Degenerative Disorders Practice Questions

Q: A 30-year-old HIV-positive male on antiretroviral therapy presents with right hip joint pain for 2 months. He has difficulty with abduction and internal rotation. Which of the following is the most likely diagnosis?

Avascular necrosis. ### **Explanation** **Correct Option: C. Avascular Necrosis (AVN)** The clinical presentation of a young patient with HIV on **Antiretroviral Therapy (ART)** presenting with insidious onset hip pain is a classic scenario for **Avascular Necrosis (AVN)** of the femoral head. * **Pathophysiology:** HIV infection itself and certain ART drugs (especially **Protease Inhibitors**) are strongly associated with metabolic derangements like hyperlipidemia and fat embolism, leading to compromised microcirculation in the femoral head. * **Clinical Sign:** Pain is typically aggravated by weight-bearing. The earliest clinical signs of hip AVN are the restriction of **internal rotation and abduction**, as seen in this patient. **Why other options are incorrect:** * **A. Septic Arthritis:** This usually presents acutely with high-grade fever, systemic toxicity, and an inability to bear any weight. A 2-month history makes this less likely. * **B. Osteoarthritis:** Primary osteoarthritis is rare in a 30-year-old. It is usually a secondary consequence of conditions like AVN or trauma in younger patients. * **D. Tubercular Arthritis:** While common in immunocompromised patients, it typically presents with a "cold abscess," significant constitutional symptoms (night sweats, weight loss), and a more chronic, destructive course on imaging (Phemister triad). **High-Yield Clinical Pearls for NEET-PG:** * **Most sensitive investigation:** MRI (shows "Double Line Sign" on T2WI). * **Staging System:** Ficat and Arlet Classification is most commonly used. * **Risk Factors for AVN:** **S**teroids (most common cause overall), **A**lcohol, **T**rauma (neck of femur fracture), **S**ickle cell anemia, and **H**IV/ART drugs (**S.A.T.S.H**). * **Treatment:** Core decompression is the treatment of choice for early stages (Ficat Stage I & II). Total Hip Arthroplasty (THA) is reserved for advanced stages with secondary collapse.

Q: Ulnar nerve paralysis causes which of the following deformities?

Claw finger deformity. **Explanation:** The correct answer is **Claw finger deformity** (specifically, Ulnar Claw Hand). **1. Why Claw Finger Deformity is Correct:** The ulnar nerve innervates the **medial two lumbricals** and all **interossei** muscles. These muscles are responsible for flexing the metacarpophalangeal (MCP) joints and extending the interphalangeal (IP) joints. In ulnar nerve paralysis, these muscles are paralyzed, leading to the opposite posture: **hyperextension at the MCP joints** (due to unopposed action of long extensors) and **flexion at the IP joints** (due to unopposed action of long flexors). This is most prominent in the ring and little fingers. **2. Analysis of Incorrect Options:** * **A. Ape thumb deformity:** Caused by **Median nerve** injury. It results from paralysis of the thenar muscles, leading to loss of thumb opposition and the thumb falling into the same plane as the fingers. * **B. Wrist drop:** Caused by **Radial nerve** injury (typically at the spiral groove). It results from paralysis of the wrist extensors. * **C. Meralgia paresthetica:** This is a clinical syndrome caused by compression of the **Lateral Femoral Cutaneous Nerve**, leading to tingling and numbness on the outer thigh; it is unrelated to the upper limb or ulnar nerve. **Clinical Pearls for NEET-PG:** * **Ulnar Paradox:** A high ulnar nerve lesion (at the elbow) results in *less* obvious clawing than a low lesion (at the wrist) because the Flexor Digitorum Profundus is also paralyzed, reducing IP joint flexion. * **Froment’s Sign:** A classic test for ulnar nerve palsy (Adductor Pollicis weakness). * **Wartenberg’s Sign:** Inability to adduct the little finger due to interossei weakness.

Q: What is the commonest degenerative joint disease?

Osteoarthritis. **Explanation:** **Osteoarthritis (OA)** is the correct answer as it is the most common degenerative joint disease and the leading cause of chronic disability in the elderly worldwide. It is characterized by the progressive loss of articular cartilage, subchondral bone changes (sclerosis and cyst formation), and the development of marginal osteophytes. Unlike inflammatory arthritides, OA is primarily a "wear and tear" process associated with aging, obesity, and mechanical stress. **Analysis of Incorrect Options:** * **Gout (A):** This is a metabolic disorder characterized by the deposition of monosodium urate crystals in joints. While it can lead to secondary degeneration, it is classified as a crystal-induced arthropathy, not a primary degenerative disease. * **Osteoporosis (B):** This is a metabolic bone disease characterized by reduced bone mineral density and micro-architectural deterioration. It affects the bone mass itself, leading to fractures, rather than the joint surfaces. * **Rheumatoid Arthritis (C):** This is a chronic, systemic autoimmune inflammatory disease. While it causes joint destruction, the primary pathology is synovial hypertrophy (pannus formation), not primary degeneration. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Hallmarks of OA:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophytes. * **Common Sites:** Weight-bearing joints (Knee > Hip) and small joints of the hand (DIP joints are more commonly involved than PIP joints). * **Nodes:** Heberden’s nodes (DIP) and Bouchard’s nodes (PIP) are classic physical findings. * **Management:** Weight loss and quadriceps strengthening are the most effective non-pharmacological interventions. Total Knee Arthroplasty (TKA) is the gold standard for end-stage OA.

Q: Anterior disc displacement with intermittent locking is classified as which type?

Type 2. ### Explanation This question refers to the **Wilkes Classification** of Internal Derangement of the Temporomandibular Joint (TMJ). This staging system is crucial for diagnosing the severity of disc displacement and planning surgical or medical management. **1. Why Option B is Correct:** **Type 2 (Early Stage)** is characterized by **anterior disc displacement with reduction**, but with episodes of **intermittent locking**. In this stage, the patient experiences reciprocal clicking (opening and closing), and the disc occasionally fails to reduce, leading to temporary "locking" episodes. Mild discomfort and early joint surface changes may be present. **2. Why Other Options are Incorrect:** * **Type 1 (Early Stage):** Characterized by painless reciprocal clicking. The disc is displaced anteriorly but reduces easily. There is **no locking** at this stage. * **Type 3 (Intermediate Stage):** This stage marks the transition to **anterior disc displacement without reduction** (Permanent Locking). The patient has a history of clicking that has now stopped, replaced by a restricted range of motion (closed lock) and significant pain. * **Type 4 (Late Stage):** Characterized by chronic symptoms, restricted motion, and **degenerative changes** (osteoarthrosis) visible on imaging, such as flattening of the condyle or osteophytes. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Imaging:** **MRI** is the investigation of choice for visualizing disc position and morphology in TMJ disorders. * **Reciprocal Click:** A classic sign of disc displacement with reduction (Stages 1 & 2). * **Closed Lock:** Occurs when the disc is permanently displaced anteriorly, preventing the condyle from sliding forward (Stage 3). * **Management:** Stages 1-2 are often managed conservatively (splints, NSAIDs, physiotherapy), while Stages 3-5 may require arthrocentesis or surgical intervention.

Q: Charcot's joint includes all of the following EXCEPT?

Arthrogryposis multiplex congenita. **Explanation** **Charcot’s Joint (Neuropathic Arthropathy)** is a progressive degenerative condition characterized by joint destruction, bone resorption, and eventual deformity, occurring in joints that have lost sensory innervation (pain and proprioception). **Why Arthrogryposis Multiplex Congenita (AMC) is the correct answer:** AMC is a non-progressive congenital disorder characterized by multiple joint contractures (stiffness) present at birth. It is a structural and muscular pathology, not a sensory denervation pathology. Therefore, it does not lead to the destructive, "bag of bones" clinical picture 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). * **Neurosyphilis (Tabes Dorsalis):** Classically associated with Charcot’s joint of the **knee**. While less common today due to antibiotics, it remains a classic textbook association. * **Leprosy:** Causes peripheral nerve damage leading to sensory loss in the hands and feet, frequently resulting in neuropathic destruction of the small joints of the **hands and feet**. **High-Yield Clinical Pearls for NEET-PG:** * **The "6 D’s" of Charcot’s Joint:** Destruction, Debris, Density (increased), Disorganization, Dislocation, and Distension. * **Common Sites by Etiology:** * **Diabetes:** Foot and Ankle. * **Syringomyelia:** Shoulder and Elbow (Upper limb). * **Tabes Dorsalis:** Knee and Hip. * **Clinical Paradox:** The hallmark is a joint that looks radiographically "destroyed" but is relatively **painless** compared to the degree of damage. * **Treatment:** The primary goal is immobilization (Total Contact Casting) and offloading to prevent further collapse.

Q: Which of the following muscles undergoes wasting first in osteoarthritis of the knee?

Quadriceps. **Explanation:** In Osteoarthritis (OA) of the knee, the **Quadriceps** muscle is the first and most significant muscle to undergo wasting (atrophy). This occurs due to a phenomenon known as **Arthrogenic Muscle Inhibition (AMI)**. When the knee joint is damaged or inflamed, sensory nerves send inhibitory signals to the spinal cord, which prevents the motor cortex from fully activating the quadriceps. This reflex inhibition leads to rapid disuse atrophy. Additionally, patients instinctively avoid full knee extension to minimize pain, further accelerating the weakening of the quadriceps, particularly the **Vastus Medialis Obliquus (VMO)**. **Analysis of Options:** * **B. Hamstrings:** While the hamstrings may eventually weaken due to overall decreased mobility, they do not show early wasting. In fact, in OA, hamstrings often become relatively "tight" or overactive to compensate for knee instability. * **C. Gastrocnemius:** This muscle crosses the knee joint posteriorly but is primarily a plantar flexor of the ankle. It is not significantly affected in the early stages of knee OA. * **D. All of the above:** Incorrect, as the atrophy follows a specific chronological pattern starting with the extensors. **Clinical Pearls for NEET-PG:** * **Vastus Medialis Obliquus (VMO):** This is the specific component of the quadriceps that wastes first and most prominently. * **Quadriceps Lag:** A clinical sign where the patient can passively straighten the knee but cannot maintain active extension, often seen due to severe quadriceps weakness. * **Management:** Strengthening the quadriceps is the cornerstone of conservative management in OA knee to improve joint stability and reduce loading forces.

Q: Heat therapy is used to treat musculoskeletal pain in many disorders. The methods of heat therapy are classified as superficial and deep heat therapies depending upon their tissue penetration. Which of the following is not a deep heat therapy?

Infrared beam. **Explanation:** Therapeutic heat (thermotherapy) is classified into **superficial** and **deep** based on the depth of tissue penetration and the mechanism of heat transfer. **1. Why Infrared Beam is the Correct Answer:** Infrared (IR) therapy is a form of **superficial heat therapy**. It utilizes radiant heat to increase the temperature of the skin and immediate subcutaneous tissues. The penetration depth of infrared rays is limited to approximately **1–3 mm**. Since it does not reach the deep-seated muscles or joint capsules, it is classified as superficial, alongside hot packs, paraffin wax baths, and whirlpool baths. **2. Analysis of Incorrect Options (Deep Heat Modalities):** Deep heat therapy, also known as **Diathermy**, uses electromagnetic or sound energy to generate heat within deeper tissues (3–5 cm depth) through conversion. * **Short Wave Diathermy (SWD):** Uses high-frequency electromagnetic currents (27.12 MHz) to heat deep soft tissues and joints. * **Microwave Diathermy (MWD):** Uses microwaves to heat tissues with high water content, such as muscles. * **Ultrasound Therapy (UST):** Uses high-frequency sound waves. It is unique because it provides the deepest penetration and is excellent for heating collagen-rich structures like tendons and ligaments. **Clinical Pearls for NEET-PG:** * **Contraindication:** Never use deep heat (Diathermy) in patients with **metallic implants** or **cardiac pacemakers**, as it can cause severe burns or device malfunction. * **Indications:** Superficial heat is preferred for localized skin conditions or superficial joints (e.g., small joints of the hand), while deep heat is indicated for chronic back pain, osteoarthritis of the hip/knee, and muscle spasms. * **Mechanism:** Superficial heat works via **conduction/radiation**, whereas deep heat works via **conversion**.

Q: Cockup splint is used in paralysis of which nerve?

Radial nerve. **Explanation:** The **Cock-up splint** is the classic orthotic management for **Radial Nerve Palsy**. **1. Why Radial Nerve is Correct:** The radial nerve (C5-T1) innervates the extensors of the wrist and fingers. Paralysis of this nerve leads to **Wrist Drop**, where the patient cannot actively extend the wrist. A Cock-up splint maintains the wrist in a functional position of **extension (20-30 degrees)**. This prevents the overstretching of paralyzed extensor muscles, prevents contractures of the flexors, and improves grip strength by optimizing the length-tension relationship of the finger flexors. **2. Why other options are incorrect:** * **Ulnar Nerve:** Paralysis leads to "Claw Hand." The specific splint used is the **Knuckle Bender splint** (to prevent hyperextension at MCP joints). * **Median Nerve:** Paralysis leads to "Ape Thumb Deformity." The specific splint used is the **Opponens splint** (to maintain the thumb in opposition). * **Sciatic Nerve:** Paralysis leads to "Foot Drop." The management involves a **Foot Drop Splint** or an Ankle-Foot Orthosis (AFO). **3. Clinical Pearls for NEET-PG:** * **Dynamic Cock-up Splint:** Used if there is also a loss of finger extension; it includes outriggers with rubber bands to assist finger extension while allowing active flexion. * **High-yield associations:** * Radial nerve injury at the spiral groove → **Saturday Night Palsy** or **Honeymoon Palsy**. * Radial nerve injury with humerus shaft fracture → **Holstein-Lewis fracture**. * The most common site of radial nerve entrapment is the **Arcade of Frohse** (Posterior Interosseous Nerve).

Question 1

A 30-year-old HIV-positive male on antiretroviral therapy presents with right hip joint pain for 2 months. He has difficulty with abduction and internal rotation. Which of the following is the most likely diagnosis?

Accepted Answer

Avascular necrosis

Answer

Septic arthritis

Answer

Osteoarthritis

Answer

Tubercular arthritis

Question 2

Which of the following is NOT an appropriate criterion for proceeding with High Tibial Osteotomy in a patient with Osteoarthritis of the knee?

Accepted Answer

Age greater than 65 years.

Answer

Isolated Ahlback grade I or II lateral compartmental arthrosis.

Answer

Knee range of motion greater than 90 degrees.

Answer

Flexion contracture less than 15-20 degrees.

Question 3

Ulnar nerve paralysis causes which of the following deformities?

Accepted Answer

Claw finger deformity

Answer

Ape thumb deformity

Answer

Wrist drop

Answer

Meralgia paresthetica

Question 4

A patient with HIV is on therapy with protease inhibitors. He presents with limitation of abduction and internal rotation of the hip. What is the most probable diagnosis?

Accepted Answer

Avascular necrosis (AVN) of the femoral head

Answer

Tuberculosis of the hip joint

Answer

Secondary osteoarthritis of the hip

Answer

Septic arthritis of the hip

Question 5

What is the commonest degenerative joint disease?

Accepted Answer

Osteoarthritis

Answer

Gout

Answer

Osteoporosis

Answer

Rheumatoid arthritis

Question 6

Anterior disc displacement with intermittent locking is classified as which type?

Accepted Answer

Type 2

Answer

Type 1

Answer

Type 3

Answer

Type 4

Question 7

Charcot's joint includes all of the following EXCEPT?

Accepted Answer

Arthrogryposis multiplex congenita

Answer

Neurosyphilis

Answer

Leprosy

Answer

Diabetes

Question 8

Which of the following muscles undergoes wasting first in osteoarthritis of the knee?

Accepted Answer

Quadriceps

Answer

Hamstrings

Answer

Gastrocnemius

Answer

All of the above

Question 9

Heat therapy is used to treat musculoskeletal pain in many disorders. The methods of heat therapy are classified as superficial and deep heat therapies depending upon their tissue penetration. Which of the following is not a deep heat therapy?

Accepted Answer

Infrared beam

Answer

Short wave diathermy

Answer

Ultrasound therapy

Answer

Microwave diathermy

Question 10

Cockup splint is used in paralysis of which nerve?

Accepted Answer

Radial nerve

Answer

Ulnar nerve

Answer

Median nerve

Answer

Sciatic nerve

Degenerative Disorders — MCQs

Degenerative Disorders — MCQs

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