Rheumatoid Hand — MCQs

10 questions

All are features of inflammatory arthritis except?

A patient of RA is taking methotrexate, steroids and NSAIDs since 4 months but activity of disease progression is same. What should be the next probable step?

What is the indication of using systemic steroids in a case of rheumatoid arthritis -

40-year-old patient having arthritis of PIP and DIP along with carpometacarpal joint of thumb and sparing of wrist and metacarpophalangeal joint, most likely diagnosis is

Which of the following statements about rheumatoid arthritis is false?

A 22-year-old male medical student was seen in the emergency department with a complaint of pain in his hand. He confessed that he had hit a vending machine in the hospital when he did not receive his soft drink after inserting money twice. The medial side of the dorsum of the hand was quite swollen, and one of his knuckles could not be seen when he "made a fist." The physician made a diagnosis of a "boxer's fracture." What was the nature of the impatient student's injury?

A 54-year-old female marathon runner presents with pain in her right wrist that resulted from a fall onto her outstretched hand. Radiographic studies indicate an anterior dislocation of a carpal bone. Which of the following bones is most likely dislocated?

Rupture of extensor pollicis longus tendon occurs in all of the following except -

Diagnostic of antemortem drowning:

Q10

How can homicidal gunshot wounds be differentiated from suicidal gunshot wounds?

Rheumatoid Hand Indian Medical PG Practice Questions and MCQs

Question 1: All are features of inflammatory arthritis except?

A. Elevated ESR
B. X-ray showing sclerosis
C. Weight gain (Correct Answer)
D. Morning stiffness

Explanation: ***Weight gain*** - **Weight gain** is typically not associated with inflammatory arthritis; instead, **weight loss** might occur due to chronic inflammation and systemic effects [1]. - While certain treatments like corticosteroids can lead to weight gain, it is not a direct feature of the inflammatory process itself. *Elevated ESR* - **Elevated ESR** (Erythrocyte Sedimentation Rate) is a common laboratory indicator of **inflammation** present in inflammatory arthritis [1]. - It reflects the increased plasma protein levels (e.g., fibrinogen) that cause red blood cells to settle faster. *X-ray showing sclerosis* - **X-ray sclerosis** (increased bone density) can be a feature of certain types of inflammatory arthritis, particularly at the **sacroiliac joints** in conditions like ankylosing spondylitis [2]. - This indicates a bony reaction to chronic inflammation and stress on the joint structures [2]. *Morning stiffness* - **Morning stiffness** lasting more than 30-60 minutes is a classic and nearly universal symptom of **inflammatory arthritis**. - It results from the accumulation of inflammatory fluid in the joints overnight and improves with activity.

Question 2: A patient of RA is taking methotrexate, steroids and NSAIDs since 4 months but activity of disease progression is same. What should be the next probable step?

A. Continue methotrexate and steroids
B. Stop oral methotrexate and start parenteral methotrexate
C. Add sulfasalazine
D. Add anti TNF alpha drugs (Correct Answer)

Explanation: ***Add anti TNF alpha drugs*** - This patient has **active rheumatoid arthritis** despite 4 months of treatment with **methotrexate**, **steroids**, and **NSAIDs**, indicating an inadequate response to conventional DMARDs [1]. - Current major rheumatology guidelines (**ACR 2021**, **EULAR 2019**) recommend escalating to **biologic DMARDs** like **anti-TNF-alpha agents** as the preferred next step for patients with persistent disease activity after 3-6 months of methotrexate therapy [1]. *Continue methotrexate and steroids* - Continuing the current regimen unchanged is not appropriate as the patient's **disease activity has not improved** over four months. - This approach would leave the patient at risk for ongoing **joint damage** and functional decline due to **uncontrolled inflammation** [2]. *Stop oral methotrexate and start parenteral methotrexate* - While changing to **parenteral methotrexate** can improve **bioavailability** and absorption, the primary issue here is the **overall lack of disease control**, not necessarily methotrexate non-response [1]. - This step alone is unlikely to provide sufficient additional benefit for a patient whose disease is still active after 4 months, especially when more potent **biologic options** are available [1]. *Add sulfasalazine* - **Sulfasalazine** is a valid conventional synthetic DMARD that can be used in **combination therapy** with methotrexate and has proven efficacy in RA treatment. - However, current major rheumatology guidelines (**ACR 2021**, **EULAR 2019**) recommend escalating to **biologic DMARDs** like **anti-TNF agents** as the preferred next step for patients with inadequate response to methotrexate after 3-6 months, especially when **disease activity remains high** as in this case [1].

Question 3: What is the indication of using systemic steroids in a case of rheumatoid arthritis -

A. Carpal tunnel syndrome
B. Presence of deformities
C. Involvement of articular cartilage
D. Mononeuritis multiplex (Correct Answer)

Explanation: ***Mononeuritis multiplex*** - Systemic steroids are indicated for severe extra-articular manifestations of **rheumatoid arthritis (RA)**, such as **mononeuritis multiplex**. - **Mononeuritis multiplex** is a serious complication involving inflammation of multiple nerves, requiring potent anti-inflammatory treatment. *Carpal tunnel syndrome* - **Carpal tunnel syndrome** in RA is usually managed locally with splinting, corticosteroid injections, or surgical decompression, not systemic steroids, unless there is widespread inflammation. - While associated with RA, it is generally considered a localized neuropathic issue rather than an indication for generalized immunosuppression. *Presence of deformities* - The presence of **deformities** in RA indicates chronic, irreversible joint damage, for which systemic steroids offer little benefit as they do not repair structural damage [1]. - Management of deformities often involves physical therapy, orthopedic surgery, or disease-modifying antirheumatic drugs (DMARDs) to prevent further progression, rather than acute steroid intervention. *Involvement of articular cartilage* - **Articular cartilage involvement** is a hallmark of RA and is primarily managed by **DMARDs** to prevent further erosion and preserve joint function [3, 4]. - Systemic steroids may temporarily reduce inflammation but do not prevent long-term cartilage degradation as effectively as DMARDs [3].

Question 4: 40-year-old patient having arthritis of PIP and DIP along with carpometacarpal joint of thumb and sparing of wrist and metacarpophalangeal joint, most likely diagnosis is

A. osteoarthritis (Correct Answer)
B. pseudo gout
C. psoriatic arthritis
D. rheumatoid arthritis

Explanation: ***Osteoarthritis*** - This classic presentation of arthritis in the **PIP, DIP**, and **first carpometacarpal (CMC) joint** with sparing of the wrist and MCP joints is highly characteristic of **osteoarthritis** [1]. - **Osteoarthritis** primarily affects cartilage and bone, leading to pain and stiffness, and commonly involves these specific hand joints [1]. *Pseudo gout* - Pseudo gout, or **calcium pyrophosphate deposition disease (CPPD)**, typically causes acute, monoarticular or oligoarticular arthritis, often affecting larger joints like the knee or wrist [3]. - While it can affect the hand, its presentation is usually more acute and less chronic, and it does not typically show the joint distribution described here. *Psoriatic arthritis* - **Psoriatic arthritis** can affect the DIP joints and can cause a "sausage digit" (dactylitis), but it often also involves the wrist or other joints, and skin/nail changes of psoriasis would typically be present. - While it can involve the DIP joints, the classic sparing of wrist and MCP for this specific pattern is less typical for psoriatic arthritis compared to osteoarthritis. *Rheumatoid arthritis* - **Rheumatoid arthritis** typically affects the **MCP joints** and **wrists symmetrically**, often sparing the DIP joints [2]. - The presented pattern of joint involvement, especially the sparing of the MCP and wrist joints and involvement of the DIP and CMC joints, makes rheumatoid arthritis unlikely [2].

Question 5: Which of the following statements about rheumatoid arthritis is false?

A. More common in females
B. Elevated CRP
C. Associated with Fetty's syndrome
D. Asymmetrical joint involvement (Correct Answer)

Explanation: ***Asymmetrical joint involvement*** - **Rheumatoid arthritis** is classically characterized by **symmetrical polyarthritis**, affecting the same joints on both sides of the body [1]. - Asymmetrical involvement would be atypical and might suggest another form of inflammatory arthritis. *More common in females* - This statement is **true**; rheumatoid arthritis has a female-to-male predilection ratio of approximately 3:1 [2]. - The higher prevalence in females suggests a possible role of hormonal or genetic factors. *Elevated CRP* - This statement is **true**; an **elevated C-reactive protein (CRP)** level is a common finding in rheumatoid arthritis, indicating systemic inflammation [1]. - CRP, along with erythrocytic sedimentation rate (ESR), is used to monitor disease activity and treatment response [1]. *Associated with Felty's syndrome* - This statement is **true**; **Felty's syndrome** is a rare but severe complication of long-standing rheumatoid arthritis [2]. - It is characterized by the triad of **rheumatoid arthritis, splenomegaly, and neutropenia** [2].

Question 6: A 22-year-old male medical student was seen in the emergency department with a complaint of pain in his hand. He confessed that he had hit a vending machine in the hospital when he did not receive his soft drink after inserting money twice. The medial side of the dorsum of the hand was quite swollen, and one of his knuckles could not be seen when he "made a fist." The physician made a diagnosis of a "boxer's fracture." What was the nature of the impatient student's injury?

A. Colles' fracture of the radius
B. Fracture of the styloid process of the ulna
C. Smith's fracture of the radius
D. Fracture of the neck of the fifth metacarpal (Correct Answer)

Explanation: ***Fracture of the neck of the fifth metacarpal*** - A **boxer's fracture** specifically refers to a fracture of the neck of the fifth metacarpal bone. - This injury commonly occurs when punching a hard object, leading to swelling and loss of the knuckle prominence. *Colles' fracture of the radius* - A **Colles' fracture** involves the distal radius, typically caused by a fall on an outstretched hand, resulting in a "dinner fork" deformity. - It does not involve the metacarpals or knuckles. *Fracture of the styloid process of the ulna* - This fracture often accompanies a **Colles' fracture** of the radius but can also occur in isolation. - It's a fracture of the distal end of the ulna and does not cause the loss of a knuckle. *Smith's fracture of the radius* - A **Smith's fracture** is a fracture of the distal radius with volar displacement, often called a "reverse Colles' fracture." - It is caused by a fall on the back of the hand or a direct blow to the forearm and does not affect the metacarpals or knuckles.

Question 7: A 54-year-old female marathon runner presents with pain in her right wrist that resulted from a fall onto her outstretched hand. Radiographic studies indicate an anterior dislocation of a carpal bone. Which of the following bones is most likely dislocated?

A. Capitate
B. Lunate (Correct Answer)
C. Trapezoid
D. Triquetrum

Explanation: ***Lunate*** - The **lunate bone** is the most commonly dislocated carpal bone, especially with a fall onto an **outstretched hand**. - Its central position in the proximal carpal row and its articulation with the radius make it vulnerable to **anterior dislocation** with forced dorsiflexion. *Capitate* - The **capitate** is the largest carpal bone but is more stable due to its central position and strong ligamentous attachments. - Isolated dislocation of the capitate is **rare** and usually accompanies other carpal injuries. *Trapezoid* - The **trapezoid** is a small, irregularly shaped carpal bone in the distal row, which is very stable. - Its strong articulations with the trapezium, capitate, and second metacarpal make its dislocation **extremely uncommon**. *Triquetrum* - The **triquetrum** is the second most commonly fractured carpal bone but is less prone to dislocation than the lunate. - While it can dislocate, it typically occurs with **ulnar impaction** or other complex carpal instabilities rather than an isolated anterior dislocation from a fall onto an outstretched hand.

Question 8: Rupture of extensor pollicis longus tendon occurs in all of the following except -

A. De Quervain's disease (Correct Answer)
B. Rheumatoid arthritis
C. Drummers
D. Colles' fracture

Explanation: ***De Quervain's disease*** - This condition involves **tenosynovitis** of the **extensor pollicis brevis** and **abductor pollicis longus** tendons, not a rupture of the extensor pollicis longus. - The pathology is an inflammation and thickening of the tendon sheaths, distinct from a tendon tear. *Rheumatoid arthritis* - **Chronic inflammation** in rheumatoid arthritis can lead to weakening and eventual rupture of tendons, including the **extensor pollicis longus**, often due to synovitis eroding the tendon. - The condition creates an environment where tendons are vulnerable to **attrition** and damage, making rupture a recognized complication. *Drummers* - Repetitive, high-force movements involved in drumming can cause significant **stress** and microscopic damage to tendons, including the **extensor pollicis longus**. - Over time, this cumulative trauma can lead to inflammation, degeneration, and eventual **rupture** due to overuse. *Colles' fracture* - A **Colles' fracture** of the distal radius can cause a delayed rupture of the **extensor pollicis longus (EPL)** tendon. - This occurs due to attrition of the tendon as it rubs over the **roughened fracture site** or due to *avascular necrosis* of the tendon as it passes through a narrow osteofibrous tunnel.

Question 9: Diagnostic of antemortem drowning:

A. Emphysema aquosum
B. Paltaufs hemorrhage
C. Water in esophagus
D. Presence of foreign material in clenched hands (Correct Answer)

Explanation: ***Presence of foreign material in clenched hands.*** - The presence of **foreign material** (such as weeds, sand, or gravel) in the **clenched hands** of a drowned victim suggests a struggle for survival while alive in the water. - This finding is strong evidence of **vital reaction**, indicating the individual was alive and actively struggling during submergence, making it highly indicative of antemortem drowning. *Emphysema aquosum* - Refers to **overinflation of the lungs** and is a common finding in drowning, resulting from fluid aspiration and spasmodic respiratory efforts. - While supportive of drowning, it can also be seen in other forms of **asphyxia** and is not specific enough to definitively diagnose antemortem drowning versus postmortem immersion. *Paltaufs hemorrhage* - Describes **subpleural hemorrhages** found on the lungs, often seen in cases of drowning. - These hemorrhages are a non-specific sign and can be present in other causes of death involving **venous congestion** or **asphyxia**, thus not definitive for antemortem drowning. *Water in esophagus* - While the aspiration of water is a hallmark of drowning, finding water in the **esophagus** (and stomach) can occur in both antemortem and **postmortem immersion**. - This finding alone does not reliably distinguish between someone who was alive and swallowed water during drowning versus someone who was dead and immersed in water.

Question 10: How can homicidal gunshot wounds be differentiated from suicidal gunshot wounds?

A. Presence of multiple gunshot wounds
B. Presence of gunpowder on hands
C. Presence of signs of struggle (Correct Answer)
D. None of the above

Explanation: ***Correct Option: Presence of signs of struggle*** - **Signs of struggle** (defensive wounds, abrasions, bruising, torn clothing, disturbed surroundings) are the **most reliable indicator of homicidal gunshot wounds** - **Forensic significance**: Defense wounds on hands/forearms, struggle marks, and signs of restraint strongly suggest the victim resisted an attacker - **Absent in suicide**: Suicidal acts occur without external confrontation, so defensive injuries and struggle signs are typically absent - This is the **primary forensic differentiator** between homicide and suicide in gunshot cases *Incorrect: Presence of multiple gunshot wounds* - While **more common in homicide**, multiple gunshot wounds **CAN occur in suicide** (documented as "hesitation wounds" or multiple attempts with non-fatal first shots) - **Not a reliable sole differentiator**: Cases of suicidal individuals firing multiple shots are well-documented in forensic literature, especially with small caliber weapons or when vital organs are missed - Other factors (wound location, distance, angle) are needed for complete assessment *Incorrect: Presence of gunpowder on hands* - **Gunshot residue (GSR) on victim's hands** actually **indicates suicide** rather than homicide, as it suggests the victim held and fired the weapon - In **homicide**, GSR is typically **absent** from the victim's hands (unless they struggled for the weapon) - This differentiates suicide FROM homicide, but the question asks how to identify homicide *Incorrect: None of the above* - This is incorrect because **specific forensic indicators exist** to differentiate homicidal from suicidal gunshot wounds - Signs of struggle provide the most reliable differentiation

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