Degenerative Disorders — MCQs
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What is the pathognomic sign of a traumatic fracture?
True about osteoarthritis?
A 60-year-old male complains of pain in both knees that has been gradually worsening over the past 2 years. The pain is relieved by rest and exacerbated by movement. Physical examination reveals bony enlargement of the knees with mild inflammation and crepitus on motion. There are no other significant findings except for bony enlargement at the distal interphalangeal joints. The patient's height is 5 feet 9 inches and his weight is 88 kg. What is the best way to prevent disease progression?
Herbeden's apoplexy affects which of the following?
Heberden's nodes are found in which location and condition?
What do Ahlback Grade 2 changes of Osteoarthritis of the knee signify?
Which is the least common joint affected in ankylosing spondylitis?
Which is the earliest bone to ossify?
Bouchard's nodes are seen in which joint?
Sectoral sign is positive in which of the following conditions?
Degenerative Disorders Indian Medical PG Practice Questions and MCQs
Question 31: What is the pathognomic sign of a traumatic fracture?
- A. Tenderness
- B. Swelling
- C. Crepitus (Correct Answer)
- D. Bruising
Explanation: ### Explanation In orthopaedics, clinical signs of a fracture are categorized into **Probable (Suggestive)** and **Definitive (Pathognomonic)** signs. **Why Crepitus is the Correct Answer:** Crepitus is the palpable or audible grating sensation produced by the friction of two broken bone ends rubbing against each other. It is considered a **pathognomonic (definitive) sign** because it can *only* occur if there is a breach in the continuity of the bone. Other definitive signs include abnormal mobility and visible deformity where no joint exists. **Analysis of Incorrect Options:** * **A. Tenderness:** This is a **suggestive sign**. While localized bone tenderness is a sensitive indicator of a fracture, it is non-specific as it also occurs in contusions, infections (osteomyelitis), or ligamentous injuries. * **B. Swelling:** This is a **general sign** of inflammation. It results from hematoma formation and soft tissue edema, which are common in sprains, strains, and various non-traumatic inflammatory conditions. * **C. Bruising (Ecchymosis):** This indicates subcutaneous bleeding. While common in fractures, it is also seen in simple soft tissue bruising or bleeding diathesis, making it non-diagnostic for a fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Definitive Signs of Fracture:** 1. Abnormal mobility, 2. Crepitus, 3. Bony deformity. * **Clinical Caution:** One should **never** intentionally elicit crepitus or abnormal mobility to diagnose a fracture, as it causes extreme pain and risks further neurovascular injury. * **Exception:** Crepitus is absent in impacted fractures, as the bone ends are wedged together and do not move against each other. * **Differential Diagnosis:** Do not confuse "Bony Crepitus" with "Joint Crepitus" (seen in Osteoarthritis) or "Gas Crepitus" (seen in Gas Gangrene/Subcutaneous Emphysema).
Question 32: True about osteoarthritis?
- A. Increased hydration of articular cartilage (Correct Answer)
- B. Decreased proteolytic enzymes of articular cartilage
- C. Increased ESR
- D. Decreased viscosity of synovial fluid
Explanation: ### Explanation Osteoarthritis (OA) is a degenerative joint disease characterized by the progressive loss of articular cartilage and subchondral bone changes. **Why Option A is Correct:** The earliest biochemical change in osteoarthritis is an **increase in the water content (hydration)** of the articular cartilage. This occurs because the damaged collagen network fails to restrain the swelling pressure of proteoglycans. While the total proteoglycan content eventually decreases, the initial disruption of the collagen "mesh" allows the cartilage to absorb more water, making it softer and less resilient (chondromalacia). **Why the other options are Incorrect:** * **B. Decreased proteolytic enzymes:** In OA, there is actually an **increase** in proteolytic enzymes, specifically **Matrix Metalloproteinases (MMPs)** like collagenase and stromelysin, which degrade the extracellular matrix. * **C. Increased ESR:** OA is primarily a "wear-and-tear" degenerative process, not a systemic inflammatory disease. Therefore, the **ESR and CRP remain normal**. An elevated ESR would point toward Rheumatoid Arthritis or an infectious etiology. * **D. Decreased viscosity of synovial fluid:** While the quality of hyaluronic acid may change, the classic hallmark of OA is **increased or normal viscosity** (non-inflammatory fluid). Decreased viscosity (watery fluid) is characteristic of inflammatory arthritides like Rheumatoid Arthritis. **High-Yield Clinical Pearls for NEET-PG:** * **First change in OA:** Increased water content (Hydration). * **Radiological Hallmarks:** Joint space narrowing (asymmetrical), Osteophytes, Subchondral sclerosis, and Subchondral cysts (Geodes). * **Heberden’s Nodes:** Osteophytes at the DIP joints (more common in females). * **Bouchard’s Nodes:** Osteophytes at the PIP joints. * **Management:** Weight loss and quadriceps strengthening are the most effective non-pharmacological interventions.
Question 33: A 60-year-old male complains of pain in both knees that has been gradually worsening over the past 2 years. The pain is relieved by rest and exacerbated by movement. Physical examination reveals bony enlargement of the knees with mild inflammation and crepitus on motion. There are no other significant findings except for bony enlargement at the distal interphalangeal joints. The patient's height is 5 feet 9 inches and his weight is 88 kg. What is the best way to prevent disease progression?
- A. Weight reduction (Correct Answer)
- B. NSAIDs and calcium supplementation
- C. Total knee replacement
- D. Oral prednisone
Explanation: ### **Explanation** The clinical presentation—a 60-year-old male with chronic, activity-related knee pain, crepitus, bony enlargement (Heberden’s nodes at the DIP joints), and a high BMI (approx. 28.5 kg/m²)—is classic for **Osteoarthritis (OA)**. **1. Why Weight Reduction is Correct:** Osteoarthritis is a degenerative "wear and tear" disease. Obesity is the most significant modifiable risk factor for both the development and progression of knee OA. Excess weight increases the mechanical load on the weight-bearing joints (the knee bears 3–6 times the body weight during walking). Weight reduction decreases the intra-articular stress and reduces the systemic pro-inflammatory cytokines (adipokines) secreted by adipose tissue, thereby slowing the rate of cartilage degradation. **2. Why Other Options are Incorrect:** * **NSAIDs and Calcium:** NSAIDs provide symptomatic relief but do not alter the disease course or prevent progression. Calcium supplementation is indicated for osteoporosis, not OA. * **Total Knee Replacement (TKR):** This is the treatment of choice for end-stage (Grade IV) OA with severe functional impairment. It is a surgical intervention, not a preventive strategy for disease progression. * **Oral Prednisone:** Systemic steroids have no role in the management of OA and carry significant long-term side effects. **3. Clinical Pearls for NEET-PG:** * **Heberden’s Nodes:** Bony enlargement of the **DIP** joints (Pathognomonic for OA). * **Bouchard’s Nodes:** Bony enlargement of the **PIP** joints. * **Radiological Hallmarks (LOSS):** **L**oss of joint space (asymmetrical), **O**steophytes, **S**ubchondral sclerosis, and **S**ubchondral cysts. * **First-line Pharmacotherapy:** Topical NSAIDs are preferred initially; Acetaminophen (Paracetamol) was historically first-line but is now considered to have limited efficacy compared to NSAIDs. * **Kellgren-Lawrence Grading:** Used to classify the severity of OA based on X-ray findings.
Question 34: Herbeden's apoplexy affects which of the following?
- A. Lumbar spine
- B. Symmetrically large joints
- C. Sacroiliac joints
- D. Distal interphalangeal joints (Correct Answer)
Explanation: **Explanation:** **Heberden’s nodes** are a hallmark clinical feature of **Osteoarthritis (OA)**, representing bony outgrowths (osteophytes) at the **Distal Interphalangeal (DIP) joints**. The term **"Heberden’s apoplexy"** refers to an acute, inflammatory phase where these nodes develop suddenly with redness, swelling, and pain, mimicking an acute inflammatory process before settling into a hard, painless bony prominence. * **Why Option D is correct:** Heberden’s nodes specifically affect the DIP joints. In contrast, **Bouchard’s nodes** affect the Proximal Interphalangeal (PIP) joints. Both are characteristic of primary nodal osteoarthritis. **Analysis of Incorrect Options:** * **Option A (Lumbar spine):** While the lumbar spine is a common site for osteoarthritis (spondylosis), it is characterized by disc space narrowing and vertebral osteophytes, not Heberden’s nodes. * **Option B (Symmetrically large joints):** This pattern is more suggestive of Rheumatoid Arthritis (RA). Notably, RA typically **spares the DIP joints**, which is a key point of differentiation from OA. * **Option C (Sacroiliac joints):** Involvement of the SI joints is the hallmark of **Spondyloarthropathies** (e.g., Ankylosing Spondylitis), not degenerative osteoarthritis. **High-Yield Clinical Pearls for NEET-PG:** * **DIP vs. PIP:** Remember **H-D** (Heberden-Distal) and **B-P** (Bouchard-Proximal). * **Gender Predilection:** These nodes are significantly more common in postmenopausal women and have a strong genetic predisposition. * **Radiological Signs of OA:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophyte formation. * **First CMC Joint:** The base of the thumb (1st carpometacarpal joint) is the most common site of OA in the hand, leading to a "squaring" deformity.
Question 35: Heberden's nodes are found in which location and condition?
- A. Proximal interphalangeal joints in osteoarthritis
- B. Distal interphalangeal joints in osteoarthritis (Correct Answer)
- C. Proximal interphalangeal joints in rheumatoid arthritis
- D. Distal interphalangeal joints in osteoarthritis
Explanation: ### Explanation **Correct Answer: B & D (Distal interphalangeal joints in osteoarthritis)** **Understanding the Concept:** Heberden's nodes are clinical hallmarks of **Osteoarthritis (OA)**. They are palpable, bony outgrowths (osteophytes) located at the **Distal Interphalangeal (DIP) joints**. Pathologically, they represent the body's attempt to repair articular cartilage damage through subchondral bone hypertrophy. These nodes are more common in women and often have a strong genetic predisposition. **Analysis of Options:** * **Option A (Incorrect):** Bony enlargements at the **Proximal Interphalangeal (PIP)** joints in Osteoarthritis are known as **Bouchard’s nodes**, not Heberden’s nodes. * **Option C (Incorrect):** Rheumatoid Arthritis (RA) typically **spares the DIP joints**. RA is characterized by inflammatory swelling, pannus formation, and joint erosions (like Swan-neck or Boutonniere deformities), rather than the hard, bony osteophytes seen in OA. * **Options B & D (Correct):** Both correctly identify the DIP joint and the condition of Osteoarthritis. **NEET-PG High-Yield Clinical Pearls:** 1. **Mnemonic:** **H**eberden’s = **H**igh (Distal/Top joint); **B**ouchard’s = **B**elow (Proximal joint). 2. **Joint Sparing:** Osteoarthritis commonly involves the DIP, PIP, and the 1st Carpometacarpal (CMC) joint (squaring of the wrist), but it characteristically **spares the Metacarpophalangeal (MCP) joints**. 3. **Radiological Signs of OA:** Joint space narrowing, subchondral sclerosis, subchondral cysts, and osteophyte formation. 4. **Erosive OA:** A specific subset where Heberden’s nodes are associated with "Gull-wing" appearance on X-ray.
Question 36: What do Ahlback Grade 2 changes of Osteoarthritis of the knee signify?
- A. Joint space obliterated or almost obliterated (Correct Answer)
- B. Minor bone attrition (<5 mm)
- C. Moderate bone attrition (5-15 mm)
- D. Severe bone attrition (>15 mm)
Explanation: The **Ahlback Classification** is a radiographic grading system used to assess the severity of knee osteoarthritis, specifically focusing on the medial or lateral compartments. It is a high-yield topic for NEET-PG as it guides the surgical decision between Unicompartmental Knee Arthroplasty (UKA) and Total Knee Arthroplasty (TKA). ### **Explanation of the Correct Answer** **Grade 2** signifies that the articular cartilage is completely worn down, leading to **joint space obliteration** or near-obliteration. At this stage, there is "bone-on-bone" contact, but significant bone loss (attrition) has not yet occurred. ### **Analysis of Incorrect Options** * **Option B (Minor bone attrition <5 mm):** This corresponds to **Grade 3**. At this stage, the joint space is gone, and the femoral condyle begins to wear away the tibial plateau. * **Option C (Moderate bone attrition 5-15 mm):** This corresponds to **Grade 4**. There is significant structural loss of the tibial plateau. * **Option D (Severe bone attrition >15 mm):** This corresponds to **Grade 5**. This stage often involves gross subluxation and severe deformity. ### **High-Yield Clinical Pearls for NEET-PG** * **Grade 1:** Joint space narrowing (less than 50% of the normal width). * **Surgical Correlation:** Grades 1 and 2 are often candidates for conservative management or UKA, whereas Grades 3, 4, and 5 typically require TKA due to significant bone loss and ligamentous laxity. * **Kellgren-Lawrence System:** Do not confuse Ahlback with Kellgren-Lawrence. K-L is more commonly used in general practice and focuses on **osteophytes** (Grade 2) and **subchondral sclerosis**, whereas Ahlback focuses on **bone attrition**.
Question 37: Which is the least common joint affected in ankylosing spondylitis?
- A. Sacroiliac joint
- B. Temporomandibular joint (Correct Answer)
- C. Costovertebral joint
- D. Hip joint
Explanation: **Explanation:** Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy that primarily targets the axial skeleton and entheses. **Why Temporomandibular Joint (TMJ) is the correct answer:** While AS can involve peripheral joints, it predominantly affects the axial skeleton. The **TMJ is involved in only about 4–10% of cases**, making it the least common joint among the options provided. When it is involved, it usually presents late in the disease course with decreased range of motion and pain during mastication. **Analysis of Incorrect Options:** * **Sacroiliac Joint (SIJ):** This is the **most common** and earliest joint affected. Bilateral, symmetrical sacroiliitis is the hallmark of AS and is mandatory for diagnosis under the Modified New York Criteria. * **Costovertebral Joint:** Involvement is very common and leads to a classic clinical feature: **reduced chest expansion** (<2.5 cm). This is a high-yield diagnostic criterion. * **Hip Joint:** This is the **most common extra-axial/peripheral joint** involved (seen in ~30-50% of patients). Hip involvement is a poor prognostic marker and often necessitates total hip arthroplasty. **Clinical Pearls for NEET-PG:** * **HLA-B27:** Strongly associated (>90% of cases). * **Bamboo Spine:** Caused by marginal syndesmophytes (ossification of the outer fibers of the annulus fibrosus). * **Dagger Sign:** Ossification of the supraspinous and interspinous ligaments. * **Most common extra-articular manifestation:** Acute Anterior Uveitis. * **Schober’s Test:** Used to clinically assess restricted lumbar flexion.
Question 38: Which is the earliest bone to ossify?
- A. Clavicle (Correct Answer)
- B. Tibia
- C. Sternum
- D. Ribs
Explanation: **Explanation:** The **clavicle** is the correct answer as it is the very first bone in the human body to begin the process of ossification. **1. Why Clavicle is Correct:** The clavicle begins to ossify between the **5th and 6th weeks of intrauterine life**. It is unique because it undergoes **intramembranous ossification** (forming directly from mesenchymal tissue) for its shaft, although its ends later undergo endochondral ossification. It is also the only long bone that lies horizontally and the only long bone to ossify in membrane. **2. Why Other Options are Incorrect:** * **Tibia:** Like most long bones of the limbs, the tibia ossifies via endochondral ossification. Its primary center appears around the **7th to 8th week** of intrauterine life, significantly later than the clavicle. * **Sternum:** The sternum develops from cartilaginous plates that fuse. Ossification centers (sternebrae) typically appear between the **5th and 6th months** of fetal life. * **Ribs:** The ribs begin their ossification process around the **8th to 9th week** of fetal development, starting near the angles of the ribs. **Clinical Pearls for NEET-PG:** * **First bone to ossify:** Clavicle (5th–6th week). * **Last bone to complete ossification:** Clavicle (medial epiphysis fuses around age 21–25). * **Cleidocranial Dysplasia:** A clinical condition characterized by the congenital absence or hypoplasia of the clavicles due to defective intramembranous ossification. * **First center of ossification to appear:** Primary center of the clavicle. * **First secondary center of ossification to appear:** Distal femur (at birth, used as a marker for fetal maturity).
Question 39: Bouchard's nodes are seen in which joint?
- A. Proximal interphalangeal joints (Correct Answer)
- B. Distal interphalangeal joints
- C. Sterno-clavicular joints
- D. Knee joint
Explanation: **Explanation:** **Bouchard’s nodes** are bony outgrowths (osteophytes) specifically located at the **Proximal Interphalangeal (PIP) joints**. They are a classic clinical sign of **Osteoarthritis (OA)**, representing the underlying joint space narrowing and reactive bone formation characteristic of the disease. * **Option A (Correct):** Bouchard’s nodes involve the PIP joints. * **Option B (Incorrect):** Bony enlargements at the **Distal Interphalangeal (DIP)** joints are known as **Heberden’s nodes**. These are more common than Bouchard’s nodes in primary osteoarthritis. * **Option C (Incorrect):** While the sternoclavicular joint can be affected by OA, it does not present with "nodes." * **Option D (Incorrect):** OA of the knee typically presents with joint line tenderness, crepitus, and varus/valgus deformity, but not specific named nodes like those in the hand. **High-Yield Clinical Pearls for NEET-PG:** 1. **Heberden’s vs. Bouchard’s:** Remember the mnemonic **"B" comes before "H"** (alphabetical order), just as **PIP** is proximal to **DIP**. 2. **Osteoarthritis vs. Rheumatoid Arthritis (RA):** * OA typically involves the **DIP, PIP, and 1st CMC** (Carpometacarpal) joints. * RA typically involves the **MCP** (Metacarpophalangeal) and **PIP** joints but **spares the DIP**. 3. **Radiological Hallmarks of OA:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophytes. 4. **First CMC Joint:** OA here leads to a "squared hand" appearance (Adduction deformity).
Question 40: Sectoral sign is positive in which of the following conditions?
- A. Avascular necrosis of femur head (Correct Answer)
- B. Osteoarthritis of hip
- C. Protrusio acetabuli
- D. Slipped capital femoral epiphyses
Explanation: ### Explanation **Sectoral Sign** is a classic radiological feature seen in the early stages of **Avascular Necrosis (AVN) of the femoral head**. **1. Why Avascular Necrosis is Correct:** The sectoral sign refers to a **wedge-shaped or sector-shaped area of radiolucency or sclerosis** (demarcated by a reactive line) typically located in the anterosuperior weight-bearing portion of the femoral head. This occurs because the blood supply to the femoral head (primarily via the medial circumflex femoral artery) is compromised in a specific distribution, leading to localized bone death. On a lateral X-ray or MRI, this "sector" of involvement is clearly visible before the entire head collapses. **2. Why Other Options are Incorrect:** * **Osteoarthritis of the hip:** Characterized by joint space narrowing, subchondral cysts, and osteophytes. It involves the entire joint surface rather than a specific "sector" of the femoral head. * **Protrusio acetabuli:** This is a deformity where the femoral head projects medially into the pelvic cavity beyond the ilioischial (Kohler’s) line. It is a structural displacement, not a localized necrotic sector. * **Slipped Capital Femoral Epiphysis (SCFE):** This involves the displacement of the epiphysis through the growth plate (physis). Key signs include **Trethowan’s sign** (Klein’s line) and the **Steel’s blanch sign**, but not the sectoral sign. **Clinical Pearls for NEET-PG:** * **Earliest Sign of AVN on X-ray:** Increased density (sclerosis). * **Most Sensitive Investigation:** MRI (shows the "Double Line Sign"). * **Crescent Sign:** Indicates subchondral fracture (Stage II/III), signifying impending collapse. * **Commonest Site:** Anterosuperior quadrant of the femoral head. * **Commonest Cause:** Trauma (fracture neck of femur); Non-traumatic causes include steroids and alcohol.
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
Practice Questions
Degenerative Spinal Conditions
Practice Questions
Conservative Management of Degenerative Disorders
Practice Questions
Pharmacotherapy of Osteoarthritis
Practice Questions
Surgical Options for Osteoarthritis
Practice Questions
Rehabilitation in Degenerative Disorders
Practice Questions
Novel Therapies in Osteoarthritis
Practice Questions
Quality of Life Assessment
Practice Questions
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