Degenerative Disorders — MCQs

Degenerative Disorders Indian Medical PG Practice Questions and MCQs

Question 21: Osteoarthritis commonly involves which of the following joints?

A. Proximal interphalangeal (IP) joint (Correct Answer)
B. Distal interphalangeal (IP) joint
C. First carpometacarpal (CMC) joint
D. Wrist joint

Explanation: **Explanation:** Osteoarthritis (OA) is a degenerative joint disease characterized by the loss of articular cartilage. In the hand, OA has a predilection for specific joints, primarily the **Distal Interphalangeal (DIP)** joints, the **Proximal Interphalangeal (PIP)** joints, and the **First Carpometacarpal (CMC)** joint. While the question asks which joint is "commonly" involved, it is important to note that in clinical practice, the **DIP joint is actually the most common** site of involvement in nodal OA, followed by the PIP and 1st CMC joints. However, based on the provided key identifying **Option A (PIP joint)** as correct, it is categorized as a hallmark site for **Bouchard’s nodes**. **Analysis of Options:** * **A. Proximal Interphalangeal (PIP) Joint:** A classic site for OA. Osteophyte formation here results in palpable swellings known as **Bouchard’s nodes**. * **B. Distal Interphalangeal (DIP) Joint:** Though frequently involved (forming **Heberden’s nodes**), if the examiner designates PIP as the answer, it often refers to the characteristic "nodal" distribution of primary OA. * **C. First CMC Joint:** Also known as the trapeziometacarpal joint; involvement leads to "squaring" of the hand and difficulty with pinch grip. * **D. Wrist Joint:** Generally **spared** in primary OA. Involvement of the wrist (specifically the radiocarpal joint) usually suggests secondary OA due to trauma or underlying conditions like CPPD (Pseudogout). **High-Yield Clinical Pearls for NEET-PG:** * **Nodal OA:** Heberden’s nodes (DIP) and Bouchard’s nodes (PIP) are more common in postmenopausal women. * **Sparing Rule:** OA typically **spares** the wrist, elbow, and shoulder (unless there is prior trauma). * **Radiological Hallmarks (LOSS):** **L**oss of joint space, **O**steophytes, **S**ubchondral sclerosis, and **S**ubchondral cysts. * **Erosive OA:** A specific subtype involving the DIP/PIP joints with a characteristic **"Gull-wing" appearance** on X-ray.

Question 22: Which of the following joints is typically NOT involved in osteoarthritis?

A. Hip joint
B. Distal interphalangeal (DIP) joints
C. Ankle joint (Correct Answer)
D. Cervical region

Explanation: **Explanation:** Osteoarthritis (OA) is a degenerative joint disease characterized by the breakdown of articular cartilage. It primarily affects **weight-bearing joints** and those subject to repetitive mechanical stress. **Why the Ankle Joint is the Correct Answer:** The **ankle joint** is remarkably resistant to primary osteoarthritis. This is due to the unique properties of its articular cartilage, which is thinner but more resilient to compressive forces compared to the hip or knee. Additionally, the ankle has a high degree of congruency and a specific metabolic profile that protects it from wear. OA in the ankle is almost always **secondary**, occurring after significant trauma (e.g., pilon fractures or chronic ligamentous instability) rather than as a primary degenerative process. **Analysis of Incorrect Options:** * **Hip Joint (A):** This is one of the most common sites for primary OA due to the high axial load it bears during ambulation. * **Distal Interphalangeal (DIP) Joints (B):** OA frequently involves the small joints of the hand. Involvement of the DIP joints leads to the formation of **Heberden’s nodes**, a classic clinical sign. * **Cervical Region (D):** The cervical and lumbar spine are common sites for OA (spondylosis), affecting the intervertebral discs and facet joints due to constant mobility and weight-bearing requirements. **Clinical Pearls for NEET-PG:** * **Nodal Involvement:** DIP joints = Heberden’s nodes; PIP joints = Bouchard’s nodes. * **Sparing Rule:** Primary OA typically **spares** the ankle, wrist, and elbow. If these joints are involved, look for a history of trauma or an underlying metabolic/inflammatory condition. * **Radiological Hallmarks:** Joint space narrowing, subchondral sclerosis, subchondral cysts, and osteophyte formation. * **First-line Management:** Weight loss and quadriceps strengthening exercises; Acetaminophen is the initial drug of choice for mild cases.

Question 23: What are the earliest imaging changes observed in stress fractures?

A. Bone scan
B. Bone biopsy
C. CT scan
D. MRI (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. MRI** **Medical Concept:** Stress fractures occur due to repetitive submaximal loading that outpaces the bone's remodeling capacity. The earliest physiological change is **marrow edema** and hemorrhage. **MRI** is the most sensitive imaging modality (sensitivity ~99%) because it can detect these fluid changes and bone marrow signals within **24 to 72 hours** of symptom onset, long before structural cortical changes occur. **Analysis of Options:** * **A. Bone Scan (Technetium-99m):** Historically, this was the gold standard for early detection as it shows increased "hot spots" due to osteoblastic activity. However, it has been replaced by MRI because it lacks specificity (cannot easily distinguish between infection, tumor, or fracture) and involves ionizing radiation. * **B. Bone Biopsy:** This is an invasive procedure and is contraindicated for diagnosing stress fractures. It may actually lead to a misdiagnosis of osteosarcoma due to the presence of exuberant periosteal reaction and immature callus. * **C. CT Scan:** While CT is excellent for visualizing cortical "dreaded black lines" or subtle fractures in complex anatomy (like the tarsal navicular), it is less sensitive than MRI for detecting early-stage marrow edema. * **X-rays (Not listed but important):** Plain radiographs are usually **negative** in the first 2–3 weeks. The earliest sign on X-ray is often a subtle periosteal reaction or a "grey cortex" sign. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard/Most Sensitive:** MRI (STIR sequences are best for visualizing edema). * **Commonest Site:** Tibia (overall), followed by metatarsals (March fracture). * **Female Athlete Triad:** Amenorrhea, eating disorder, and osteoporosis; high risk for stress fractures. * **Dreaded Black Line:** Refers to a stress fracture on the anterior cortex of the tibia; it has a high risk of non-union.

Question 24: Which condition is associated with Froment's sign?

A. Ulnar nerve palsy (Correct Answer)
B. Median nerve palsy
C. Musculocutaneous nerve palsy
D. Posterior interosseous nerve palsy

Explanation: **Explanation:** **Froment’s sign** is a classic clinical test used to identify **Ulnar nerve palsy**, specifically assessing the paralysis of the **Adductor Pollicis** muscle. 1. **Why Ulnar Nerve Palsy is Correct:** The Adductor Pollicis is the only muscle of the thumb supplied by the Ulnar nerve. When a patient with ulnar nerve palsy is asked to hold a piece of paper between the thumb and the index finger (key pinch), they cannot adduct the thumb. To compensate and maintain grip, the patient recruits the **Flexor Pollicis Longus (FPL)**, which is supplied by the **Median nerve**. This results in visible **flexion of the thumb at the Interphalangeal (IP) joint**, constituting a positive Froment’s sign. 2. **Why Other Options are Incorrect:** * **Median nerve palsy:** This would result in "Ape thumb deformity" and loss of opposition (Opponens pollicis). In fact, the Median nerve is the "compensator" in Froment's sign, not the cause of the deficit. * **Musculocutaneous nerve palsy:** This affects the Biceps brachii and Brachialis, leading to loss of elbow flexion and forearm supination, but does not affect intrinsic hand muscles. * **Posterior interosseous nerve (PIN) palsy:** This is a branch of the Radial nerve. Palsy leads to "Finger drop" and "Thumb drop" (loss of extension), but does not affect thumb adduction. **High-Yield Clinical Pearls for NEET-PG:** * **Jeanne’s Sign:** If the IP joint flexes (Froment's) AND the Metacarpophalangeal (MCP) joint hyperextends simultaneously, it is called Jeanne’s sign (also seen in Ulnar nerve palsy). * **Wartenberg’s Sign:** Inability to adduct the little finger due to weakness of the 3rd Palmar Interosseous muscle. * **Mnemonic:** "Ulnar nerve is the Musician’s nerve" (controls fine intrinsic movements). * **Site of Lesion:** Froment's sign is positive in both high and low ulnar nerve palsies.

Question 25: Which carpal bone is most prone to avascular necrosis?

A. Talus
B. Scaphoid (Correct Answer)
C. Pisiform
D. Navicular

Explanation: **Explanation:** The **Scaphoid** is the most commonly fractured carpal bone and is uniquely susceptible to **Avascular Necrosis (AVN)** due to its peculiar blood supply. **Why Scaphoid is correct:** The blood supply to the scaphoid is **retrograde** (distal to proximal). Approximately 70-80% of the bone is covered by articular cartilage, leaving limited space for vascular entry. The primary blood supply comes from the dorsal carpal branch of the radial artery, which enters the bone at the **distal pole or waist**. Consequently, a fracture through the waist of the scaphoid can easily disrupt the blood flow to the **proximal pole**, leading to ischemia and subsequent AVN (Preiser’s disease). **Why other options are incorrect:** * **Talus:** While the talus is highly prone to AVN (Hawkins' sign), it is a **tarsal bone** of the foot, not a carpal bone. * **Pisiform:** This is a sesamoid bone within the Flexor Carpi Ulnaris tendon; it has a robust blood supply and is rarely associated with AVN. * **Navicular:** This is a **tarsal bone** located in the midfoot. While it can undergo AVN (Kohler’s disease in children or Mueller-Weiss syndrome in adults), it is not a carpal bone. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of scaphoid fracture:** The Waist (60-70%). * **Risk of AVN:** Increases the more proximal the fracture line is located. * **Radiology:** Scaphoid fractures may not appear on initial X-rays; if clinical suspicion exists (tenderness in the **Anatomical Snuffbox**), repeat X-rays in 10-14 days or perform an MRI (most sensitive). * **Kienbock’s Disease:** AVN of the **Lunate** (another high-yield carpal bone disorder).

Question 26: Which of the following is NOT a deformity of rheumatoid arthritis?

A. Swan neck deformity
B. Boutonnière deformity
C. Hallux valgus
D. Claw hand (Correct Answer)

Explanation: **Explanation:** The correct answer is **Claw hand** because it is a neurological deformity, not a primary manifestation of Rheumatoid Arthritis (RA). 1. **Claw Hand:** This deformity results from **peripheral nerve palsies**, most commonly the **Ulnar nerve** (at the wrist or elbow). It is characterized by hyperextension at the Metacarpophalangeal (MCP) joints and flexion at the Interphalangeal (IP) joints. While RA can cause nerve entrapment (like Carpal Tunnel Syndrome), "Claw hand" is classically associated with conditions like Leprosy, Syringomyelia, or Brachial Plexus injuries (Klumpke’s palsy). 2. **Why other options are incorrect (RA Deformities):** * **Swan neck deformity:** Caused by laxity of the volar plate, leading to **hyperextension of the PIP joint** and flexion of the DIP joint. * **Boutonnière deformity:** Results from the rupture or attenuation of the **central slip** of the extensor tendon, leading to **flexion of the PIP joint** and hyperextension of the DIP joint. * **Hallux valgus:** RA frequently involves the forefoot. Synovitis of the first MTP joint leads to lateral deviation of the great toe (Hallux valgus) and bunion formation. **Clinical Pearls for NEET-PG:** * **Earliest sign of RA on X-ray:** Periarticular osteopenia (juxta-articular rarefaction). * **Most common joint involved in RA:** MCP joints (specifically the 2nd and 3rd). * **Z-deformity:** Refers to radial deviation of the wrist with ulnar deviation of the fingers. * **Mnemonic for Boutonnière:** "Central slip is ripped" (Flexed PIP). * **Mnemonic for Swan Neck:** "Volar plate is late" (Extended PIP).

Question 27: Kienbock's disease is osteochondritis of which bone?

A. Lower pole of patella
B. Lunate (Correct Answer)
C. Capitellum
D. Navicular

Explanation: **Explanation:** **Kienbock’s disease** is the idiopathic **avascular necrosis (AVN)** or osteochondritis of the **Lunate** bone. It typically affects the dominant hand of young adults (20–40 years) subjected to repetitive trauma. The underlying pathophysiology is often linked to **negative ulnar variance** (a shorter ulna), which leads to increased mechanical stress on the lunate between the radius and the capitate, resulting in microfractures and subsequent ischemia. **Analysis of Options:** * **Lunate (Correct):** As described, Kienbock’s is specific to this carpal bone. Diagnosis is made via X-ray (increased density/collapse) or MRI (early stages). * **Lower pole of patella:** This is known as **Sinding-Larsen-Johansson disease**, an overuse injury seen in active adolescents. * **Capitellum:** Osteochondritis dissecans of the capitellum is known as **Panner’s disease**, typically seen in young baseball pitchers. * **Navicular:** Osteochondritis of the tarsal navicular is **Kohler’s disease** (common in children), while AVN of the carpal scaphoid is known as **Preiser’s disease**. **High-Yield Clinical Pearls for NEET-PG:** * **Radiographic Sign:** Look for "negative ulnar variance" as a predisposing factor. * **Classification:** The **Lichtman Classification** is used to stage the disease (Stage I: Normal X-ray; Stage IV: Pancarpal arthritis). * **Treatment:** Early stages (I-II) may be treated with joint leveling procedures (e.g., radial shortening osteotomy); late stages (IV) require proximal row carpectomy or wrist arthrodesis.

Question 28: Primary osteoarthritis affects all joints except:

A. Hip Joint
B. Knee joint
C. Distal interphalangeal joint
D. Metacarpophalangeal joint (Correct Answer)

Explanation: **Explanation:** Primary Osteoarthritis (OA) is a chronic degenerative disorder of the articular cartilage, typically associated with aging and mechanical "wear and tear." It characteristically involves **weight-bearing joints** and specific small joints of the hand. **Why the Metacarpophalangeal (MCP) joint is the correct answer:** Primary OA characteristically **spares** the MCP joints, the wrists, and the elbows. If a patient presents with involvement of the MCP joints, clinicians must investigate for secondary causes, most notably **Rheumatoid Arthritis** (where MCP involvement is a hallmark) or metabolic conditions like **Hemochromatosis** (the "Iron-handler’s grip"). **Analysis of incorrect options:** * **Hip and Knee Joints (Options A & B):** These are the most common sites for primary OA due to the constant mechanical stress of weight-bearing. The knee is the most frequently affected large joint. * **Distal Interphalangeal (DIP) Joint (Option C):** This is a classic site for primary OA. Involvement here often leads to the formation of **Heberden’s nodes**. The Proximal Interphalangeal (PIP) joints are also commonly affected (Bouchard’s nodes). **NEET-PG High-Yield Pearls:** * **Nodal Distribution:** Primary OA typically involves the DIP, PIP, and the **1st Carpometacarpal (CMC) joint** (base of the thumb), leading to a "squared hand" appearance. * **Radiological Hallmarks (LOSS):** **L**oss of joint space (asymmetrical), **O**steophytes, **S**ubchondral sclerosis, and **S**ubchondral cysts. * **ESR/CRP:** Usually normal in primary OA, helping differentiate it from inflammatory arthritides. * **First-line Management:** Weight reduction and quadriceps strengthening exercises; Paracetamol is the initial drug of choice for pain.

Question 29: Which of the following statements regarding Mseleni joint disease is true?

A. Shoulder, elbow, and wrist involvement is characteristic.
B. Elderly males are commonly involved.
C. Height is unaffected.
D. It is endemic to the northern KwaZulu-Natal area in South Africa. (Correct Answer)

Explanation: **Mseleni Joint Disease (MJD)** is a rare, endemic form of polyarticular osteoarthritis first described in the 1970s. It is a progressive, debilitating condition characterized by premature degeneration of multiple joints. ### **Explanation of the Correct Answer** **Option D is correct.** Mseleni Joint Disease is geographically restricted and **endemic to the Mseleni region of northern KwaZulu-Natal, South Africa**. It primarily affects the Tsonga-Zulu population. While the exact etiology remains unknown, it is hypothesized to be multifactorial, involving environmental factors (such as mineral deficiencies in soil/water) or genetic predispositions. ### **Analysis of Incorrect Options** * **Option A:** MJD predominantly affects the **large weight-bearing joints**, specifically the **hips (most common)** and knees. Involvement of the upper limbs (shoulder, elbow, wrist) is rare and not a characteristic feature. * **Option B:** The disease shows a strong gender predilection for **females**, who are significantly more affected than males. It can manifest in childhood but becomes progressively severe with age. * **Option C:** **Stature is often affected.** Many patients suffer from epiphyseal dysplasia, leading to shortened limbs and **stunted growth (short stature)**, alongside secondary osteoarthritic changes. ### **High-Yield Clinical Pearls for NEET-PG** * **Radiological Hallmark:** Generalized epiphyseal dysplasia and protrusio acetabuli are frequently seen. * **Clinical Presentation:** Patients present with chronic joint pain, a waddling gait, and progressive physical disability. * **Differential Diagnosis:** Must be distinguished from **Kashin-Beck disease** (endemic in China/Siberia, linked to Selenium deficiency) and **Handigodu disease** (endemic in Karnataka, India). * **Management:** Treatment is largely supportive, focusing on pain management and total hip replacement in advanced cases.

Question 30: Which joint is LEAST involved in primary osteoarthritis?

A. Hip
B. Trapezio-metacarpal
C. Knee
D. Coraco-clavicular (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Coraco-clavicular**. **1. Why Coraco-clavicular is the correct answer:** Primary Osteoarthritis (OA) typically affects **weight-bearing joints** and **high-mobility synovial joints**. The coraco-clavicular connection is primarily a syndesmosis (fibrous joint) maintained by the conoid and trapezoid ligaments. It is not a synovial joint and does not undergo the typical hyaline cartilage degeneration seen in primary OA. While the adjacent Acromioclavicular (AC) joint is a common site for OA, the coraco-clavicular space is rarely involved unless there is secondary ossification following trauma. **2. Analysis of Incorrect Options:** * **A. Hip:** This is a major weight-bearing ball-and-socket joint and is one of the most common sites for primary OA, often leading to total hip arthroplasty. * **B. Trapezio-metacarpal (1st CMC joint):** This is the most common site of primary OA in the hand (especially in post-menopausal women). It is a classic "high-yield" joint for OA questions. * **C. Knee:** The knee is the most common weight-bearing joint affected by primary OA globally, characterized by medial compartment narrowing. **3. Clinical Pearls for NEET-PG:** * **Most common joint in OA:** Knee. * **Most common hand joint in OA:** 1st Carpometacarpal (Trapezio-metacarpal) joint, followed by DIP joints (Heberden’s nodes) and PIP joints (Bouchard’s nodes). * **Joints typically SPARED in primary OA:** Wrist (except 1st CMC), Elbow, and Ankle. If OA is seen here, suspect **Secondary OA** (e.g., post-traumatic or hemophilic). * **Radiological Hallmarks:** Joint space narrowing, Osteophytes, Subchondral sclerosis, and Subchondral cysts (mnemonic: **LOSS**).

Practice by Chapter

Osteoarthritis: Pathophysiology

Practice Questions

Osteoarthritis of Hip

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Osteoarthritis of Knee

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Osteoarthritis of Shoulder

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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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