of the above

Explanation: **Explanation:** **Double Contrast Arthrography** is a specialized imaging technique used to visualize the internal structures of a joint. It involves the simultaneous injection of two types of contrast media into the **joint space**: 1. **Radiopaque (Positive) Contrast:** Usually an iodine-based dye that appears white on X-rays. 2. **Radiolucent (Negative) Contrast:** Usually air or carbon dioxide that appears black on X-rays. The combination allows for a thin coating of the positive contrast over the mucosal and cartilaginous surfaces, while the air distends the joint. This provides superior mucosal detail and allows for the detection of intra-articular pathologies like meniscal tears, loose bodies, and synovial abnormalities. **Analysis of Options:** * **Option B (Correct):** Arthrography is specifically designed to study **joint spaces** (e.g., knee, shoulder, hip). It outlines the articular cartilage and internal ligaments. * **Option A (Incorrect):** Imaging of the intervertebral discs is called **Discography**. While it involves contrast, it is distinct from peripheral joint arthrography. * **Option C (Incorrect):** Arthrography is a **diagnostic** tool, not a treatment modality. Dislocations are primarily managed via closed or open reduction. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Shift:** While double-contrast arthrography was historically significant, **MRI** and **Diagnostic Arthroscopy** have largely replaced it for evaluating internal derangements of joints. * **CT Arthrography:** Currently used in patients with contraindications to MRI (e.g., pacemakers) to evaluate labral tears or osteochondral defects. * **Pneumoarthrography:** A variation using only air (negative contrast) as the medium.

Practice by Chapter

Principles of Arthroscopy

Practice Questions

Knee Arthroscopy

Practice Questions

Shoulder Arthroscopy

Practice Questions

Hip Arthroscopy

Practice Questions

Ankle Arthroscopy

Practice Questions

Elbow Arthroscopy

Practice Questions

Wrist Arthroscopy

Practice Questions

Arthroscopic Equipment and Setup

Practice Questions

Diagnostic Arthroscopy

Practice Questions

Therapeutic Arthroscopic Procedures

Practice Questions

Complications in Arthroscopy

Practice Questions

Post-Arthroscopy Rehabilitation

Practice Questions

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