Musculoskeletal Radiology Practice Questions

Q: Which investigation is least effective in diagnosing acute osteomyelitis?

X-ray. ***X-ray*** - **Plain radiographs** are often normal in the early stages of acute osteomyelitis, as bony changes take time to develop. - Changes like **periosteal elevation** or **bony destruction** typically become visible only after 10-14 days following infection onset. *Bone scan* - A **three-phase bone scan** (technetium-99m) is highly sensitive for detecting early osteomyelitis by showing increased blood flow and uptake in the affected area. - It can detect changes within 24-48 hours of infection, making it useful when plain radiographs are normal. *MRI* - **Magnetic Resonance Imaging (MRI)** is considered the most sensitive and specific imaging modality for diagnosing acute osteomyelitis. - It provides excellent soft tissue contrast, allowing early detection of **marrow edema**, **abscess formation**, and **cortical disruption**. *CT scan* - **Computed Tomography (CT) scans** are useful for visualizing cortical bone changes, **sequestra**, and defining the extent of bone involvement, especially helpful for surgical planning. - While more sensitive than X-rays, it is typically less sensitive than MRI in detecting early marrow changes in acute osteomyelitis.

Q: Shenton's line is seen in X-ray of -

Antero-posterior pelvis with both hips. ***Antero-posterior pelvis with both hips*** - Shenton's line is a curved line that can be drawn along the inferior border of the **femoral neck** and continuous with the inferior border of the **superior pubic ramus** (obturator foramen). - It is best visualized on an **antero-posterior X-ray of the pelvis** including both hips and is commonly assessed for hip dislocations or fractures. *Antero-posterior shoulder* - This view is primarily used to assess the **glenohumeral joint**, clavicle, and scapula. - Shenton's line specifically relates to the hip joint anatomy and is not relevant to the shoulder. *Lateral cervical spine* - A lateral cervical spine view focuses on the alignment of the **vertebral bodies**, intervertebral discs, and neural foramina in the neck. - It is used for assessing conditions like cervical fractures, dislocations, or degenerative changes, not hip pathology. *Lateral lumbosacral spine* - This view is used to evaluate the **lumbar vertebrae** and sacrum, looking for disc herniations, spondylolisthesis, or spinal alignment issues. - Shenton's line is not a landmark assessed on a lateral lumbosacral spine X-ray.

Q: Which of the following is not a typical radiological finding in rheumatoid arthritis?

Subchondral sclerosis. ***Subchondral sclerosis*** - **Subchondral sclerosis** is a hallmark of **osteoarthritis**, representing bone hardening beneath damaged cartilage, which is not characteristic of rheumatoid arthritis. - In rheumatoid arthritis, the primary pathology involves **synovial inflammation** leading to bone erosion rather than bone thickening. *Symmetrical involvement* - **Symmetrical polyarthritis** is a defining feature of rheumatoid arthritis, often affecting the same joints on both sides of the body. - This pattern helps differentiate it from other inflammatory arthropathies that might exhibit asymmetrical joint involvement. *Marginal erosion* - **Marginal erosions** are a classic early radiological sign of rheumatoid arthritis, caused by the inflammatory pannus invading the bare areas of bone. - These erosions typically appear at the edges of the joint, where the synovial membrane attaches. *Juxta-articular osteopenia* - **Juxta-articular osteopenia** (localized bone thinning near the joint) is an early and common radiological finding in rheumatoid arthritis. - It results from local inflammatory mediators and disuse around the affected joints.

Q: Cotton wool skull is a radiological feature of which condition?

Paget's disease. ***Paget's disease*** - The "cotton wool skull" appearance is a **classic radiological finding** in **Paget's disease of bone**, particularly in the **sclerotic phase** - This appearance results from patchy areas of **osteosclerosis** (increased bone density) interspersed with areas of **osteolysis** (bone destruction) - The mixed lytic-sclerotic pattern creates the characteristic fluffy, cotton wool-like appearance on skull radiographs *Eosinophilic granuloma* - Presents as **well-demarcated lytic (punched-out) lesions** in the skull - Does not cause the mixed osteolytic and osteosclerotic changes characteristic of cotton wool appearance - Typically affects children and young adults *Fibrous dysplasia* - Appears as **ground-glass opacity** or lytic lesion with sclerotic rim on radiographs - Shows homogeneous expansion of bone rather than patchy changes - Does not produce the cotton wool pattern seen in Paget's disease *Osteopetrosis* - Characterized by abnormally **dense, uniformly sclerotic bones** throughout the skeleton - Results from defective osteoclast function (Albers-Schönberg disease) - Presents with diffuse increased density rather than the patchy cotton wool pattern

Q: Tufting of the distal phalanx is characteristically seen in which of the following conditions?

Hyperparathyroidism. ***Hyperparathyroidism*** - Tufting of the distal phalanx is a classic radiological feature associated with **hyperparathyroidism**, due to increased bone resorption. - This condition leads to **subperiosteal bone resorption**, especially noticeable in the phalangeal tufts of the fingers [2]. *Gout* - Gout is characterized by the **deposition of uric acid crystals**, typically affecting the **metatarsophalangeal** joint [1]. - It does not exhibit the specific bony changes such as tufting seen in hyperparathyroidism. *Hypoparathyroidism* - Hypoparathyroidism leads to **hypocalcemia** and symptoms such as tetany, but does not cause tufting of the distal phalanx. - This condition is marked by **bone density increases**, contrary to the resorption seen in hyperparathyroidism. *Hyperkalemia* - Hyperkalemia refers to abnormally high **potassium levels** and is primarily associated with renal issues and cardiac symptoms. - It has no direct connection to bony changes or tufting of the phalanges.

Q: Based on the X-ray image, which condition is indicated by a sunray appearance?

Osteosarcoma. ***Osteosarcoma*** - A **sunray or sunburst appearance** on X-ray is a classic radiologic sign of osteosarcoma, representing new bone formation perpendicular to the bone cortex. - This aggressive primary bone tumor often presents with a combination of **osteoblastic (bone-forming)** and osteolytic (bone-destroying) features. *Osteochondroma* - Osteochondromas appear as **bony outgrowths** from the surface of bones, covered by a cartilage cap. - They are typically benign and do not exhibit the aggressive periosteal reaction seen in a sunray appearance. *Osteoclastoma* - Also known as a **giant cell tumor of bone**, osteoclastomas are typically **lytic lesions** that cause bone destruction. - They do not form new bone in a sunray pattern. *Chondroblastoma* - Chondroblastomas are rare, benign cartilaginous tumors usually found in the **epiphysis** of long bones. - They are typically **well-circumscribed lytic lesions** with fine, punctate calcifications, not a sunray pattern.

Q: A 14-year-old boy presents with a 3-month history of dull aching pain in the distal tibia that is worse at night and not relieved by NSAIDs. He has a low-grade fever, and laboratory findings show an elevated ESR (68 mm/hr) and CRP (18 mg/L) with a mild leukocytosis. There is no history of trauma. Identify the condition based on the provided image of a bone lesion. Ensure the diagnosis is based on the radiological and clinical features provided.

Brodie abscess. ***Brodie abscess*** - This lesion typically presents as a **well-defined, lucent lesion** with a surrounding rim of **sclerotic bone**, often located in the metaphysis of long bones. - It represents a subacute or chronic form of osteomyelitis, which can be **painful** and may mimic a bone tumor. - On MRI, the lesion demonstrates a central lytic cavity with a thick sclerotic rim. A **penumbra sign** — a zone of intermediate signal between the central cavity and the outer sclerotic margin — is a characteristic MRI feature of Brodie abscess when visible on appropriate sequences (e.g., T1-weighted imaging). The elevated ESR, CRP, and low-grade fever further support an infectious/inflammatory etiology. *Osteoid osteoma* - While also a lucent lesion with surrounding sclerosis, an osteoid osteoma is characterized by a small, central **nidus** that is typically **less than 1.5 cm** and causes **nocturnal pain relieved by NSAIDs**. - In this case, the pain is not relieved by NSAIDs, and the elevated inflammatory markers (ESR, CRP) and low-grade fever favor an infectious process over osteoid osteoma. *Intracortical hemangioma* - An intracortical hemangioma is a rare benign vascular tumor of bone that typically presents as an **expansile, lytic lesion** with internal trabeculations, sometimes described as a "sunburst" or "spoke-wheel" pattern. - It does not typically exhibit the prominent sclerotic rim seen in the image. *Chondromyxoid fibroma* - This is a rare benign cartilaginous tumor often presenting as an **eccentric, lobulated lytic lesion** with a sclerotic margin, usually in the metaphysis of long bones. - While it can have a sclerotic margin, it typically lacks the dense, uniform sclerosis and central lucency characteristic of a Brodie abscess.

Q: Investigation of choice for soft tissue sarcoma is -

MRI. ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the investigation of choice for soft tissue sarcomas due to its superior **soft tissue contrast resolution**, allowing for detailed assessment of tumor size, location, and extent within muscle, fat, and neurovascular structures. - MRI is crucial for **surgical planning**, helping to define tumor margins and evaluate involvement of adjacent critical structures. *CT* - While CT scans can identify masses, they have **limited soft tissue contrast resolution** compared to MRI, making it less effective for precise delineation of soft tissue sarcomas. - CT is often used for **staging to detect metastatic disease**, particularly in the lungs, rather than for primary tumor characterization. *Ultrasound* - **Ultrasound** is a good initial screening tool for soft tissue masses due to its accessibility and lack of radiation, but it is **operator-dependent** and has limitations in assessing deep or large lesions. - It can help differentiate cystic from solid lesions and guide biopsies but **lacks the comprehensive detail** of MRI for definitive diagnosis and staging. *X-ray* - **X-rays** are primarily used to visualize **bone abnormalities** and are generally not effective for evaluating soft tissue masses unless there is associated calcification or bone erosion. - They provide **minimal information** regarding the internal structure or extent of a soft tissue sarcoma.

Q: What condition is best diagnosed using a Skyline view X-ray?

Patellofemoral problem. ***Patellofemoral problem*** - The **Skyline view**, also known as the **Merchant view** or tangential patella view, is specifically designed to visualize the **patellofemoral joint**. - It is crucial for assessing conditions like **patellar subluxation**, tracking disorders, and **chondromalacia patellae** by showing the articulation between the patella and the femoral trochlea. *Radioulnar problem* - Problems with the **radioulnar joint** are typically evaluated with standard **AP and lateral views of the forearm and elbow**. - The Skyline view offers no diagnostic value for the radioulnar joint as it focuses on the knee. *Tibiofibular problem* - Issues concerning the **tibiofibular joints** (proximal or distal) are best assessed using **AP and lateral views of the lower leg or ankle**, depending on the specific joint. - The Skyline view is not used to evaluate these structures. *Skull fracture* - **Skull fractures** are diagnosed using standard **skull X-rays** (e.g., AP, lateral, Towne, Caldwell views) or more commonly, a **CT scan of the head**. - The Skyline view is specific to the knee and entirely inappropriate for evaluating the skull.

Q: What does the fallen fragment sign indicate in radiology?

Indicates a simple bone cyst. ***Indicates a simple bone cyst*** - The **fallen fragment sign** is a classic radiographic finding seen in **simple bone cysts** (unicameral bone cysts), particularly after a pathological fracture. - It occurs when a **fractured piece of bone** falls through the fluid-filled cyst cavity due to gravity, creating a characteristic appearance that indicates a benign, fluid-filled lesion. - This sign is considered **pathognomonic** for simple bone cysts. *Indicates osteosarcoma* - Osteosarcoma is a **malignant bone tumor** characterized by aggressive bone destruction and **osteoid formation**. - It typically does not demonstrate a fallen fragment sign; instead, it often shows a **Codman triangle** or **sunburst periosteal reaction**. - The aggressive nature and solid tumor composition make this sign incompatible with osteosarcoma. *Indicates an aneurysmal bone cyst* - An aneurysmal bone cyst (ABC) is a **benign, vascular bone lesion** that is usually multiloculated and blood-filled. - While it can cause bone expansion and pathological fractures, the fallen fragment sign is **not characteristic** of ABCs, which are typically hemorrhagic and contain blood-filled septa rather than clear fluid. - ABCs show a characteristic **fluid-fluid level** on imaging, not a fallen fragment. *Indicates adamantinoma* - Adamantinoma is a **rare, low-grade malignant bone tumor** most commonly found in the tibia. - This tumor does not exhibit a fallen fragment sign; its radiographic features often include **lobulated osteolytic lesions** with a sclerotic rim. - It is a solid tumor without the fluid-filled cavity necessary for this sign.

Question 1

Which investigation is least effective in diagnosing acute osteomyelitis?

Accepted Answer

X-ray

Answer

Bone scan

Answer

MRI

Answer

CT scan

Question 2

Shenton's line is seen in X-ray of -

Accepted Answer

Antero-posterior pelvis with both hips

Answer

Antero-posterior shoulder

Answer

Lateral cervical spine

Answer

Lateral lumbosacral spine

Question 3

Which of the following is not a typical radiological finding in rheumatoid arthritis?

Accepted Answer

Subchondral sclerosis

Answer

Marginal erosion

Answer

Symmetrical involvement

Answer

Juxta-articular osteopenia

Question 4

Cotton wool skull is a radiological feature of which condition?

Accepted Answer

Paget's disease

Answer

Osteopetrosis

Answer

Eosinophilic granuloma

Answer

Fibrous dysplasia

Question 5

Tufting of the distal phalanx is characteristically seen in which of the following conditions?

Accepted Answer

Hyperparathyroidism

Answer

Hyperkalemia

Answer

Hypoparathyroidism

Answer

Gout

Question 6

Based on the X-ray image, which condition is indicated by a sunray appearance?

Accepted Answer

Osteosarcoma

Answer

Osteochondroma

Answer

Osteoclastoma

Answer

Chondroblastoma

Question 7

A 14-year-old boy presents with a 3-month history of dull aching pain in the distal tibia that is worse at night and not relieved by NSAIDs. He has a low-grade fever, and laboratory findings show an elevated ESR (68 mm/hr) and CRP (18 mg/L) with a mild leukocytosis. There is no history of trauma. Identify the condition based on the provided image of a bone lesion. Ensure the diagnosis is based on the radiological and clinical features provided.

Accepted Answer

Brodie abscess

Answer

Osteoid osteoma

Answer

Intracortical hemangioma

Answer

Chondromyxoid fibroma

Question 8

Investigation of choice for soft tissue sarcoma is -

Accepted Answer

MRI

Answer

CT

Answer

Ultrasound

Answer

X-ray

Question 9

What condition is best diagnosed using a Skyline view X-ray?

Accepted Answer

Patellofemoral problem

Answer

Tibiofibular problem

Answer

Skull fracture

Answer

Radioulnar problem

Question 10

What does the fallen fragment sign indicate in radiology?

Accepted Answer

Indicates a simple bone cyst

Answer

Indicates osteosarcoma

Answer

Indicates an aneurysmal bone cyst

Answer

Indicates adamantinoma

Musculoskeletal Radiology — MCQs

Musculoskeletal Radiology — MCQs

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