Degenerative Disorders — MCQs

Degenerative Disorders Indian Medical PG Practice Questions and MCQs

Question 11: 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?

A. Septic arthritis
B. Osteoarthritis
C. Avascular necrosis (Correct Answer)
D. Tubercular arthritis

Explanation: ### **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.

Question 12: Which of the following is NOT an appropriate criterion for proceeding with High Tibial Osteotomy in a patient with Osteoarthritis of the knee?

A. Age greater than 65 years. (Correct Answer)
B. Isolated Ahlback grade I or II lateral compartmental arthrosis.
C. Knee range of motion greater than 90 degrees.
D. Flexion contracture less than 15-20 degrees.

Explanation: **Explanation:** High Tibial Osteotomy (HTO) is a "joint-preserving" realignment procedure designed to shift the weight-bearing axis from a diseased compartment to a healthier one. It is primarily indicated for **young, active patients** with **medial compartment** osteoarthritis and a **varus deformity**. **1. Why Option A is the Correct Answer:** Age greater than 65 years is generally considered a **relative contraindication** for HTO. In older patients, the regenerative capacity of the cartilage is lower, and the progression of global osteoarthritis is more likely. For patients over 60-65, Total Knee Arthroplasty (TKA) is preferred as it offers more predictable, long-term outcomes. **2. Analysis of Incorrect Options:** * **Option B:** HTO is specifically indicated for **isolated unicompartmental disease** (usually medial). Ahlback Grade I or II represents early-to-moderate changes where joint preservation is still viable. *Note: The option mentions lateral compartment; while HTO is usually for medial disease (varus), distal femoral osteotomy is used for lateral disease (valgus). However, the core contraindication remains age.* * **Option C:** A good preoperative **Range of Motion (ROM) > 90°** is essential. If the knee is stiff, the realignment will not result in functional improvement and may accelerate joint stiffness. * **Option D:** A **flexion contracture < 15-20°** is required. Severe fixed flexion deformities are difficult to correct with osteotomy alone and are better managed with Arthroplasty. **Clinical Pearls for NEET-PG:** * **Ideal Candidate:** Age < 60, BMI < 30, non-smoker, isolated medial compartment pain, and stable ligaments. * **Goal:** Convert a Varus knee into a slight Valgus (overcorrection is often desired). * **Fujisawa Point:** The target point for the new weight-bearing axis, located at 62.5% of the width of the tibial plateau (lateral side). * **Contraindications:** Tricompartmental OA, Inflammatory arthritis (RA), and limited ROM.

Question 13: Ulnar nerve paralysis causes which of the following deformities?

A. Ape thumb deformity
B. Wrist drop
C. Claw finger deformity (Correct Answer)
D. Meralgia paresthetica

Explanation: **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.

Question 14: 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?

A. Tuberculosis of the hip joint
B. Avascular necrosis (AVN) of the femoral head (Correct Answer)
C. Secondary osteoarthritis of the hip
D. Septic arthritis of the hip

Explanation: **Explanation:** The correct diagnosis is **Avascular Necrosis (AVN) of the femoral head**. **Why it is correct:** There is a well-documented association between **HIV infection, Protease Inhibitors (PIs), and AVN**. Protease inhibitors (such as Ritonavir or Indinavir) are known to cause metabolic complications, including **hyperlipidemia and insulin resistance**. These metabolic changes lead to fat emboli or increased intraosseous pressure, compromising the blood supply to the femoral head. Clinically, AVN typically presents with a painful, progressive **limitation of abduction and internal rotation**, which are the first movements to be restricted in hip joint pathologies involving the femoral head. **Why other options are incorrect:** * **Tuberculosis of the hip:** While common in immunocompromised patients, it usually presents with systemic symptoms (fever, weight loss) and a "cold abscess." The specific link to Protease Inhibitors makes AVN a more targeted diagnosis. * **Secondary Osteoarthritis:** This is usually a late sequela of a pre-existing condition (like old trauma or AVN). While it causes similar movement restrictions, the acute association with HIV therapy points toward the primary underlying pathology (AVN). * **Septic Arthritis:** This presents acutely with high-grade fever, severe pain, and an inability to bear weight (pseudoparalysis). The patient would be systemically ill, which is not the primary focus of this drug-related presentation. **NEET-PG High-Yield Pearls:** * **Most common site for AVN:** Femoral head (due to retrograde blood supply via the medial circumflex femoral artery). * **Risk Factors for AVN:** Alcoholism, Steroids (most common overall), Trauma, Sickle cell anemia, and HIV/Protease inhibitors. * **Early Diagnosis:** **MRI** is the most sensitive investigation for early AVN (showing the "double line sign"). X-rays may be normal in early stages (Stage I). * **Clinical Sign:** Pain is typically felt in the groin and is exacerbated by weight-bearing.

Question 15: What is the commonest degenerative joint disease?

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

Explanation: **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.

Question 16: Anterior disc displacement with intermittent locking is classified as which type?

A. Type 1
B. Type 2 (Correct Answer)
C. Type 3
D. Type 4

Explanation: ### 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.

Question 17: Charcot's joint includes all of the following EXCEPT?

A. Neurosyphilis
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 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.

Question 18: Which of the following muscles undergoes wasting first in osteoarthritis of the knee?

A. Quadriceps (Correct Answer)
B. Hamstrings
C. Gastrocnemius
D. All of the above

Explanation: **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.

Question 19: 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?

A. Short wave diathermy
B. Infrared beam (Correct Answer)
C. Ultrasound therapy
D. Microwave diathermy

Explanation: **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**.

Question 20: Cockup splint is used in paralysis of which nerve?

A. Ulnar nerve
B. Radial nerve (Correct Answer)
C. Median nerve
D. Sciatic nerve

Explanation: **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).

Practice by Chapter

Osteoarthritis: Pathophysiology

Practice Questions

Osteoarthritis of Hip

Practice Questions

Osteoarthritis of Knee

Practice Questions

Osteoarthritis of Shoulder

Practice Questions

Osteoarthritis of Ankle and Foot

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Degenerative Spinal Conditions

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Conservative Management of Degenerative Disorders

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Pharmacotherapy of Osteoarthritis

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Surgical Options for Osteoarthritis

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Rehabilitation in Degenerative Disorders

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Novel Therapies in Osteoarthritis

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Quality of Life Assessment

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