Musculoskeletal Radiology Practice Questions

Q: Wimberger ring sign is present in which condition?

Scurvy. **Explanation:** **Wimberger Ring Sign** is a classic radiographic feature of **Scurvy (Vitamin C deficiency)**. It refers to a thin, sclerotic (dense) rim of calcification surrounding a radiolucent (pale) epiphysis. This occurs because Vitamin C deficiency leads to defective osteoid formation; while the center of the epiphysis becomes osteoporotic and lucent, the zone of provisional calcification at the periphery remains dense, creating a "halo" or "ring" appearance. **Analysis of Options:** * **Scurvy (Correct):** In addition to Wimberger’s sign, other high-yield signs include **Frankel’s line** (dense zone of provisional calcification), **Trummerfeld zone** (lucent scorbutic zone), and **Pelkan spurs** (marginal osteophytes). * **Rickets:** Characterized by "Cupping, Fraying, and Splaying" of the metaphysis and an increased growth plate width. It does not feature the ring-like epiphyseal calcification seen in scurvy. * **Secondary Syphilis:** Typically presents with periostitis or "Wimberger’s **Sign**" (not Ring sign). *Note the distinction:* Wimberger’s sign in syphilis refers to localized bone destruction/erosion of the medial aspect of the proximal tibial metaphysis. * **Tuberculosis:** Usually presents with Phemister’s triad (juxta-articular osteopenia, peripheral joint erosions, and gradual joint space narrowing) or spinal involvement (Pott’s disease). **NEET-PG High-Yield Pearls:** * **Wimberger Ring Sign:** Scurvy (Epiphysis). * **Wimberger Sign:** Congenital Syphilis (Metaphysis). * **White line of Frankel:** Scurvy (dense metaphyseal line). * **Ground glass osteoporosis:** Common in Scurvy due to lack of collagen matrix.

Q: The Scottish terrier sign is typically observed in which radiographic view?

Oblique view. The **Scotty Dog (Scottish Terrier) sign** is a classic radiographic finding seen on **oblique views** of the lumbar spine. It is used to identify the integrity of the **pars interarticularis**. ### Why the Oblique View is Correct In a 45-degree oblique radiograph, the various components of the lumbar vertebrae align to resemble the silhouette of a Scottish Terrier dog: * **Eye:** Pedicle * **Nose:** Transverse process * **Ear:** Superior articular facet * **Foreleg:** Inferior articular facet * **Neck:** **Pars interarticularis** * **Body:** Lamina The clinical significance lies in the "neck" of the dog. A break or lucency in the neck indicates **spondylolysis** (a defect in the pars interarticularis). If the dog appears to be wearing a collar or is "decapitated," the diagnosis is confirmed. ### Why Other Options are Incorrect * **AP View:** Best for assessing vertebral body alignment, pedicle shadows ("winking owl sign"), and transverse processes, but it overlaps the posterior elements, making the pars difficult to visualize. * **PA View:** Similar to the AP view; it does not provide the necessary angular perspective to project the posterior elements in the "dog" configuration. * **Lateral View:** Best for assessing **spondylolisthesis** (forward slippage of vertebrae) and disc space height, but it does not clearly isolate the pars interarticularis from the surrounding bone as the oblique view does. ### NEET-PG High-Yield Pearls * **Spondylolysis:** A defect in the pars interarticularis (the "collar" on the dog). * **Spondylolisthesis:** Forward displacement of one vertebra over another; best graded using the **Meyerding Classification** on a **Lateral view**. * **Winking Owl Sign:** Seen on **AP view**; indicates destruction of a pedicle, often due to spinal metastasis. * **Bamboo Spine:** Classic for Ankylosing Spondylitis (seen on AP/Lateral views).

Q: In a patient presenting with shoulder pain and no clear history of trauma, what does this radiograph most likely suggest?

Calcific tendinitis. ***Calcific tendinitis*** - Radiograph shows **calcium deposits** within the **supraspinatus tendon** or other rotator cuff tendons, appearing as dense white opacities near the greater tuberosity. - Clinical presentation of **shoulder pain without trauma** is characteristic, often with **night pain** and restricted range of motion. *Shoulder dislocation* - Would show **loss of normal humeral head-glenoid relationship** with the humeral head positioned anteriorly, posteriorly, or inferiorly relative to the glenoid fossa. - Typically presents with **severe pain**, **inability to move the arm**, and obvious deformity following trauma. *Acromioclavicular dislocation* - Radiograph would demonstrate **separation** or **step-off** between the **acromion** and **distal clavicle** at the AC joint. - Usually results from **direct trauma** to the shoulder, such as a fall onto the lateral aspect of the shoulder. *Hill-Sachs lesion* - Appears as a **compression fracture** of the **posterolateral humeral head**, creating an indentation or flattening on the bone surface. - Associated with **anterior shoulder dislocation** and would require a history of significant trauma or recurrent dislocations.

Q: What is the possible diagnosis based on the provided X-ray image?

Osgood-Schlatter disease. ***Osgood-Schlatter disease*** - X-ray shows **tibial tuberosity fragmentation** and **irregularity** on lateral knee view, characteristic of this condition in adolescents - Presents as **anterior knee pain** below the patella with **tibial tubercle prominence** in active adolescents during growth spurts *Pellegrini-Stieda lesion* - Appears as **calcification** along the **medial collateral ligament** attachment at the medial femoral condyle on AP knee X-ray - Results from **chronic MCL injury** and shows **linear calcification** rather than tibial tuberosity changes *SLAP tear* - **Superior labrum anterior-posterior tear** of the shoulder **glenoid labrum** cannot be diagnosed on plain X-rays - Requires **MRI** or **MR arthrography** for visualization as it involves **soft tissue structures** not visible on X-ray *Segond fracture* - Shows as a **small avulsion fracture** of the **lateral tibial plateau** on AP knee X-ray - Associated with **ACL injury** and appears as a **small bony fragment** at the lateral joint line, not tibial tuberosity

Q: What is the best imaging modality to distinguish acute osteomyelitis from a soft tissue infection?

MRI. **Explanation:** The gold standard and most accurate imaging modality for distinguishing acute osteomyelitis from a soft tissue infection (like cellulitis or abscess) is **MRI**. **Why MRI is the Correct Answer:** MRI offers superior soft-tissue contrast and high sensitivity (90-100%) for detecting early bone marrow changes. In acute osteomyelitis, MRI can detect **bone marrow edema** (low signal on T1, high signal on T2/STIR) as early as 1–2 days after the onset of infection. It clearly demarcates whether the inflammatory process is confined to the soft tissues or has breached the cortex to involve the marrow, which is critical for diagnosis. **Why Other Options are Incorrect:** * **Clinical Examination:** While essential for initial suspicion (rubor, tumor, calor, dolor), it cannot definitively differentiate between deep cellulitis and underlying bone involvement. * **X-ray:** Plain radiographs are insensitive in the early stages. Bone changes (periosteal reaction or bone destruction) typically do not appear until **10–14 days** after infection begins and require at least 30-50% bone mineral loss to be visible. * **CT Scan:** While excellent for identifying sequestrum (dead bone) in chronic osteomyelitis or cortical destruction, it is less sensitive than MRI for early marrow edema and involves significant radiation. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign on X-ray:** Soft tissue swelling. * **Earliest sign on MRI:** Bone marrow edema. * **Triple Phase Bone Scan (Technetium-99m):** Highly sensitive but lacks the anatomical detail of MRI; it is often used if MRI is contraindicated. * **Gold Standard for Diagnosis:** Bone biopsy and culture (though MRI is the best *imaging*).

Q: "Corner sign of Park" is a feature of which of the following conditions?

Scurvy. **Explanation:** **Corner Sign of Park** (also known as the Wimberger sign of scurvy) refers to a small marginal metaphyseal fracture or "beaking" seen at the edges of the zone of provisional calcification. **1. Why Scurvy is Correct:** Scurvy is caused by Vitamin C deficiency, which leads to defective collagen synthesis. This results in weakened capillary walls (leading to subperiosteal hemorrhages) and brittle osteoid. The **Corner Sign** occurs because the zone of provisional calcification is calcified but brittle; under mechanical stress, the edges of this zone fracture, creating a "corner" defect. This is often seen alongside the **Pelkan Spur**, which is the healing/ossification of the periosteum at these corners. **2. Why Other Options are Incorrect:** * **Rickets:** Characterized by a failure of mineralization. Key findings include cupping, splaying, and fraying of the metaphysis, and an increased growth plate width, but not discrete marginal fractures. * **Battered Baby Syndrome:** While it involves metaphyseal fractures (Bucket-handle or Corner fractures), these are traumatic avulsions of the metaphysis. The "Corner Sign of Park" is a specific eponym reserved for the metabolic pathology of Scurvy. * **Sickle Cell Disease:** Radiographic features include "H-shaped" vertebrae (Reynold’s sign), dactylitis (hand-foot syndrome), and bone infarcts, but not specific metaphyseal corner signs. **3. High-Yield Clinical Pearls for Scurvy (NEET-PG):** * **Wimberger Ring Sign:** A thin, sclerotic rim surrounding a lucent epiphysis. * **Frankel’s Line:** Dense, sclerotic line at the zone of provisional calcification. * **Trummerfeld Zone:** A lucent (scorbutic) band proximal to Frankel’s line representing a zone of debris. * **Subperiosteal Hemorrhage:** Leads to lifting of the periosteum, which becomes visible as "cloaking" upon healing/calcification.

Q: Bone density is best studied by which imaging modality?

DEXA scan. **Explanation:** **1. Why DEXA Scan is the Correct Answer:** Dual-Energy X-ray Absorptiometry (DEXA) is the **gold standard** for measuring Bone Mineral Density (BMD). It utilizes two X-ray beams with different energy levels to differentiate between bone and soft tissue. Its clinical superiority stems from its high precision, low radiation dose (1/10th of a chest X-ray), and its ability to provide standardized **T-scores** and **Z-scores**, which are essential for diagnosing Osteoporosis and Osteopenia according to WHO criteria. **2. Why Other Options are Incorrect:** * **CT Scan:** While Quantitative CT (QCT) can measure bone density in 3D, a standard CT scan is not the primary tool due to significantly higher radiation exposure and cost. QCT is usually reserved for research or specific complex cases. * **MRI Scan:** MRI is excellent for visualizing soft tissues, bone marrow edema, and occult fractures, but it cannot accurately quantify mineral density because cortical bone yields a low signal (appears black). * **Bone Scan (Scintigraphy):** This functional imaging modality uses Technetium-99m MDP to detect **osteoblastic activity** (bone turnover). It is used to identify metastases, infections, or stress fractures, not to measure density. **3. High-Yield Clinical Pearls for NEET-PG:** * **Sites for DEXA:** The most common sites measured are the **Lumbar spine (L1-L4)** and the **Proximal Femur (Neck of femur)**. * **T-score:** Compares patient BMD to a young healthy adult (30-year-old). * Normal: > -1.0 * Osteopenia: -1.0 to -2.5 * Osteoporosis: ≤ -2.5 * Severe Osteoporosis: ≤ -2.5 + fragility fracture. * **Z-score:** Compares patient BMD to an age-matched and sex-matched peer. A Z-score < -2.0 suggests secondary causes of bone loss.

Q: Trolly tract sign is seen in which of the following conditions?

Ankylosing spondylitis. **Explanation:** **Ankylosing Spondylitis (AS)** is the correct answer. The **Trolley Track sign** is a classic radiographic feature of advanced AS. It is caused by the ossification of the **supraspinous and interspinous ligaments**, which creates a central vertical radiodense line, combined with the ossification of the **apophyseal (facet) joint capsules**, which create two lateral vertical lines. Together, these three parallel lines resemble trolley tracks on a frontal (AP) X-ray of the spine. **Analysis of Incorrect Options:** * **Achondroplasia:** Characterized by "bullet-shaped" vertebrae, posterior scalloping, and a progressive narrowing of the interpedicular distance in the lumbar spine. * **Psoriatic Arthritis:** Typically shows "pencil-in-cup" deformities in the hands and asymmetrical sacroiliitis, but not the trolley track sign. * **Osteopetrosis:** Known for "Erlenmeyer flask" deformities and the "bone-within-a-bone" appearance (endobone) due to defective osteoclast activity. **High-Yield Clinical Pearls for NEET-PG:** * **Bamboo Spine:** Formed by marginal **syndesmophytes** (ossification of the outer fibers of the annulus fibrosus). * **Dagger Sign:** A single central radiodense line on AP X-ray due to ossification of the supraspinous and interspinous ligaments. * **Shiny Corner Sign (Romanus Lesion):** Early sign of AS representing small erosions at the corners of vertebral bodies. * **Andersson Lesion:** Non-infectious spondylodiscitis seen in AS. * **HLA-B27:** Strongly associated with AS (approx. 90% of cases).

Q: What is the best method to evaluate a discrepancy in the articular disc of the temporomandibular joint (TMJ)?

MRI. **Explanation:** The **Temporomandibular Joint (TMJ)** is a complex bicondylar joint containing a fibrocartilaginous articular disc. Evaluating "discrepancies" (such as internal derangement, disc displacement, or perforation) requires high-quality visualization of soft tissue structures. **Why MRI is the Correct Answer:** **MRI (Magnetic Resonance Imaging)** is the **gold standard** for TMJ evaluation. It provides superior soft-tissue contrast, allowing for the precise visualization of the articular disc, its position relative to the condyle (in both open and closed mouth positions), and the surrounding ligaments and muscles. It is non-invasive and does not use ionizing radiation. **Analysis of Incorrect Options:** * **Transpharyngeal projection (Parchman’s view):** This is a plain radiographic technique. While useful for identifying gross bony changes or fractures of the condyle, it cannot visualize the radiolucent articular disc. * **Arthrography:** This involves injecting contrast into the joint spaces. While it was historically used to diagnose disc perforations or adhesions, it is invasive and has been largely replaced by MRI. * **Arthroplasty:** This is a **surgical procedure** (treatment) to repair or replace the joint, not a diagnostic imaging method. **High-Yield Clinical Pearls for NEET-PG:** * **Best initial investigation for TMJ bony changes:** Non-contrast CT (NCCT) or Cone Beam CT (CBCT). * **Best investigation for TMJ soft tissue/disc:** MRI. * **Most common disc displacement:** Anterior displacement (often associated with "clicking" sounds). * **T1-weighted sequences** are excellent for anatomy, while **T2-weighted sequences** help identify joint effusion or inflammation.

Question 1

Which one of the following conditions is not associated with cupping and fraying of metaphyses of long bones in children?

Accepted Answer

Lead poisoning

Answer

Rickets

Answer

Metaphyseal dysplasia

Answer

Hypophosphatasia

Question 2

Wimberger ring sign is present in which condition?

Accepted Answer

Scurvy

Answer

Rickets

Answer

Secondary syphilis

Answer

Tuberculosis

Question 3

The Scottish terrier sign is typically observed in which radiographic view?

Accepted Answer

Oblique view

Answer

Anteroposterior (AP) view

Answer

Posteroanterior (PA) view

Answer

Lateral view

Question 4

In a patient presenting with shoulder pain and no clear history of trauma, what does this radiograph most likely suggest?

Accepted Answer

Calcific tendinitis

Answer

Shoulder dislocation

Answer

Acromioclavicular dislocation

Answer

Hill-Sachs lesion

Question 5

What is the possible diagnosis based on the provided X-ray image?

Accepted Answer

Osgood-Schlatter disease

Answer

Pellegrini-Stieda lesion

Answer

SLAP tear

Answer

Segond fracture

Question 6

What is the best imaging modality to distinguish acute osteomyelitis from a soft tissue infection?

Accepted Answer

MRI

Answer

Clinical examination

Answer

X-ray

Answer

CT scan

Question 7

"Corner sign of Park" is a feature of which of the following conditions?

Accepted Answer

Scurvy

Answer

Rickets

Answer

Battered baby syndrome

Answer

Sickle cell disease

Question 8

Bone density is best studied by which imaging modality?

Accepted Answer

DEXA scan

Answer

CT scan

Answer

MRI scan

Answer

Bone scan

Question 9

Trolly tract sign is seen in which of the following conditions?

Accepted Answer

Ankylosing spondylitis

Answer

Achondroplasia

Answer

Psoriatic arthritis

Answer

Osteopetrosis

Question 10

What is the best method to evaluate a discrepancy in the articular disc of the temporomandibular joint (TMJ)?

Accepted Answer

MRI

Answer

Transpharyngeal projection

Answer

Arthrography

Answer

Arthroplasty

Musculoskeletal Radiology — MCQs

Musculoskeletal Radiology — MCQs

On this page

Practice by Chapter

Want unlimited practice?