Musculoskeletal Radiology Practice Questions

Q: Honda or H sign on STIR MRI is characteristic of which condition?

Sacral insufficiency fracture. ***Sacral insufficiency fracture*** - The **Honda sign** (also known as the H sign or butterfly sign) is a characteristic finding on **STIR MRI** of the sacrum, particularly suggestive of a **sacral insufficiency fracture** caused by chronic microtrauma in osteoporotic bone. - It represents bilateral vertical fracture lines through the sacral alae connected by a horizontal fracture line through the body of S3 (or S2/S4), showing **medullary edema**/fracture line hyperintensity on STIR sequences. ***Multiple myeloma*** - Myeloma typically presents on MRI as multiple **focal lesions** (plasmacytomas) or diffuse marrow infiltration, often showing low signal intensity on T1 and variable T2/STIR signals. - While sacral involvement is possible, the classic H sign or Honda sign is not a typical presentation; rather, it often shows **lytic lesions** on plain films/CT. ***Acute osteomyelitis*** - Acute osteomyelitis of the sacrum would show localized **marrow edema** with corresponding T1 hypointensity and contrast-enhancing soft tissue/periosteal reaction. - It is usually unilateral and focal, lacking the characteristic H pattern of stress or insufficiency fractures. ***Bone marrow edema*** - Bone marrow edema is a generalized finding on STIR, indicating pathology such as trauma, infection, tumor infiltration, or avascular necrosis (AVN). - While the H sign is a type of bone marrow edema pattern, the sign itself is specific to a **sacral insufficiency fracture**, not a general edema observation.

Q: A 56-year-old female presents with chronic lower back pain. A lateral lumbar spine X-ray is provided. Based on the radiological findings, which of the following is the most likely diagnosis?

Spondylolisthesis. ***Spondylolisthesis*** - The lateral X-ray view demonstrates classic evidence of **anterior displacement** (slippage) of the superior vertebral body relative to the inferior body (shown by the red measurement line). - This condition is often due to a defect in the **pars interarticularis** (spondylolysis), indicated by the yellow arrows, causing mechanical instability and chronic pain. *Spondylitis* - Refers specifically to **inflammation** of the spinal vertebrae, seen in conditions like **Ankylosing Spondylitis** or infectious processes (e.g., spinal tuberculosis). - Radiological findings would include bone erosions, endplate destruction, or squaring of vertebrae, not clear mechanical vertebral slippage. *Osteosarcoma* - This is a primary malignant bone tumor, usually presenting radiographically as a solitary, aggressively lytic, or **sclerotic mass** with poorly defined margins. - It does not cause the characteristic pattern of forward vertebral body slip and pars defect visible in this chronic mechanical pathology. *Vertebral fracture* - An acute **compression fracture** results in a loss of vertebral height, often a wedge-shaped deformity, which is not the predominant finding here. - While traumatic fracture-dislocation can cause displacement, the image shows a chronic slip pattern, often secondary to a **spondylolysis** (pars defect), rather than an acute traumatic bone break.

Q: Which is the earliest imaging modality used to detect ankylosing spondylitis?

MRI sacroiliac joint. ***MRI sacroiliac joint*** - **Most sensitive modality** for detecting early ankylosing spondylitis - Detects **bone marrow edema** and active sacroiliitis before structural changes appear - Shows **inflammatory changes** in cartilage, synovium, and entheses - Can identify disease **years before X-ray changes** become apparent - STIR and T1-weighted sequences with contrast are particularly useful *Incorrect: X-ray* - Detects only **late structural changes** (erosions, sclerosis, fusion) - Takes **several years** for radiographic sacroiliitis to develop - Low sensitivity in early disease stages - Still used for initial screening due to availability and cost *Incorrect: Bone scan* - Shows **non-specific** increased uptake in sacroiliac joints - Lower sensitivity and specificity compared to MRI - Cannot differentiate inflammatory from mechanical causes - Largely replaced by MRI in current practice *Incorrect: CT sacroiliac joint* - Better than X-ray for detecting **bony erosions** and structural detail - Still detects structural rather than inflammatory changes - Higher radiation exposure than X-ray - Less sensitive than MRI for early disease

Q: What are the correct diagnoses for lesions A and B shown in the image?

A= Giant cell tumour, B= Aneurysmal bone cyst. ***A= Giant cell tumour, B= Aneurysmal bone cyst*** - Image A shows a **lytic lesion** in the distal radius, extending to the articular surface without sclerotic margins, which is characteristic of a **giant cell tumor (GCT)**. GCTs are typically epiphyseal/metaphyseal and bone-expanding. - Image B shows an **expansile, lytic lesion** in the proximal humerus with internal septations and trabeculations, giving a **"soap bubble" appearance**, classic for an **aneurysmal bone cyst (ABC)**. *A= Simple bone cyst, B= Aneurysmal bone cyst* - A **simple bone cyst (unicameral bone cyst)** is usually centrally located in the metaphysis of long bones, often with a **"fallen fragment sign"** if fractured, and is typically radiolucent and expansile without internal septations. Image A does not show these features. - While Image B is consistent with an aneurysmal bone cyst, Image A is not a simple bone cyst. *A= Aneurysmal bone cyst, B= Simple bone cyst* - As described, Image A is consistent with a **giant cell tumor**, not an aneurysmal bone cyst, due to its characteristic location and aggressive lytic nature near the joint. - Image B shows features of an **aneurysmal bone cyst**, not a simple bone cyst, given its multiseptated appearance. *A= Osteochondroma, B= Aneurysmal bone cyst* - An **osteochondroma** appears as a **bone outgrowth** with a cartilaginous cap, typically arising from the metaphysis and pointing away from the joint. This is clearly not what is seen in Image A. - Image B is consistent with an **aneurysmal bone cyst**, but Image A does not represent an osteochondroma.

Q: The following view of the knee joint is known as: (The image was obtained with the patient supine, knee flexed at approximately 30–60°, and the X-ray beam directed tangentially along the long axis of the patella from the foot end upward.)

Sunset view. ***Sunset view*** - Also known as the **skyline view** or **tangential view** of the patella, this view is taken with the knee flexed (typically 30–60°), allowing visualization of the **patellofemoral joint space** in axial projection. - It is excellent for diagnosing **patellar tracking issues**, patellar fractures, **chondromalacia patellae**, and assessing the patella's articulation with the **femoral trochlea**. *Merchant's view* - The Merchant's view is another tangential axial view of the patella, performed with the patient **supine and the knees flexed at 45°** over the edge of the table with the X-ray beam angled caudally. - While it also visualizes the **patellofemoral joint**, the patient positioning and beam angulation differ from the standard sunset/skyline view. *Tunnel view* - Also called the **notch view** or **intercondylar view**, this is a PA projection with the knee flexed at 40–50°, used to visualize the **intercondylar notch** and posterior femoral condyles. - It is primarily used to detect **osteochondral defects**, loose bodies in the notch, and **osteochondritis dissecans**. *Rosenberg view* - The Rosenberg view is a **weight-bearing PA view** taken with the knee flexed at 45°, used to assess **joint space narrowing** in the posterior tibiofemoral compartment. - It is more sensitive than a standing AP view for detecting **early osteoarthritis** of the knee.

Q: What is correct about the finding in X-ray shoulder?

Lateral view with anterior dislocation of shoulder. ***Lateral view with anterior dislocation of shoulder*** - The image is a **scapular Y lateral view**, which shows the scapula in a Y-shaped configuration formed by the scapular body, spine, and coracoid process - In anterior shoulder dislocation on a scapular Y view, the humeral head is displaced **anteriorly** relative to the glenoid (the center of the Y) - Anterior dislocations account for **95% of all shoulder dislocations** and typically result from a fall on an outstretched arm with the shoulder in abduction and external rotation - The scapular Y view is particularly useful for confirming the **direction of dislocation** and is complementary to the AP view *AP shoulder view with posterior dislocation* - Posterior dislocations on an AP view show the humeral head fixed in **internal rotation** with the characteristic **"light bulb" sign** (symmetric rounded appearance) - This represents only 2-5% of shoulder dislocations and is often associated with seizures or electrocution - This is not an AP view *AP shoulder view with anterior dislocation* - This is a **lateral scapular Y view**, not an AP view - On an AP view, anterior dislocation would show the humeral head displaced **inferiorly and medially** relative to the glenoid - The Y-shaped scapular configuration visible in this image confirms it is a lateral view *Lateral view with posterior dislocation of shoulder* - The dislocation seen is **anterior**, not posterior - On a scapular Y lateral view, posterior dislocation would show the humeral head displaced **posteriorly** relative to the center of the Y (glenoid) - Posterior dislocations are frequently missed on AP views alone, making lateral views essential for complete evaluation

Q: The findings in the following skull X-ray are most characteristic of:

Multiple myeloma. ***Multiple myeloma*** - The X-ray shows multiple well-defined, lytic, **punched-out lesions** throughout the skull, which is the classic presentation of multiple myeloma. - These lesions represent areas of bone destruction due to proliferation of **plasma cells** within the bone marrow. *Histiocytosis-X* - Histiocytosis X (Langerhans cell histiocytosis) can cause lytic skull lesions, but they are often described as **"beveled edge"** or **"hole within a hole"** appearance, which is not clearly depicted here. - While it can cause bony lesions, the widespread, uniformly punched-out appearance is more characteristic of multiple myeloma. *Hyperparathyroidism* - Hyperparathyroidism typically causes **generalized demineralization** of the skull, leading to a **"salt-and-pepper"** appearance, and possibly **subperiosteal bone resorption**. - It does not typically present with discrete, punched-out lytic lesions like those seen in the image. *Sickle cell anemia* - In sickle cell anemia, the skull X-ray may show **widening of the diploic spaces** and a **"hair-on-end"** or **"crew-cut"** appearance, especially in severe cases, due to marrow hyperplasia. - This is distinct from the multiple punched-out lesions observed in the provided image.

Q: What is the most likely diagnosis based on the MRI findings?

Eumycetoma. ***Eumycetoma*** - The image displays multiple **interconnected, thick-walled lesions with central low-signal dots within high-signal lesions surrounded by low-signal rims**, often described as a **"dot-in-circle" sign**, which is characteristic of **eumycetoma** on MRI. - This pattern reflects the **granules within abscesses and granulomatous tissue**, typical of this chronic fungal infection, specifically in the context of soft tissue involvement. *Spina ventosa* - **Spina ventosa** refers to a **cystic expansion of bone**, typically seen in tuberculosis of the short tubular bones (e.g., phalanges). - While it involves bone, the radiographic findings are distinct, presenting as **fusiform expansion with lytic lesions** rather than the numerous soft tissue lesions with central foci seen here. *Tophaceous gout* - **Tophaceous gout** involves deposits of **monosodium urate crystals** in soft tissues and joints, appearing as well-defined, heterogeneous masses on imaging. - Unlike eumycetoma, these deposits do not typically show the characteristic **"dot-in-circle" sign** and are often associated with erosions and sclerosis in adjacent bones. *Cysticercosis* - **Cysticercosis** results from larval cysts of *Taenia solium* and typically presents as **single or multiple cysts with a scolex** within them ("hole-with-dot" appearance) in various tissues, including muscle and brain. - The cystic lesions of cysticercosis are usually more discrete and do not demonstrate the extensive, interconnected, and granular morphology characteristic of eumycetoma.

Question 1

Honda or H sign on STIR MRI is characteristic of which condition?

Accepted Answer

Sacral insufficiency fracture

Answer

Multiple myeloma

Answer

Acute osteomyelitis

Answer

Bone marrow edema

Question 2

A 56-year-old female presents with chronic lower back pain. A lateral lumbar spine X-ray is provided. Based on the radiological findings, which of the following is the most likely diagnosis?

Accepted Answer

Spondylolisthesis

Answer

Spondylitis

Answer

Vertebral fracture

Answer

Osteosarcoma

Question 3

Which is the earliest imaging modality used to detect ankylosing spondylitis?

Accepted Answer

MRI sacroiliac joint

Answer

X ray

Answer

Bone scan

Answer

CT sacroiliac joint

Question 4

What are the correct diagnoses for lesions A and B shown in the image?

Accepted Answer

A= Giant cell tumour, B= Aneurysmal bone cyst

Answer

A= Simple bone cyst, B= Aneurysmal bone cyst

Answer

A= Aneurysmal bone cyst, B= Simple bone cyst

Answer

A= Osteochondroma, B= Aneurysmal bone cyst

Question 5

The following view of the knee joint is known as: (The image was obtained with the patient supine, knee flexed at approximately 30–60°, and the X-ray beam directed tangentially along the long axis of the patella from the foot end upward.)

Accepted Answer

Sunset view

Answer

Merchant's view

Answer

Tunnel view

Answer

Rosenberg view

Question 6

What is correct about the finding in X-ray shoulder?

Accepted Answer

Lateral view with anterior dislocation of shoulder

Answer

AP shoulder view with posterior dislocation

Answer

AP shoulder view with anterior dislocation

Answer

Lateral view with posterior dislocation of shoulder

Question 7

What is the correct diagnosis for the image shown?

Accepted Answer

Rugger jersey spine

Answer

Fish vertebra

Answer

Hemivertebra

Answer

Block vertebra

Question 8

Which of the following best describes the image shown in patient with carcinoma prostate?

Accepted Answer

A = Osteosclerotic secondaries in X-ray KUB, B= Skeletal metastasis in bone scan

Answer

A = Osteolytic secondaries in X-ray KUB, B= Skeletal metastasis in Bone scan

Answer

A = Osteonecrotic secondaries in X-ray KUB, B = normal study in bone scan

Answer

A = over-penetrated X-ray KUB, B= skeletal metastasis in bone scan

Question 9

The findings in the following skull X-ray are most characteristic of:

Accepted Answer

Multiple myeloma

Answer

Histiocytosis X

Answer

Hyperparathyroidism

Answer

Sickle cell anemia

Question 10

What is the most likely diagnosis based on the MRI findings?

Accepted Answer

Eumycetoma

Answer

Spina ventosa

Answer

Tophaceous gout

Answer

Cysticercosis

Musculoskeletal Radiology — MCQs

Musculoskeletal Radiology — MCQs

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