Download 1. 1991 - Bonepit.com

Bone Section
The following are True/False questions
1996
Concerning congenital hip dysplasia:
1. more common in females than males
2. acetabular angle is less than 30 degrees
3. following operative treatment, follow-up plain films are best in the PA projection
4. femoral head has delayed ossification
1??
2???
3???
4???
1996
bone scans
1. decreased blood flow and blood pool in area of a tarsal stress fracture
2. increased uptake on delayed imaged in region of a fracture
3. increased uptake on delayed images in the femoral head on a child
with known synovitis
4. ??
1??
2???
3???
4???
1996
25 yo male with history Ewings sarcoma 12 years ago presents with pelvic pain.
Differential possibilities include:
1. recurrent Ewings
2. osteosarcoma
3. insufficiency fracture
4. osteomyelitis
1??
2???
3???
4???
1994, 1992, 1988
Which two of the following are typical of Legg-Calve-Perthes?
1. delayed bone age
2. bilateral
3. average age 2-4 years old
4. early fragmentation of the epiphysis
5. usually takes 3 years to heal ???
6. rapid onset of pain
*
Legg-Calve-Perthes is osteonecrosis of the femoral head ossification center. It is
bilateral in only 10% of cases. The 2 hips are affected successively. If bilateral, think
about hypothyroidism, epiphyseal dysplasia, Gaucher’s, sickle cell, or steroids. There is
early fragmentation. It is most common in 4-8 year-olds. It is much more frequent in
boys and is rare among blacks. A history of trauma can be observed in approximately
25% of cases. Variable course in this disease. better prognosis in younger pt and boys..
Most pt are aSx 30-40 years later but persistent xray findings are usually evident.-- Group
IV.
Delayed skeletal maturation of person with this disease and higher reported
frequency of congenital anomalies suggest genetic and dev. factors.
Reference: Resnick 1994, pp. 980-985
*
Answer: 1. True 2. False
3. False
4. True
5. False?
6. True
1993 ITE
Regarding infectious arthritis and osteomyelitis:
7. destruction of the disc makes tuberculosis spondylitis a much more likely diagnosis
than pyogenic spondylitis
8. three-phase bone scanning can usually differentiate septic arthritis from periarticular
cellulitis
9. Staphylococcus aureus is the most common cause of acute osteomyelitis in patients
with sickle-cell anemia
10. septic arthritis is seen with increased incidence in patients with rheumatoid arthritis
11. the epiphysis is the most common site of osteomyelitis in the neonate
*
In osteomyelitis, the arterial route is believed to be the most common pathway of
inoculation.. Staphylococcus aureus is the most frequent pathogen to cause diskitis,
osteomyelitis, and epidural abscess. Diskitis and osteomyelitis are most common in the
lumbar spine. Tuberculous osteomyelitis (Pott disease) is characterized by late
preservation of the disc space, multilevel involvement, and a tendency to spread along the
anterior longitudinal ligament.
Reference: Atlas, pp. 1001-1007
Septic arthritis is common in RA and is usually secondary to Staph aureus. The
etiology is thought to be secondary to intrarticular injections, ulcerated RA skin nodule,
etc.
ref; Resnick, p 280
*
Answer: 7. False
8. True
9. true
10. true
11. False
1995
Regarding mallet finger:
12. involves the proximal interphalangeal joint
13. always involves a tendon or ligament tear
14. can involve an avulsion fracture of the distal phalanx
15. the extensor apparatus is disrupted
*
Mallet finger is flexion deformity at the distal interphalageal joint that is
associated with proximally retracted avulsion fx of the dorsum of the base of the distal
phalanx. Secondary to hyperflexion of the distal interphalangeal jt or forced
hyperextension. The flexion deformity results from the unopposed action of the intact
common flexor tendon that inserts on the volar aspect of the distal phalanx. Proximal
retraction of the fx means that extensor tendon is attached to the fragment.
ref:p.458,-63, Harris and harris
Answer: 12 false 13. false 14. true 15. true
1995, 1992
Fracture dislocations include:
16. Lisfranc (92)
17. Colles
(95, 92)
18. Bennett (92)
19. Chauffer (95, 92)
20. Barton (95, 92)
21. Galeazzi (95)
22. Monteggia (95)
*
The Lisfranc fracture is also a tarso-metatarsal dislocation.
Colles fracture is the most common fracture of the carpal region. It usually results
from a fall on an outstretched hand. The classic description is a fracture in the distal 2 cm
of the radius and dorsal displacement of the distal fracture fragment. There also may be
an ulnar styloid fracture.
Bennett’s fracture and dislocation is a non-comminuted fracture of the base of the
1st metacarpal with dislocation. Rolando’s fracture is a comminuted fracture dislocation
at the same location. The fragment follows the carpus.
The Chauffer fracture is a fracture of the distal radius secondary to acute
dorsiflexion and abduction of the hand. There is a triangular fracture of the radial styloid.
The Barton fracture is also secondary to fall on an outstretched hand. It is an
intrarticular oblique fracture of the dorsal lip of the distal radius with the carpus displaced
up and back with the distal fragment.
Reference: Dahnert 1993, pp. 49-51
Galeazzi fx-dislocation consists of a fx of the distal third of the radius and a
dislocation of the distal radioulnar jt.p.400
Monteggia fx-dislocation 4 types. Bado I- proximal ulnar fx, w/ volar angulation
at the fx site and volar dislocation of the prox radius. --60%. Bado II post angulation of
the ulnar fx . BADO III lateral or anterolateral dislocation of radial head and ulnar fx.
Bado IV - anterior disloc of radial head, fx of proximal third of radius, ulnar fx.
ref: Harris and Harris
*
Fracture dislocations include:
16. Lisfranc (92)
17. Colles
(95, 92)
18. Bennett (92)
19. Chauffer (95, 92)
20. Barton (95, 92)
21. Galeazzi (95)
22. Monteggia (95)
Answer: 16. True
17. False
18. True
19. False
20. false 21. true 22. true
1995, 1991
Regarding osteoid osteoma:
23. may induce a synovitis when intraarticular (95, 91)
24. blush of contrast on angiography (91)
25. it is most common in the metadiaphysis of long bones (91)
26. it shows the “double density” sign on nuclear medicine bone scan (91)
27. 5% undergo malignant degeneration (95)
28. in a young child may cause enlargement of the affected limb (95)
29. there is pooling of contrast within the nidus at angiography (95)
*
Osteoarthritis occurs with an intraarticular site in 50% of cases.
There is a highly vascularized nidus with intense circumscribed blush appearing in
early arterial phase and persisting late into the venous phase.
It occurs in the metadiaphyseal region of long bones in 73% and in the spine in
14% (most common in the posterior elements).
Reference: Dahnert 1993, pp. 80-81
In the immature skeleton, there can be significant abberations in bone growth,
muscle atrophy and skeletal deformity.
ref:p 1113 Resnick.
There is no malignant potential. The lesion is hot on scintigraphy even in blood
flow stage.
ref: AFIP 1995, FF-9
On Angio, oo has a hypervascular nidus with tumor staining but no
neovascularity.
Kadir p. 336 , Lateur,L: Skeletal Radiology 2:75-79, 1977
In Danhert, states that oo has a blush in the early arterial phase which persists into
late venous phase.
*
Answer: 23. True 24. True 25. True 26. True 27. false
28.true ?? 29.
???true
1995, 1991
Which of the following are not uncommonly present in a patient with long-standing renal
failure?
30. holes in carpal bones (95, 91)
31. cervical spine changes (91)
32. Brown tumors (91)
33. beta-globulin amyloid (95, 91)
34. spontaneous tendon rupture (95)
another one ???
*
Chemical analysis of the amyloid fibrils shows that they (those associated with
amyloidosis of hemodialysis) consist of monomers and dimers of beta-2-microglobulin,
the light chain of cell surface major histocompatibility antigens A, B, and C.
Reference: Cecil’s 1988, p. 1200
*
Answers: 30. True 31. True 32. True (although more common in primary
hyperparathyroidism) 33. True 34. true
1995
Regarding dorsiflexion intercalated instability:
35. widened scapholunate space
36. scaphoid appears horizontal on the lateral view
37. the lunate is tilted volarly
38. Kienbock’s malacia
39. there is proximal migration of the capitate
*
DISI is when the lunate is tilted dorsally, the scaphoid is flexed, and the
sapholunate angles is greater than 70 degrees. Commonly occurs after scapoid fx w/
scapholunate separation. The scaphoid is nearly horizontal on the lateral view. The
lunate is tilted toward the back of the hand.-- dorsal.
ref: 845-6 Resnick
Kienbock is osteochondrosis of the lunate which can lead to scapholunate
separation. The lunate is usually collapsed.
Answer: 35. prob true 36. true
prox migration...
37. false
38. false
39. ?? true-- minimal
1995
Regarding the skeletal mainfestations of sickle cell anemia:
40. H-shaped vertebral bodies can be present at birth
41. cortical splitting is the result of bone infarction
42. dactylitis most commonly occurs in adolescents
43. osteomyelitis is most common in the metadiaphysis
44. greater than 50% of patients demonstrate obliteration (???) of the paranasal sinuses
*
Sickle dactylitis occurs in children 6months to 2years and is osteonecrosis that
involves the tubular bones of the hands and feet.
Diaphyseal infarction is common. Extensive infarction is asociated with patchy
lucency and sclerosis of the medullary bone. The diaphysis my be broadened or enlarged
by the appearance and incorporation of subperiosteal new bone. On plain film this
appears initially as a linear rasiodense area adjacent to the cortex. This gives a bone
within a bone appearance. H-shape vertebral bodies are thought to be secondary to central
infarction.
Sickle cell rarely has its clinical onset until after age 6months because of
persistence of HbF.
Osteomyelitis usually affects to the long tubular bones. In generic osteo in kids, it
usually is at the metaphysis and the epiphysis is adults. Infection is Hbss, esp salmonella
can produce symmetric diaphyseal localization.
Resnick p 666-667
? Sickle Thal get obliteration of paranasal sinuses.
Answer: 40.false
41. ?false 42. false 43. true 44. ?false
1994, 1991
In a young boy with painful scoliosis, which of the following are likely causes? (1994
added dense pedicle on opposite side of scoliosis)
45. osteoid osteoma
46. pars defect
47. metastasis
48. eosinophilic granuloma
49. osteomyelitis
*
Child with a painful scoliosis and convexity away from a dense pedicle:
This description is "classic" for a posterior element (pars interarticularis) osteoid
osteoma. Acquired pars defect of the contralateral side, osteomyelitis, and EG are
differential possibilities. Osteoid osteoma has a scoliosis that is concave towards the
lesion, aka same side as the lesion.
Regarding pars interarticularis defect, most series demonstrate a male
predominance. Typically, spondylolysis is discovered in childhood or early adulthood.
The frequency of these defects rises precipitously between the ages of 5 and 7 years. The
cause of lumbar spondylolysis has long been debated; however, the current consensus
strongly supports an acquired traumatic lesion originating sometime between infancy and
early adult life. It seems probable that spondylolysis results most frequently from a
fatigue fracture occurring after repeated trauma rather than from an acute stress fracture
following a single traumatic episode. The appearance may simulate that of an osteoid
osteoma. Furthermore, similar hypertrophy occurs contralateral to a congenitally absent
pedicle, lamina, or articular facet.
(Order of likelihood: osteoid osteoma > pars defect > osteomyelitis > EG)
Reference: Resnick 1989, pp. 812-814
*
Answers: 45. True 46. True 47. False
1991
Regarding fractures of the carpal triquetrum:
50. occur along the dorsal surface
51. occur at the articulation with the capitate
52. occur along the ventral surface
53. are best seen on the PA view of the wrist
48. True
49. True
*
The scaphoid is the most frequently fractured carpal bone.
As for the triquetrum, it is the dorsal surface that is typically fractured. Since the
triquetrum is the most dorsal bone in the wrist, it makes sense that this fracture would be
best seen on lateral examination.
Reference: Resnick 1989, p. 848
*
Answer: 50. True 51. True (rare!) 52. False 53. False
1995
Regarding the physis in a child:
54. widened in cases of severe lead intoxication
55. obtains its blood supply from the same artery that supplies the metaphysis
56. most susceptible to trauma during periods of rapid growth
57. susceptible to infection???
*
Lead poisoning leads to thick dense bands in the metaphysis. Also metaphyseal
flaring or widening is seen. p 929 Resnick
The epiphyseal plate is involved in 6-15% of fx in long bones. More than 75% of
physeal fx occur between 10-16y.o.. Many of physeal injuries are atheletic related and
male predominant. most frequent sites include distal radius, distal tib, distal ulna, distal
fib, prox humerus. p 347 Kirks Slipped capital femoral epiphysis occurs during
adolescent growth spurt. Growth plate injuries about the ankle occur as the plate is
closing. Resnick p. 891
Tubular bones have diaphyseal arteries which are joined by the terminals of the
metaphyseal and epiphyseal arteries. In Children, capillaries on the metaphyseal side
have loops and join large sinusoidal veins. Epiphyseal blood supply is distinct.
Metaphyseal location of osteomyelitis is related to peculiar anatomy of the vascular tree
and the inablity of vessels to penetrate the plate. But atypical infection of the physis or
extending to the physis exist.
p. 731-32 Resnick
Answer: 54. true 55. false 56. true 57. not most common site but not impossible.-because of the blood flow , it is not as susceptible as the metaphysis.-- prob false. not as
susceptible to infection as metaphysis.
1995
Regarding rupture of the quadriceps tendon:
58. most commonly occurs soon after the femoral physis has fused
59. associated with hemarthosis of the knee joint
60. tendon degeneration or partial tear can appear as a thickened tendon on MR with
increased signal in the tendon
61. rupture commonly occurs in a tendon with preexisting degeneration
*
Tendon rupture can occur anywhere and is usually secondary to significant trauma
or associated with RA SLE, Local steroid injection. p 892Resnick Lipohemarthrosis can
also be seen in significant cartilaginous or ligamentous injury.
In Chronic renal disease, tendon rupture is secondary to decreased tendon tensile
strength and acclerated degeneration. After rupture, focal STS, effusion, subluxation.
AFIP notes CC-15.
Ligaments are stronger in children than the growth plate. Therefore more likely to
have a plate injury than tear a ligament. Kirks, trauma
ref; Resnick p 892, AFIP 1995, CC-15
Answer: 58. false
59. true
60. true
61. ?true
1992
Which of the following are prominent features of seronegative spondyloarthropathy?
62. periostitis
63. dental ???
64. significant osteoporosis
*
seronegative arthropathy includes ank spond, reiters and psoriasis. Hallmarks of
reiters and psoariasis include normal mineralization, periostitis, enthesitis, aggressive
erosions.. Ank Spond radiographic hallmarks include ankylosis, ligamental ossificiation,
ear- small erosions.
AFIP, 1995, Anne Brower
Answer: 62. true 63. ????
64. false
1993
First rib fracture is associated with:
65. thoracic outlet syndrome
66. Horner’s syndrome
67. absent radial pulse
68. brachial plexus injury
69. phrenic nerve injury
*
According to Harris and Harris, “Contrary to an opinion frequently cited in
surgical and radiographic literature, upper (thoracic inlet) rib fractures are not associated
with an increased incidence of aortic injury. In fact, Fisher et al., in a series of
approximately 200 patients, clearly demonstrated that there is no statistically significant
difference in the frequency of acute aorticobrachiocephalic injury between patients with
or without thoracic inlet rib fractures. However, because of the magnitude of the
causative force, upper rib fractures are commonly associated with pneumothorax or
hemothorax, subcutanous emphysema, pulmonary contusion, and scapular fractures.”
According to Resnick, “Fractures of the first or second rib indicate major trauma
to the thorax or shoulder. Associated abnormalities include rupture of the apex of the
lung or subclavian artery, aneurysm of the aortic arch, T-E fistula, pleurisy, hemothorax,
cardiac abnormalities, neurologic injury, and other fractures.”
The first rib is typically resected surgically in thoracic outlet syndrome.
No specific mention could be found regarding first rib fracture causing Horner’s
syndrome; however, a hematoma in this location could theoretically produce Horner’s
syndrome.
References: Resnick 1989, p. 838; Harris and Harris 1993, p. 493
*
Answer: 65. True
66. False (? see above)
67. True
68. True 69 False
1993
The ulnar carpal impingement syndrome is associated with:
70. neutral ulnar variance with lunate malacia
71. ulnar negative variance with lunate malacia
72. ulnar positive variance and an intact TFC
73.. ulnar positive variance and disruption of the lunatotriquetral ligament
74. positive ulnar variance with Kienbock’s
*
Ulnar carpal impingement syndrome is secondary to painful impaction of the
distal ulna on the medial surface of the lunate. It is seen with positive ulnar variance. It
is associated with TFC tears, lunatotriquetral ligament tears, and degeneration of the
lunate cartilage.
Mechanical forces across the lunate bone may be accentuated by the presence of a
short ulna (negative ulnar variance associated), a finding that can be encountered in as
many as 75% of cases of Kienbock’s disease.
References: Stoller, pp. 742-770; Resnick 1989, p. 986
*
Answer: 70. False
71. false
72. False
73. True 74. False
1993, 1991
Enlargement of the digits is seen in which of the following
75. neurofibromatosis
76. macrodystrophia lipomatosa
77. Mafucci’s syndrome
78. lipodermatoarthritis
79. Holt-Oram syndrome
*
Neurofibromatosis causes overgrowth of the ossification center.
Macrodystrophia lipomatosa is secondary to overgrowth of the fatty elements. It
is a subset of neural fibrolipomas (lipomatous hamartoma of a nerve) - it is usually in the
2nd or 3rd digit (median nerve distribution is most common). Growth of the digit stops at
puberty.
Mafucci’s syndrome consists of hemangiomas and enchondromas. It has a
unilateral predominance. Hemangiomas alone may result in an enlarged digit.
Holt-Oram syndrome consists of first ray abnormalities. The thumb may also
have three phalanges.
This question serves as a good differential diagnosis for localized gigantism.
Klippel-Trenaunay-Weber may also have local gigantism (it is associated with unilateral
cutaneous capillary hemangiomas, so you probably could put it in with hemangiomas - it
just sounds more impressive).
References: Dahnert 1993, pp. 66, 198; Resnick 1989, pp. 1031-1034, 1077; AFIP notes,
August 1994, p. KK9, bone section (Murphey); Ibid, p. J6, bone section (Kransdorf)
*
Answer: 75. True 76. True 77. True 78. False 79 False
1993, 1992, 1991
Inversion injury of the ankle is associated with:
80. deltoid ligament tear
81. tibiocalcaneal ligament tear
82. oblique fracture of the medial malleolus
83. spiral fracture of the fibula
84. fracture involving the base of the 5th metatarsal
*
Inversion injury of the ankle is associated with:
1) deltoid ligament tear (?)
2) oblique fracture of the medial malleolus
3) fracture of the base of the 5th metatarsal
4) fibular fractures are usually transverse
Eversion injuries may result in:
1) transverse fractures of the medial malleolus
2) spiral or transverse fibular fracture
3) deltoid ligament rupture
4) rupture of the tibiofibular syndesmosis
5) fracture of the posterior tibial margin
Reference: Resnick 1989, pp. 857-859
In inversion injuries, lateral ligament tears may also occur -- tibial-fibular,
calcaneal fibular ligaments.
*
Answer: 80. True 81. true 82. True 83. False 84. True
1991
Which of the following are true regarding pyknodysostosis?
85. there is absence of the greater cornu of the hyoid bone
86. there is acroosteolysis
87. there are small bowel polyps
*
Pyknodystostosis is autosomal recessive and is probably a variant of cleidocranial
dysostosis. It is twice as common in males. Patients have dwarfism (resembling
osteopetrosis), mental retardation (10%), dystrophic nails, widened hands and feet,
yellowish discoloration of teeth, and characteristic facies (beaked nose, receding jaw)
Radiographically, there is brachycephaly and platybasia, wide cranial sutures,
Wormian bones, a thick skull base, hypoplasia of the mandible, hypoplasia and
nonpneumotization of the paranasal sinuses, nonsegmentation of C1/2 and L5/S1,
generalized increased density of long bones with thickened cortices, clavicular dysplasia,
hypoplastic tapered terminal tufts, and multiple spontaneous fractures.
Reference: Dahnert 1993, p. 90
Get hypoplasia or osteolysis of the terminal tufts. p. 1048 Resnick
*
Answer: 85. False? 86. True 87 False
1994
Aggressive fibromatosis has the following characteristics:
88. variable appearance on MR sequences
89. ill-defined margins
90. common local recurrence after surgical excision
91. pulomonary metastases
*
Aggressive infantile fibromatosis appears as a painless soft tissue mass in the
extremity, usually during the first two years of life. The tumor rarely metastasizes;
however, it is locally aggressive, infiltrating into muscles, vessels, nerves, fasciae,
tendons, and subcutaneous fat. Histologic features make differentiation from
fibrosarcoma difficult, and the lesions tend to recur after surgery. The radiographs
demonstrate a soft tissue mass with occasional bone erosion.
Reference: Resnick 1994, p. 1187
*
Answers: 88. True 89. True 90. True 91. False
1994
Regarding bony manifestations of child abuse:
92. a greater proportion of the injuries occur on the child’s right side
93. metaphyseal fractures are common
94. rib fractures are seen at the costochondral junction
*
References: Resnick 1994, pp. 895-896; Dahnert 1993, pp. 29-30
Can get rib fractures either posteriorly from squeezing type injuries or can get
anterior rib fractures from anterior blunt injury. peds conf w/ Harty 9/25/96
*
Answers: 92. ??? prob false b/c most people are right handed leading to mostly left sided
injuries 93. True 94. True
“Psychiatry is the study of the id by the odd,” Salter of Salter-Harris fame.
1996, 1993
Concerning crystal deposition disease:
95. CPPD is weakly positive on birefringent light microscopy
96. Hydroxyapatite deposition disease crystals can only be seen by electron microscopy
97. Hydroxyapatite deposition (HADD) disease is usually at multiple sites
98. CPPD usually involves the wrists, hips, and the knee
*
CPPD is weakly positively birefringent on light microscopy. The crystals are
rhombic or odd-shaped. (Monosodium urate crystals from gout have negative
birefringence.)
HADD crystals are too small to be seen by light microscopy. they are best seen by
electron microscopy as needle-like crystals. (Clumps of crystals may be seen by light
microscopy with Wright’s stain.)
HADD most commonly affects the shoulder. It is usually monoarticular.
CPPD typically involves the wrists, hips, and the knee (predilection for the
patellofemoral compartment).
Diseases associated with CPPD include: (only these!)
1) primary hyperparathyroidism
2) hemochromatosis
3) old age
Reference: Resnick 1989, pp. 477-497
*
Answer: 95. True 96. True 97. False 98. True
1993
Types of injuries associated with seizures include:
99. bilateral posterior shoulder dislocation
100. radial head fracture
101. central fracture-dislocation of the hip
102. thoracic spine fracture
*
Answer: 99. True 100. False 101. False
102. False
1993
Findings in rickets include:
103. osteoporosis
104. widening of the physis
105. widened sutures in the skull
106. subperiosteal hemorrhage
*
Widening of the physis and widening of the skull sutures is secondary to increased
production of osteoid. Flattening anteriorly and posteriorly cause a square appearance
called craniotabes. The periosteum is elevated also secondary to increased osteoid.
There is osteomalacia, not osteoporosis. Other findings include a rachitic rosary, bowing
of the long bones, scoliosis, basilar invagination, and a triradiate pelvis.
References: Resnick 1989, pp. 591-593; AFIP Notes, August, 1994, pp. K5-K6
(Kransdorf)
*
Answer: 103. False 104. True 105. True 106. False
1991
Regarding a slipped capital epiphysis:
107. it causes epiphyseal plate trauma
108. usually occurs in 2-4 year-olds
109. the femoral head (epiphysis) slips inferoposteriorly
110. there is no evidence of remodeling with an acute slip
*
Slipped capital femoral epiphysis is an entity that affects males more often than
females and blacks more often than whites. The mean age is 13-14 y/o in males and 1112 y/o in females. Boys are more commonly affected than girls by a ratio of 2.5 to 1.
Overweight and physically active adolescents are at increased risk. The adolescent
growth spurt has been identified as the period of greatest risk, hence the coincidence in
the age ranges with puberty. Approximately 20-25% of patients, mostly girls, have
bilateral involvement. An underlying disorder or traumatic cause should be sought when
the diagnosis is made in an infant or young child. A fracture-separation (Salter I type
injury) occurs at the epiphyseal plate in relation to chronic stress. The most common
direction of slippage is for the femoral head to slip posteriorly, medially, and inferiorly
with respect to the femoral shaft. Complications include severe deformity of the femoral
neck and varus angulation, with osteonecrosis and osteoarthritis occurring as longer term
complications.
*
Answer: 107. True
108. False 109. True
110. True
1991
Fracture through the epiphyseal plate may cause:
111. early fusion
112. limb overgrowth
*
Salter Harris V, VI carry a poor prognosis leading to sequelae of growth
impairment, premature growth plate fusion, epiphyseal malformation or rotation,
osteonecrosis. Premature partial arrest with a resultant bone bar-- the remaining portion
of the physis that continues to grow results in angular deformity.
ref : Resnick p 887
Answer: 111. True
112. false
1996, 1994, 1992, 1990
The lateral collateral ligament complex includes:
113. iliotibial band
114. tendon of the biceps femoris
115. lateral meniscus
116. lateral head of the gastrocnemius
117. popliteus tendon
118. rectus femoris
*
Lateral collateral ligament complex consists of:
1. iliotibial band anteriorly which is the distal continuation of the tensor fascia
lata.
2. lateral collateral ligament which is a thickening of the lateral retinaculum.
3. biceps femoris tendon posteriorly.
Typically, a thin layer of fat is present between the collateral ligament and the
lateral meniscus.
Reference: Higgins, “MRI of the Body,” 1992, p. 1108
*
Answers: 113. True 114. True 115. False 116. False 117. False 118. False
1992
The axillary view of the shoulder is useful for:
119. fracture of the coracoid
120. AC joint separation
121. posterior fracture of the humeral head
122. determining the angulation of a humeral neck fracture
*
The axillary view is the only true lateral of the humerus and shoulder.
Axillary view should be considered in shoulder trauma. Only view which can ID
minmally diplaced fx of the coracoid process of the scapula, cortical fx of the ant/ post
surfaces of the humeral head, post dislocation of the humeral fx, direction of angulation
of the proximal humeral fx fragments.
p 285, Harris and Harris.
*
Answer: 119. True 120. False 121. True 122. True
1992
The Hill-Sachs defect:
123. is seen only after multiple dislocations
124. is associated with injury of the inferior labrum
125. is best seen on external rotation view
126. is caused by the superior labrum impacting on the humeral head
127. is on the posteromedial aspect of the humerus
*
The Hill-Sachs defect can occur after only one dislocation.
The associated injury of the inferior labrum is called the Bankhart deformity. It is
a tear of the anterior capsular complex including the main stabilizer, the inferior
glenohumeral ligament.
Since the defect is posterolateral, it is best seen on a view with the humerus in
internal rotation.
*
Answer: 123. False
124. True 125. False
126. False
127. False
1996, 1992
Advanced bone age is seen with:
128. hypothalamic tumor
129. ovarian tumor
130. Leydig cell tumor of the testis
131. Cushing’s
132. simple obesity
*
See table 4-9 p. 286 Kirks Cushings can have either advanced or delayed bone
age.
Answer: 128. True 129. True (especially if the tumor produces sex hormones)
130. True 131. True
132. True
1992
Ligaments that contribute to pelvic stability include:
133. posterior sacroiliac ligament
134. sacrospinous ligament
135. sacrotuberous ligament
136. symphyseal ligament
137. iliolumbar ligament
*
Reference: Resnick 1989, p. 866
*
Answer: 133. True 134. True 135. True 136. True (False???)
137. True
1992, 1990v
Which of the following statements are true?
138. in van Buchem’s disease, the new bone laid down at the cortex is primitive (woven)
bone
139. PVNS involves the sacroiliac joint
140. ossification of the posterior longitudinal ligament in the lumbar region is common in
ankylosing spondylitis
141. retinoic acid therapy can cause an appearance similar to DISH
*
Endosteal hyperostosis, also called van Buchem’s syndrome that is autosomal
recessive in which signs and symptoms occur at an earlier age than in the autosomal
dominant form (Worth’s syndrome). There is severe enlargement of the mandible and
frequent cranial nerve involvement, including facial nerve palsy and deafness. Affected
patients also have a prominent forehead and widened nasal bridge, and the serum level of
alkaline phosphatase may be elevated. Radiographic findings are endosteal thickening in
the cortex of tubular bones with encroachment on the medullary cavity. The bones are
not expanded, and abnormal modeling is not seen.
Dahnert does not list the SI joint among the 7 most common joints affected in
PVNS.
Patients with ankylosing spondylitis have marginal syndesmophyte formation
(“bamboo spine”). They also have ossification of the annulus fibrosis which may be
confused with ossification of the anterior longitudinal ligament. There is no association
with calcification/ossification of the posterior longitudinal ligament. Ossification of the
posterior longitudinal ligament is associated with DISH and Ossification of the
ligamentum flavum.p 452, Resnick
References: Resnick 1989, p. 1049; Dahnert 1993, pp. 27, 87-88
*
Answer: 138. False???
139. False
140. False
141. True
1992, 1990v
Regarding dialysis-associated bone changes:
142. perfect biochemical control limits sclerosis
143. an elevated calcium phosphate product is associated with soft tissue calcification
144. fractures of radiographically normal bone can result from incorporation of aluminum
145. are associated with spondyloarthropathy
*
In the vast majority of patients with chronic renal failure who are placed on
maintenance hemodialysis, many of the bone changes of renal osteodystrophy resolve
provided that the hemodialysis is of adequate quality and duration.
Soft tissue calcification in patients with chronic renal failure occurs when
multiplication of the respective concentrations (in mg/dl) of plasma calcium and plasma
phosphorous produces a value greater than 70.
It is now generally believed that the primary cause of the progression of skeletal
abnormalities in patients on chronic regular hemodialysis is osteomalacia attributable to
aluminum intoxication.
Reference: Resnick 1989, pp. 642-643
*
Answer: 142. True
143. True
144. False
145. True
1996, 1994
Regarding Chance fractures:
146. they are most common at T12
147. they commonly involve the posterior elements
148. they have a 10% incidence of association with seat belt injury (??small bowel
injuries??)
149. they are secondary to hyperextension injury
150. they usually are secondary to falls from heights
*
Chance fractures:
Commonly at the thoracolumber junction (T12-L2), involves the posterior
elements, but can involve the middle and anterior "columns" with anterior wedging of
associated vertebral bodies, hyperflexion injuries used to be commonly associated with
the use of "lapbelt" safety belts, however, with the use of shoulder harnesses, they are
now probably more commonly associated with falls from a height.
While Dahnert indicates the location is L2 or L3, both Resnick and Duke Review
of Radiology merely say “upper lumbar spine.” Nevertheless, this would make it unlikely
that T12 is the most common location. Also called “seat-beat injuries,” they are
characterized by failure of the posterior and middle spinal columns under tension forces
and, potentially, failure of the anterior column under compression. Although they may be
associated with a fall from a height, the more classic finding is a burst fracture.
References: Review of Radiology (Duke-Ravin) 1994, p. 124; Resnick 1989, pp. 879880; Dahnert 1989, p. 129
*
Answers: 146. False 147. True 148. prob.True 149. False
150. False
1994
Which of the following are associated with posttraumatic collapse of the vertebral body
and subsequent gibbus deformity?
151. progressive sclerosis of the vertebral body
152. involvement of the intervertebral disc
153. osteophyte formation
154. periarticular demineralization
155. neural arch affected
*
Post-traumatic vertebral collapse:
Kummel's disease ("Joey Kummel owns a bakery on Second Ave" - Joshua Hirsh
to J. Bruce Kneeland at Stump the Stars in 1993. I'll always remember this entity thanks
to the Hirshey Bar). Can occur even following mild trauma to vertebral bodies in older
people and can be a late sequella (years!). Usually at the thoracolumbar junction with
early osteoporotic change followed by late sclerosis. Intravertebral vacuum phenomenon
and vertebral collapse with preservation of the disc.
Do they mean Calve-Kummel-Verneuil disease? It sounds similar to regular ole’
Kummel’s disease except it occurs in 2-15 year-olds. The answers are the same.
Reference: Dahnert 1993, pp. 32, 130
*
Answers: 151. True 152. False 153. False?
154. True
155. False
1991
Epiphyseal overgrowth is seen in:
156. JRA
157. hemochromatosis
*
Most pt with hemochromatosis become symptomatic between the ages of 40 and
60 y.o. Bone findings include osteporosis, articular calicification, arthropathy. p 510-511
In JRA, epiphyseal enlargement owing to accelerated growth stimulated by
hyperemia is frequent. p 292
ref: Resnick p 510-55, 292
Answer: 156. true
157. false
1991
Which of the following are present in rheumatoid arthritis?
158. cranial base settling
159. odontoid erosions
160. multilevel subluxations
*
Early changes in RA = soft tissue swelling, periarticular osteoporosis, joint space
narrowing, and marginal osseous erosions (initially located in the bare areas).
Late changes in RA = fibrous ankylosis, subluxations, “rice bodies” (detached
fibrotic synovial villi)
Spontaneous tendon ruptures (Achilles, rotator cuff, infrapatellar, among others)
are a known manifestation of rheumatoid arthritis.
The most frequent soft tissue lesion in RA is the subcutaneous nodule (seen in
20% of patients with RA). These nodules rarely calcify.
Synovial cysts are a well-known manifestation of RA - they usually occur in the
popliteal region.
Reference: Dahnert 1993, pp. 92-94
Verticle subluxation can occur in RA , aka cranial settling/atlantoaxial impaction.
Synovial inflammation and hyperemia leads to relaxation of the transverse ligament. Can
see erosions along the odontoid process.--14-35%. Subluxation and dislocation can occur
at multiple levels in pt with RA.
ref : Resnick, p 278
*
Answers: 158. true 159. true 160. True
1995 ITE
Concerning joint dislocations:
161. perilunate dislocation is more common than lunate dislocation in the wrist
162. interphalangeal joint dislocation of a finger is the most common traumatic
dislocation in children
163. the femur is in adduction with posterior hip dislocation
164. subtalar dislocations occur from extreme dorsiflexion of the foot
165. arterial injury is a more common complication of elbow dislocation than of knee
dislocation.
*
Perilunate dislocations account for 75% of wrist subluxations. They are usually
associated with a transscaphoid fracture. Barton’s fracture is fracture of the dorsal rim of
the radius with dislocation of the carpus. (AFIP notes, 8/11/94)
Posterior dislocations of the hip are the most common type.
In posterior hip dislocations, the hip is adducted. The femoral head is dislocated
posteriorly and laterally. Occurs in a MVAp 790
Subtalar dislocation is rare and accounts for less than 1% of dislocations. Can
dislocate the subtalar bones medially or laterally. p 1013
Knee dislocation are rare but are limb threatening because of vascular disruption
in the popliteal space. Injury to the popliteal vessels and nerves and hamstring muscles is
common.
Dislocation of the elbow is only second most common to dislocations of the
shoulder. Most common dislocation is posteriorly. (??Not usually associated with
arterial compromise) Dislocations of the shoulder are rare in children.
.
*
Answer: 161. True 162. ?false
163. true 164.?false
165.false
1995 ITE
Causes of radiodense metaphyseal lines include:
166. hypervitaminoses
167. transplacental infections
168. treated leukemia
169. Paget’s disease
170. fluorosis
*
Although it wasn’t a choice, scurvy is also a cause of dense metaphyseal bands.
Other findings of scurvy: ring epiphysis (=?), lucent metaphyseal bands, metaphyseal
beaks, periostitis, and subepiphyseal infractions. Radiographic features include:
1) Wimberger’s Ring
2) Pelkin’s Spur
3) Frankel’s Line
4) Trummerfeld’s Zone
5) Osteopenia
Causes of dense metaphyseal lines include--p 930, table 67-1
heavy metal poisoning
healing stages of rickets, leukemia, scurvy
hypothyroid,
hypoparathyroid
hypervitaminosis D
transplacental infections TORCH
stress lines of Park or Harris
Flourosis involves the axial skeleton with osteosclerotic changes. In the appendicular
skeleton, there are finding of periosteal thickening, ligamentous calcification,
excrescences. p918-19
ref: Resnick p 930, 918
Answer: 166. true 167. true 168. true 169. false
170. false
1995 ITE
Features useful for differentiating a benign lipoma from a malignant liposarcoma include:
171. size
172. irregular margins
173. homogeneity of the lesion
174. intramuscular location
175. demonstration of bone within the lesion
*
Liposarcoma is a malignant mesenchymal tumor. It is the second most common
soft tissue tumor after malignant fibrous histiocytoma and usually presents at 40-60 y/o.
It is most common in the thigh, gluteal region, retroperitoneum, and leg. They rarely (if
at all) arise from preexisitng lipomas. Well-differentiated liposarcomas can occasionally
contain calcification or ossification. The myxoid variety is most common (40-50%).
Lipomas can occur intramuscularly.
Reference: AFIP Notes, August, 1994 pp. J9-J10 (Kransdorf)
In Danhert, liposarc are discribed as inhomogeneous mass with soft tissue and
fatty components, with + enhancement.
*
Answer: 171. False
172. ??? false -- benign usually has regular margins. 173. true
174. False
175. False
1995 ITE
Concerning arthritis:
176. osteoporosis is a feature of robust (cystic) rheumatoid arthritis
177. psoriatic arthritis is characterized by central erosions
178. whiskering periosteal reaction is most commonly indicative of a seronegative
spondyloarthropathy
179. gout causes concentric joint space narrowing
180. large subchondral cysts are a manifestation of pyrophosphate arthropathy
*
Robust (cystic) rheumatoid arthritis is an uncommon variant of rheumatoid
arthritis which is seronegative in 50%. Increased pressure in the synovial space forms a
joint effusion which decompresses through microfractures of weakened marginal cortex
into subarticular bone (i.e., large radiolucent cystic areas are commonly seen). This also
seems to be more common in patients who have maintained a high level of activity.
There is a relative lack of cartilage loss, osteoporosis, and joint disruption.
Characteristics of Gout:
1) negative birefringence
2) monosodium urate
3) overhanging edges (secondary to periarticular (marginal) erosions)
4) no osteopenia
5) most common in 1st metatarsalphalangeal joint
6) the joint space is relatively well-preserved
Characteristics of Pseudogout
1) weak positive birefringence
2) secondary to CPPD (calcium pyrophosphate dihydrate)
3) chondrocalcinosis: knee > symphysis pubis > TFC
4) associated with hemochromatosis and hyperparathyroidism
Reference: Dahnert 1993, pp. 92-93
Psoriatic arthritis is characterized by marginal erosions initially. As the disease
progresses, the erosions can extend centrally. p 321, Resnick.
Bone production-- enthesitis, periostitis, ankylosis, is seen in
spondyloarthopathies such as Reiters, Psoriasis, Ank Spond., which are seronegative
spondyloarthropathies. Brower pJ-1 1995 AFIP
CPPD is characterized radiographically : OA, Normal mineralization, uniform
loss of jt space, large subchondral cysts, bone colllapse, fragmentation. AFIP p. L-2,
Brower 1995
ref: AFIP Brower 1995: p L-2, J-1, Resnick p 321
*
Answer: 176. False 177. false 178. true 179. False
180. true
1995 ITE
Concerning primary bone tumors:
181. Ewing’s sarcoma metastasizes to bone more commonly than osteosarcoma
182. calcification of an osteosarcoma during chemotherapy indicates a positive response
(>90% tumor necrosis)
183. the pelvis is the most common site of primary chondrosarcomas
184. malignant fibrous histiocytoma is the most common malignant bone tumor after age
50
185. ossified soft tissue masses are a recognized manifestation of recurrent giant cell
tumors
*
Ewing’s sarcoma is a highly malignant primary bone sarcoma, probably derived
from primitive neural tissue. It is one of the small cell sarcomas of bone in children (the
others being non-Hodgkin’s Lymphoma, metastatic neuroblastoma, or embryonal
rhabdomyosarcoma). In contrast to osteosarcoma, it develops in the axial skeleton in a
large proportion of patients (40%), but it is most common in the femur (25%), followed
by the pelvis (20%), the ribs (11%), and the humerus (8%). 75% of patients are 10-25
y/o. Pain and swelling are the most common symptoms. Histology is characterized by
sheets of “round cells.” 44% are in the metadiaphysis and 33% are in the diaphysis.
About 20-30% present with metastases - 85% to lungs, 69% to bones, 46% to pleura,
12% to CNS.
Intramedullary chondrosarcoma, which is the most common type of primary
chondrosarcoma (the others being periosteal/juxtacortical, clear cell (2%), mesenchymal
(<10%), myxoid (12%), dedifferentiated (10-20%), and extraskeletal), is most commonly
found in the pelvis (30%). The femur is a close second with 25%. Some of the less
common types of primary chondrosarcoma do not have the pelvis as the most common
site, however.
Malignant fibrous histiocytoma carcinoma can be an osseous or soft tissue tumor.
It is the most common adult soft tissue sarcoma. The most common malignant bone
tumor after age 50 is myeloma. Malignant fibrous histiocytoma is most common around
the knee (40-80%). Also, if you see cortical erosion with a soft tissue tumor, think
malignant fibrous histiocytoma or synovial cell sarcoma.
About 90% of cases of osteosarcoma arise in the long bones of the extremities.
10-20% of patients have clinically detectable metastases at time of diagnosis. Peak
incidence occurs during adolescence. Osteosarcoma mets can appear as calcified or
ossified lesions. p 1122 Resnick. In Danhert, states that osteosarcoma mets to bone are
uncommon unlike Ewings. Mets are usually to lung, LN, liver, brain. p 85 2nd ed.
In AFIP notes (7/25/94, Bone, p. HH-5), the appearance of soft tissue recurrence
of giant cell tumor is “mass and calcification” (not ossification!).
References: AFIP notes, 8/94, Kransdorf, pp. E1-E3 and Murphey, pp. HH1-HH5,
Danhert 2nd ed, p 85
*
Answer: 181. true 182. false 183. True (see above)
184. False
185. False?
1995 ITE
Paralysis may lead to which of the following findings?
186. cartilage atrophy
187. periostitis
188. osteonecrosis
189. osteomyelitis
190. heterotopic ossification
*
AFIP notes indicate that heterotopic ossification can be found in paraplegics (even
in areas with no history of trauma). (August, 1994, p. JJ19, bone section)
Musculoskeletal abnormalities in paralysis is listed in table 68-1 p; 932 Resnick
as : osteoporosis, soft tissue atrophy/hypertrophy, osseous deformities, growth
disturbances, stress fragmentation of bone, epipyseal and metaphyseal fx or fragmentation
of bone, infection, heterotopic ossification, cartilage atrophy, synovitis, abnormalites of
the joint capsule, reflex sympathetic dystrophy syndrome.
*
Answer: 186. true 187. true-- in infection 188. ??? false
189. True
190. True
1994
Which of the following can cause delayed healing of fractures?
191. dicoumeral
192. corticosteroids
193. colchicine
194. diphosphonates
*
Drugs involved in delayed union of fractures:
steroids are definitely yes!
Search of the 1995 PDR did not list delayed union of fractures as a complication
or side effect with dicoumeral.
Diphosphonates inhibit bone resorption and formation by interfering with calcium
phosphate crystal formation and dissolution. They decrease the rate of formation and
activity of osteoclasts.
p893 DE6
*
Answers: 191. False
192. True 193. ??? 194. true
1994
Regarding a tear of the anterior cruciate ligament:
195. there is poor visualization of the anterior cruciate
196. it is associated with lateral contusion of the femoral condyle
197. there is posterolateral contusion of the tibial plateau
198. there is anteromedial contusion of the tibial plateau
199. medial meniscal tear
*
Signs of ACL tear:
True - poor visualization of the ACL, contusion of the lateral femoral condyle and
posterolateral contusion of the tibial plateau.
Note: anteromedial contusion of the tibial plateau is not a secondary sign of ACL
tear.
Whenever an abnormality of the anterior cruciate ligament is observed, it is
always important to carefully examine the menisci because accompanying meniscal tears
are frequently encountered
Reference: MRI of the Body, Higgins 1992, p. 1106
*
Answers: 195. True 196. True 197. True 198. False
199. True
1994
Regarding stress fractures:
200. known scan abnormality reverts to normal within four months
201. shin splints are within the spectrum of the disease
202. it is clinically indistinguishable from osteoid osteoma
203. calcaneus is the most common location
*
Stress fractures:
Clinically may suspect from osteoid osteoma since pain pattern is different.
Shin splints are tugging of the tendinous insertions at the periostium and on
delayed bone scan involve at least 1/3 of the cortical length without focality as in stress
fractures (Dave Mozely's Israeli army story). Scan abnormality reverts back to normal in
several months if activity is ceased.
Stress fracture is a continum of early periosteal reaction to overt fx. If the process
is allowed to continue to overt fx, several months are required for healing vs. weeks for
just stress reaction.
For general non-displaced fx, the time it takes for scintigraphy to return to normal
is 60-80% in1 year, 95% in 3 years. There are many documented instances where fx
remain positive indefinitely.
ref: Nuc Med: the Requisites p 109, 111
References: Dahnert 1993, p. 48; Resnick 1989, pp. 808-813
*
Answers: 200. false 201. False?
202. False 203. False
1994 ITE
Features associated with an enostosis (bone island) include:
204. aligned perpendicular to the long axis of bone
205. peripheral radiating bone spicules
206. normal radionuclide bone scan in >75% of patients
207. protruding from cortical surface
208. histologically normal bone
*
Are aligned with the long axis of the bone, have radiating spicules, and do not
protrude from the cortical surface. Scintigraphy usually yields normal results.
Histologically are normal appearing compact bone.
ref: Resnick, p 1233
Answer: 204. false- parallel 205. True 206. true 207. False 208. True
1994 ITE
The following are associated with uniform loss of articular cartilage:
209. paralyzed extremity
210. treated slipped capital femoral epiphysis
211. tuberculosis
212. pigmented villonodular synovitis
213. radiation therapy
*
The classic radiographic appearance of tuberculous arthritis is Phemister’s triad,
which consists of juxtaarticular osteoporosis, gradual joint space narrowing, and
peripheral erosions.
p. 932 Cartilage atrophy is associated with paralysis.
The sequelae of SCFE includes varus deformity, shortening and broadening of the
fem neck, osteonecrosis, chondrolysis, DJD. Chondrolysis of unknown cause. Xrays
demonstrate osteopenia, concentric narrowing to the joint space. Some recovery of the jt
space is seen after several months in 1/3 of cases.. p887-888.
p. 906. Articular cartilage is radioresistant. Severe cartilaginous destruction can
occasionally be seen with jt space narrowing. This may be secondary to subchondral
collapse leading to DJD or may be direct affect of XRT.
PVNS causes enlarged synovial cavity. p. 174 Jt space is preserved until late in
the disease ref: handbook in skel. rad-- Manaster
ref: Resnick p932, 906, 887-8, Manaster p 174
*
Answer: 209. true 210. true 211. True
212. False 213. true
1994 ITE
Concerning anterior dislocation of the sternoclavicular joint:
214. it is more common than a posterior dislocation
215. the involved clavicle lies superior to the contralateral clavicle
216. associated disruption of the great vessels occurs in about 20% of cases
217. it is associated with a concomitant injury to the shoulder
218. it is optimally evaluated by CT
Posterior dislocation of the left sternoclavicular jt is clinically important b/c of
the proximity to the lt innominate v. The most accurate dx is with CT. ?? The involved
clavicle can lie inferior to the normal clavicle in posterior sternoclavicular dislocation. -as in fig 8.47 , p501 Harris and Harris. The mechanism for sternoclavicular dislocation is
from indirect trauma applied the the posterolateral shoulder or direct anterior chest wall
injury.
ref: Harris and Harris p 498-500.
(Sternoclavicular disloc is rare and is usually posterior. The costoclavicular
ligament causes the medial end of the clavicle to be levered posteriorly. -- according to
Harris and Harris) In Resnick-- Anterior dislocations predominate over posterior.p. 833.
p 225Manaster. Disloc may be ant or posterior but in either case the clavicle
moves superiorly slightly. Anterior is more common than posterior. Sternoclavicular jt
dislocation IS a shoulder injury
ref: Manaster. Handbooks in Skeletal Rad.
ref: Harris and harris references-- Cope, R- Skeletal Radiology 1988:17:247-50, and
Nettles, JL- J Trama 1968;8:158-64
*
Answer: 214. true 215. ???true 216. False
217. true
218. True
1994 ITE
Concerning septic arthritis:
219. intravenous drug abusers have a higher incidence of involvement of the
sternoclavicular joint than do non-abusers
220. the underlying bone is infected about 10% of the time
221. ultrasonography can reliably distinguish between a sterile and a pyogenic joint
222. radionuclide bone scans show increased epiphyseal activity in the affected joint
223. aspiration is best accomplished with an 18-gauge or larger needle
*
Scintigraphy demonstrates increased uptake on dynamic scans without increased
interossesus uptake on the static scans. On the delayed images there may be diffuse
uptake in the adjacent bones if there is soft-tissue infection. Complications of septic
arthritis include dislocation, epipyseal separation, jt destruction, osteomyelitis, jt capsule
contracture. p 329-230 Kirks
Answer: 219. True
220. ???true
221. False
222. ???
223. True
1994 ITE, 1992 ITE
Diseases associated with overtubulation of long bones include:
224. osteogenesis imperfecta
225. Gaucher’s disease
226. cerebral palsy
227. lead poisoning
228. juvenile chronic arthritis
*
Overtubulation is related to failure of periosteal depositon of bone as in
osteogenesis imperfecta. Get narrow diaphysis and wider metaphysis. and epiphysis.
Undertubulation is seen in bone dysplasias and certain anemias and storage
diseases. Get metaphyseal enlargement e.g. Gaucher's p. 20 Resnick. Also see in
osteopetrosis b/c no bone resorption.
Lead poisoning can get widening of the metaphysis giving an Erlenmyer flask
deformity.
In JRA, growth disturbance is manifested by epiphyseal enlargement secondary to
hyperemia. Overgrowth is further accentuated by adjacent constricted appearance of the
metaphysis and diaphysis.
Premature physeal closure can become evident in other neuromuscualr diseases
and may be associated with epiphyseal overgrowth resembling JRA or hemophilia.p 934
ref: Resnick
Answer: 224. true
225. false
226. ???true
227. False
228. True
1993 ITE
The metacarpophalangeal joints are frequently involved in:
229. erosive osteoarthritis
230. hemochromatosis
231. gout
232. Wilson’s disease
233. acromegaly
Gout involves these jt in decreasing frequency, 1st MTP/IP jt, toes, metatarsaltarsal, ankle, hands, metacarpal=carpal jt, elbow, other.
Hemochromatosis is associated with CPPD which involves the MCP jts, wrist at
radio-carpal, patello-fem, and hip.
Erosive OA has the same distribution as OA -- DIP. And PIP with rare
involvement more proximally unless the peripheral jts are severly involved.
AFIP, Brower, 1995
Wilson's disease does cause an arthropathy which has been reported to have
subchondral bone fragmentation ( possibly secondary to spasticity), cortical irregularity
and sclerosis in the hand, wrist, foot ,hip ,shoulder, elbow and knee in have of the persons
with the disease. Fragmentation can be seen in the MCP, IP, wrist jts. Articular
alterations are rare in children but may be seen in as many as 50% of adults. p 515
Resnick.
Acromegaly in the hand reveals soft tissue thickening, thickening and squaring of
the phalanges and metacarpals, overtubulation and overconstriction of the shafts of the
phalanges. Accelerated degenerative changes are seen in the same distribution as OA.
The joint space is thickened in acromegaly. >2.5mm Thickeness of the jt space of the
MCP is a measurement suggestive of acromegaly. p. 618
*
Answer: 229. false 230. true 231. ??? frequently? false-- usually the feet 232. true
233. true
1993 ITE, 1990
Regarding the reflex sympathetic dystrophy syndrome:
234. a characteristic distribution is the foot and ankle
235. preservation of articular cartilage is characteristic
236. bone scintigraphy is normal
237. the process is usually bilateral
238. soft tissue swelling usually accompanies the osseous alterations
*
The diagnosis of reflex sympathetic dystrophy (also called Sudeck atrophy) relies
not only on the clinical evaluation but also on the radiographic examination. Soft tissue
swelling and regional osteoporosis are the most important roentgenographic findings.
Fine detail radiography has revealed five types of bone resorption: resorption of
cancellous or trabecular bone in the metaphyseal region leads to band-like, patchy, or
periarticular osteoporosis; subperiosteal bone resorption is similar to that occurring in
cases of hyperparathyroidism (findings that support the concept that parathyroid hormone
is fundamental in mediating the resorptive changes in this syndrome); intracortical bone
resorption produces excessive striation or “tunneling” in cortices; endosteal bone
resorption, which is the region of greatest bone mineral loss in this condition, causes
initial excavation and scalloping of the endosteal surface, with subsequent uniform
remodeling of the endosteum and widening of the medullary canal; and subchondral and
juxtaarticular erosion which may lead to small periarticular erosions and intra-articular
gaps in the subchondral bone. Because of the widespread nature and severity of bone
resorption in RSDS, the radiographs may reveal rapid and severe osteopenia, particularly
in periarticular regions, which simulates the appearance of primary articular disorders.
The absence of significant intra-articular erosions and joint space loss usually allows
accurate differentiation of RSDS from these various arthritides. The preservation of joint
space cannot be overemphasized as a characteristic finding in this syndrome, although
articular space loss and focal bony ankylosis have been noted in some cases, presumably
owing to immobilization.
Bone and joint scintigraphy also demonstrate typical abnormalities in RSDS,
which may antedate clinical and radiographic changes. Joint imaging with Tc-99mpertechnetate revels increased radionuclide accumulation in articular regions.
The process is usually bilateral, although involvement of one side is often more
prominent.
Answer: 234. True
235. True
236. False
237. True
238. True
1993 ITE
Concerning pigmented villonodular synovitis:
239. it is a premalignant condition
240. there is usually diffuse loss of cartilage
241. the ankle is the joint usually affected
242. it is the most common cause of lytic (“cystic”) lesions on both sides of a joint
243. calcifications occur in 30% of cases
*
Osseous erosion is uncommon 10-15%-- erosion is smooth and undulating. (Can
get cystic lytic lesions on both sides of the joint in DJD, RA) Etiology of PVNS
unknown. Has giant cells, fibrous tissue, xanthoma cells. There are two types diffuse (
15-25%) and localized (75-85%) The localized form-- 80% are in the finger and 12% in
the knee. Treatment is usually surgical resection. Recurrence rate is 10-20% in local
form and 40-50% in diffuse. Pathologically the same as giant cell tumor of the tendon
sheath.
ref: AFIP jj5-6, Murphey 1995
Can get very rarely calcific metaplasia. Cartilage loss is seen late in the disease. p
175 Manaker.-- Handbook.
Answer: 239. False
OA 243. false
240. false
241. False
242. False - most commonly geodes in
1993 ITE
Regarding osteoid osteoma:
244. malignant transformation occurs in approximately 2% of cases
245. multifocal involvement occurs in approximately 5% of cases
246. in the spine, involvement is predominantly in the vertebral body
247. intraarticular involvement gives rise to a lymphoproliferative synovitis
248. in the spine, patients present with painful scoliosis
*
Osteoid osteoma may present as a monoarticular arthritis with an inflammatory
synovitis.. In the spine, the lumbar region is most common (59%), followed by the
cervical spine (27%).
No malignant transformation. AFIP p FF9 Murphey 1995 Multifocality is not
mentioned in the AFIP notes.
*
Answer: 244.false 245. ???
246. False
247. True
248. True
1993 ITE
The following usually have low-signal-intensity synovial masses on both T1 and T2
weighted spin-echo MR images:
249. inactive (“burned out”) rheumatoid arthritis
250. septic arthritis
251. hemophilic arthropathy
252. pigmented villonodular synovitis
253. synovial chondromatosis
*
Chronic synovitis in RA is intermediate signal on T1 and T2 because there is less
edema and more fibrosis.
Infection results in an inflammed synovium. It's intermediate T1 and high T2.
ref: Bergman, p 265-280 MRI Clinics may 1995
Hemophilia has synovial inflammation and pannus formation. There is
hyperemia. p. 716 Resnick. In the MRI clinics article, these same findings were in acute
RA which has intermediate T1 and high T2. Get articular hemmorage. As a result of
absorption of hemosiderin, get synovial inflammation and edema. Get hemosiderin laden
synovial hypertrophy. p 717 Resnick.
Synovial chondromatosis is cartilage formation through metaplasia of synovial
membrane. The is varying degrees of mineralization. High signal is related to water
content in hyaline cartilage p. 333 Clinics and p. 1186 Resnick. Low signal is secondary
to the calcification. Calcification is commonly demonstrated in synovial
osteochondromatosis.
ref: MRI Clinics May 1995, p 333, 265-80, Resnick, p717, 1186
Answer: 249. false 250. false 251. false 252. True (AFIP Notes, August, 1994)
?true
1995 my own
Which of the following are causes of disc space calcification?
254. CPPD
255. acromegaly
256. neurofibromatosis
257. hemochromatosis
258. hyperparathyroidism
*
The differential diagnosis for calcification of the disc spaces:
1) acromegaly
2) ochronosis (hydroxyapatite?)
3) hemochromatosis
4) CPPD
5) neuropathic
*
Answer: 254. True 255. True 256. False 257. True 258. False
1992 ITE
253.
Which of the following are associated with intra-articular cartilaginous and/or osseous
loose bodies?
259. synovial metaplasia
260. neuropathic joints
261. trauma
262. pigmented villonodular synovitis
263. degenerative joint disease
*
Causes of neuropathic joint: syringomyelia, diabetes mellitus, leprosy,
neurosyphilis, myelomeningocele, spinal cord injury, congenital insensitivity to pain.
"joint mice" are seen in OA. Thes represent osteocartilaginous bodies which arise
from transchondral fx, disintegration of articular surface and synovial metaplasia. This
can occur in many disease processes such as OA. p. 390 Resnick.
*
Answer: 259. true 260. True 261. True 262. True 263. true
1992 ITE
Regarding avulsion fractures about the pelvis and hips:
264. avulsions of the lesser trochanter are usually pathologic fractures
265. the rectus femoris attaches to the greater trochanter
266. the gluteus muscles have tendinous attachments to the ischial tuberosities
267. healing avulsion fractures may resemble a primary bone tumor radiographically and
histologically
268. the sartorius muscle attaches to the anterior superior iliac spine
*
Fractures of the lesser trochanter almost never occur by direct trauma but are the
result of avulsion forces (by contraction of the iliopsoas). They are not pathologic
fractures, however.
The gluteus medius and minimus attach to the greater trochanter. Iliopsoas m
attaches to the lesser trochanter.
ref: p 56 Schwartz, Language of Fx
Answer: 264. False
265. False
266. False
267. True
268. True
1992 ITE
Which of the following lesions may be associated with radiographic features of a central
area of sclerosis surrounded by lucency?
269. osteoid osteoma
270. eosinophilic granuloma
271. intraosseous lipoma
272. chronic osteomyelitis
273. melanoma metastatic to bone
*
Eosinophilic granuloma is a subtype of Langerhans cell histiocytosis (histiocytosis
X). About 90% of patients present by age 15 with a mean age of 11. The flat bones are
affected in 70% of cases, especially the skull, mandible and maxilla, spine, pelvis, and
ribs. When the spine is affected, the vertebral body is involved most frequently, with
sparing of the posterior elements and intervertebral disc space. The radiographic
appearance is variable, ranging from a simple skull lesion (soft-tisue density by CT) that
has a “beveled-edge” appearance to a markedly destructive lesion. Sometimes the degree
of periosteal reaction and soft-tissue extension is so great that it is difficult to differentiate
from osteomyelitis or a Ewing tumor.
In an intraosseous lipoma, can have osteolytic area with surrounding sclerosis and
a central calcified nidus. p 1154-55 Resnick.
Differentiation of active and chronic osteo on xray is difficult . Have areas of
osteolysis and osteosclerosis. Osteonecrosis can occur-- bone sequestrum which is
radiodense.
In osteoid osteoma, there is usually a radiolucent nidus surrounded by sclerosis.
The nidus can have varying degrees of calcification-- usually complete/partial
calcification in oo of the carpal bones. p. 1108-9 Resnick
Melanoma usually has osteolytic lesions.. p 1202 Resnick
*
Answer: 269. True
270. False
271. true
272. True
273. ???false
1992 ITE
A wide symphysis pubis is associated with:
274. cleidocranial dysostosis
275. extrophy of the bladder
276. Ehlers-Danlos syndrome
277. hyperparathyroidism
278. Paget’s disease
*
Ehler's-Danlos is a disease of hyperlax ligaments, skin fragility, bleeding
diathesis. Radiographic findings include calcification of fatty spherules in subcutaneous
lesions, jt effusions, dislocations and subluxations. Ligamentous laxity results in pes
planus deformites and abnormalities of the axial skeleton. p. 1019 Resnick
Cleidocranial dysplasia is autosomal dominant with high penetrance. xray
findings include poor skull ossificiation with wormian bones, deformed foramen
magnum, partial clavicular abscence, hypoplastic scapula, bell shaped thorax, delay of
ossificiation of pelvic bones, wide symphysis pubis and narrow iliac wings. Can get coxa
vara or valga(more frequent). Hands have small distal phalanges. p 1041-3
Answer: 274. true 275. True
276. ???true
277. True
278. False
1992 ITE
Which of the following characteristics are more typical of juvenile chronic arthritis than
adult onset rheumatoid arthritis?
279. synovial cysts
280. periostitis
281. bone erosions
282. joint ankylosis
283. joint space loss
*
Table 23-3 p 291 compares JRA with RA. Jt space loss and bone erosion are
early manifestations in RA and late in JRA. Jt space abnormalities is less frequent in JRA
than RA. Intraarticular bone ankylosis and periostitis are common in JRA and rare in
Adult RA. Synovial cysts are uncommon in JRA and common in RA.
ref: Resnick
Answer: 279. false
280. true 281. false
282. true 283. false
1989
Regarding a Segund fracture:
284. fracture of the proximal fibula
285. represents avulsion fracture of the insertion of the tensor fascia lata (iliotibial band)
c. ???
*
Segund’s fracture is a fracture of the margin of the lateral tibial condyle and
represents an avulsion fracture of the bony insertion of the tensor fascia lata (iliotibial
band). The significance of the lesion rests in its differential diagnosis, from an avulsion
fracture of the tip of the proximal fibula.
*
Answer: 284. False 285. True
1990
Regarding the wrist:
286. Kienboch fracture is associated with ulnar negative variance
287. the articular surface of the distal radius is oriented dorsally
288. the radial styloid process extends more distally than the ulnar styloid process
289. the lateral film is the best to diagnosis triquetral fracture
*
Kienboch’s fracture is osteonecrosis of the lunate. It is associated with ulnar
negative variance. TFC tears are associated with ulnar positive variance.
The articular surface of the radius has a 15-25 degree volar tilt. This is referred to
as “palmar inclination.”
The radial styloid process extends more distally than the ulnar styloid process.
Triquetral fractures are dorsal chip fractures and are best seen on lateral
examination.
*
Answer: 286. True 287. False 288. True 289. True
1992, 1990
Regarding post-menopausal osteoporosis:
290. there is elevated serum alkaline phosphatase
291. there is elevated serum calcium
292. there is more resorption of horizontal trabecular bone than vertical trabecular bone
293. there is more resorption of cancellous trabeculae than of compact bone
294. there is fibrous replacement of medullary bone
*
Individual trabecula are thinned and some are lost in osteopenia. The changes are
more prominent in the horizontal trabecula than in the vertical. This leads to vertical
radiodense striations (“bars”) which may simulate a hemangioma.
There is accelerated and disproportionate loss of trabecular bone in
postmenopausal osteoporosis.
Although serum calcium is not elevated, 25% have increased urinary calcium.
The alkaline phosphatase level is normal unless there also is a fracture.
Other causes of osteoporosis include catabolic steroids, hyperthyroidism,
alcoholism, plasma cell myeloma, and less, often, pregnancy, heparin therapy (greater
than 15,000 units per day), hyperparathyroidism, and acromegaly.
Compact bone is the cortex and cancellous/spongy bone is the trabeculae.p21. In
post menopausal women, compact and spongy bone is lost. The magnitude of loss of
compact bone in women is greater than men. p 570 Resnick
Osteoporosis is basically increased resorption and decreased formation.
Resorption is at the corticoendosteal surface with enlargement of the medullary cavity.
There is also resorption of cancellous bone. Histologically. the bone is normal matrix
and mineral content. p 1325 Robbins
*
Answer: 290. False 291. False 292. True 293. True ? false-- same rate 294. False
1990
Which of the following are common responses of the physis to injury?
295. metaphyseal cupping
296. increased growth
297. early fusion
298. slipping of epiphysis
299. bridging of epiphysis and metaphysis
*
Cupping of the metaphysis can be seen in rickets, trauma, bone dysplasia, scurvy,
trauma, infection, post-radiation, immobilization, vitamin A poisoning, sickle cell
anemia, and hereditary bone disorders.
*
Answer: 295. True 296. False 297. True 298. True 299. True
1995
Regarding Paget’s disease:
300. It is more common in the Scandanavian population
301. malignant degeneration is most common in the mandible
302. commonly causes secondary osteoarthritis of the hip
303. osteomalacic fractures are on the convex (tensile) side of the bone
304. diaphyseal Paget’s most commonly involves the tibia
*
Pagets affects 3% of the population over 40y.o. It appears to particulary common
in inhabitants of Australia, Great Britain, areas of continental Europe. Rare amongst
Chinese.
Degenerative jt disease is reported in Paget's usually most common in the hip and
knee. In the hip ,degeneration depends on if the femur or pelvis is involved. More
frequently get superior jt space narrowing but can also get medial narrowing.
Fractures are usually prominent in the lower extremity. Appear as multiple
horizontal radiolucent areas with prediliction for the convex side of the bone( lat aspect of
the femoral neck and shaft, anterior tibia).
malignant degeneration is fewer than 1% of pt with pagets. The most frequent
bones involved include femur, pelvis, and the humerus, but any bone can be involved.
Diaphyseal involvement is rare but may be observed particularly in the tibia. p
609
ref: pagets p 603-14
Answer: 300. true 301. false
endhere
302. true
303. true 304. true
Bone
Select the single best answer:
1996
Fracture of the medial facet of the patella is secondary to:
a. lateral patellar dislocation
b. quadraceps tendon avulsion
c. avulsion of the patellar tendon
d. lateral collateral ligament complex avulsion
Answer:??
1996
The most common type of tarsal coalition is:
a. calcaneal navicular at the posterior subtalar joint
b. calcaneal navicular at the medial subtalar joint
c. talonavicular at the posterior subtalar joint
d. talonavicular at the medial subtalar joint
e. calcaneocuboid at the posterior subtalar joint
Answer: ??
1996
A woman comes in with ulnar pain primarily with ulnar deviation. On a plain radiograph,
cytic lesions are seen within the ulna, lunate, triquetium. The best diagnosis is:
a. ulnar impaction syndrome
b. SLE
c. lunatotriquetial ligament tear
d. TFC tear
Answer:???
1996
Enlargement of the humeral head in a pt with hemophilia is due to :
a. inflammation
b. hemmorrhage
c. hyperemia
d. ??
Answer:???
1995
1. Which of the following is the most likely reason for failure of a total knee arthroplasty?
a. loosening of the tibial component
b.patellar component failure
c. PCL tear
d. stress shielding of the femur
e. osteomyelitis
Loosening and or infection are the most common complication in hip and knee
arthroplasty. They are difficult to differentiate. Occurs 7-10% of the TKA. Infection is
the major long term complication. AA 4-6. AFIP 1995. Murphey
complications of TKA include: intraop or p-op fx, stress fx, patellar dislocation or
locking, instability, dislocation or subluxation, migration of a wire, loosening or
infection, implant fx, heterotopic bone formation, p-op synovial cyst, patellar pain and
degenerative changes. table 20-3 p 238 Resnick
Answer: e
1996, 1995, 1994
2. Which muscle of the rotator cuff inserts on the lesser tuberosity?
a. supraspinatus
b. infraspinatus
c. teres minor
d. subscapularis
*
Concerning the rotator cuff insertions:
subscapularis - lesser tuberosity
supraspinatus, infraspinatus, teres minor - greater tuberosity
*
Answer: d. subscapularis
1995
3. A 53 y/o woman presents with a 3 month history of mild sacral and moderate pubic
pain. She had radiation treatment for cervical cancer 8 years ago but otherwise is healthy.
Plain film reveals sight widening of the symphysis pubis and a lesion with ill-defined
borders in the left ischium. Which of the following is the most likely diagnosis?
a. radiation-induced necrosis
b. low grade osteomyelitis, tuberculosis excluded
c. metastases from cervical carcinoma
d. metastases from an unknown carcinoma
Radiation necrosis is secondary to XRT affecting the osteoblasts. Can get
immediate or delayed cell death, injury with recovery, arrest of cell division, abnormal
repair, neoplasia. Radiation osteitis refers to osseous abnormalities including cessation of
growth, periostitis, bone sclerosis, increased fragility, ischemic necrosis, infection. Fx
heal normally.
Pelvis p-XRT can have fx as early as 5 months p- therapy. In Resnick, examples
of fx are seen 9mos, 4 and 6 years p-XRT.
ref: Resnick p 908
Answer: prob a-- could it be c?
1996, 1995, 1993
4. What is the most likely cause in a middle-aged woman with a painful flat foot with
minimal periosteal reaction at the medial malleolus on plain film and no clinical signs of
infection?
a. plantar fasciitis
b. tarsal tunnel syndrome
c. rupture of the posterior tibial tendon
d. spastic peroneal flat foot
e. none of the above
*
Chronic tears occur in women over 40 y/o.
Plantar fasciitis produces medial pain.
Tarsal tunnel syndrome produces plantar pain and parathesias secondary to
compression of the posterior tibial nerve (by tumors, fibrosis, tarsal coalitions, etc.).
The posterior tibial tendon is the principal inverter of the foot. It also functions as
a sling which helps maintain the longitudinal arch of the foot through its broad insertion
onto the plantar aspect of the navicular, medial, and intermediate cuneiforms, as well as
onto the second through fourth metatarsal bases. Rupture of the posterior tibial tendon
classically occurs in women over the age of 50 who present with an acute painful flatfoot
deformity which progressively worsens. Patients with rheumatoid arthritis are especially
prone to rupture. The treatment of choice is surgery, because conservative measures
usually provide no benefit. Unrecognized posterior tibial tendon rupture results in
progressive flatfoot and debilitating degenerative changes that may require subtalar joint
arthrodesis.
Reference: Higgins, “MRI of the Body,” 1992, p. 1192
*
Answer: c. rupture of the posterior tibial tendon
1995
5. Which one of the following structures travels through the carpal tunnel?
a. ulnar nerve
b. tendon of the flexor pollicis longus
c. tendon of the flexor carpi radialis
d. tendon of the flexor carpi ulnaris
*
Contents of the carpal tunnel include; median nerve, eight tendons of the flexor
digitorum superficialis and profundus, tendon of the flexor pollicis longus muscle.
The flexor carpi radialis travels in its own retinaculum carved into the trapezium.
The neurovascular bundle( ulnar n and artery) travels in a more superficial canal(Guyon's
canal) bounded by the flexor retinaculum, pisiform, and superficial layer. Flexor carpi
ulnaris adjacent to ulnar nerve medially.
ref: MRI Clinics: Hand and Wrist May 1995, Prendergast p. 203-4
Answer: b
1995
6. What is the most likely cause of death in a patient with a closed pelvic ring fracture?
a. hemorrhage
b. pulmonary embolism
c. sepsis
d. fat embolism
*
Hemorrhage into the extraperitoneal perivesical space is the major cause of death
associated with pelvic ring disruption itself or in conjunction with other injuries or
sources of hemorrhage.
p. 762 Harris and Harris
Answer: a. hemorrhage
1995
7. Regarding serial examination of the spine in a patient with scoliosis, which one of the
following is true?
a. AP examination so the vertebra have less distortion and angles can be measured more
accurately
b. PA examination in order to minimize radiation dose to the breast
c. AP examination in order to minimize magnification
d. PA examination in order to decrease the dose to the gonads
*
Initial radiologic exam should be limited to one to confirm the abnormal spinal
curvature, estimate magnitude and location, and congenital anomalies.
The entire spine is examined in the erect position with the pt standing w/o shoes.
Lateral film is needed to ID kyphosis. Gonadal shielding is used in all pt. Need to reduce
radiation as much as possible. For routine use, PA films are done to minimize radiation
to the breast. Measurement uncertainty is in the range of 3-4 degrees. Radiography
repeated at less than 3-4months may not be reliable because of the uncertainty range.
p 1066 Resnick
Answer: b.
1995
8. A patient has had significant trauma and has prevertebral soft tissue swelling on lateral
examination of the cervical spine, evidence of central cord syndrome, and facial trauma.
Which of the following is the most likely cause?
a. odontoid fracture
b. atlantooccipital disassociation (????)
c. C1 fracture
d. hyperextension injury
e. hangman’s fracture
Diagnosis of Hyperextension dislocation is based on constellation of clinical and
radiographic signs. Clinically, the pt should have facial trauma(not mandibular or
cranial), acute central cervial spinal cord syndrome- upper exremity paresthesia to
complete permanent quadriplegia or paraplegia.
p 187 Harris and Harris
answer: d.
1995
9. Which of the following is most commonly affected by posttraumatic osteolysis?
a. iliac bone
b. carpal scaphoid
c. femoral head
d. posterior rib
e. clavicle
*
Post traumatic osteolysis commonly occurs at distal clavicle, pubic and ischial
rami(trauma or frequently, chronic stress on an osteopenic skeleton) , and also noted in
the distal ulna, distal radius, carpus, femoral neck. Post traumatic osteolysis of the
clavicle may be secondary to acute or repeated trauma which can be very minor.
Post traumatic osteolysis can be evident particularly at the distal clavicle, pubic and
ischial rami, and femoral neck.
p 1252 Resnick
Answer: e
1994
10. Popliteal artery rupture is not associated with:
a. supracondylar femur fracture
b. dislocation of the knee
c. tibial plateau fracture
d. patellar dislocation
e. proximal tibial fracture
*
Popliteal artery damage occurs in:
1. dislocation of the knee
2. proximal tibial fracture ("T or V" , bumper fracture)
3. p 853 Resnick. A supracondylar fx can be like a knee
dislocation if the distal fx fragment is displaced.
Answer: d. patellar dislocation
1995
11. A patient with a history of epilepsy refuses to move his right arm. What would be the
most likely radiologic finding?
a. frozen shoulder
b. anterior shoulder dislocation
c. posterior shoulder dislocation
d. clavicle fracture
e. anterior sternoclavicular dislocation
*
Most cases of posterior dislocation result from convulsions. p 830 Resnick.
Answer: c .
1994, 1992
12. Which of the following is false regarding the growth plate:
a. impervious to infection
b. most susceptible to trauma during rapid growth
c. fed by the same arterial supplies as the metaphysis
d. widened with lead heavy metal poisoning
*
Growth plate is:
- resistant to but not impervious to infection
- very susceptible to trauma during rapid growth (ie "SCFE time" - early teenage
years)
- I believe fed by same arterial supply as the epiphysis? see mini Resnick p 884,
Fig 62-149. Growth disturbance can be noted in disruption of the blood supply to
the physis as stated on p 882. In a child, the metaphysis and the epiphysis have
distinct vascular sources. p. 729
- Metaphysis is widened in heavy metal poisoning as in Pyle's disease “Ehrlenmeyer flask" deformity.
Also see similar question in True/False section
*
Answer: a. impervious to infection
1993
13. A sternal fracture is most commonly associated with:
a. flail chest
b. cardiac contusion
*
The usual mechanism leading to fractures or dislocations of the sternum is direct
trauma, and associated injuries of the anterior portion of the ribs and costocartilages are
common. Aortic, tracheal, cardiac, and pulmonary injuries represent serious
complications of direct sternal trauma.
Clinically, the significance of sternal fracture lies in the 25-45% mortality rate,
which results not from the fracture per se but from associated injuries within the chest,
such as myocardial or pulmonary contusion or traumatic rupture of the diaphragm or a
mainstem bronchus. There is a 75% incidence of head trauma associated with sternal
fracture caused by MVA. The essential radiograph necessary to establish the diagnosis of
sternal injury is the lateral projection.
Reference: Harris and Harris 1993, pp. 491-498; Resnick 1989, p. 869
*
Answer b. cardiac contusion???
1993, 1989
14. The most common abnormal test in Paget’s disease is:
a. elevated urine hydroxyproline
b. elevated serum acid phosphatase
c. elevated urine ethyl phenylamine
d. hypercalcemia
e. hyperphosphatemia
f. elevated serum alkaline phosphatase
*
Elevated urine and serum hydroxyproline (increased bone resorption) and serum
alkaline phosphatase (increased bone formation) is seen in Paget’s. Serum calcium, phos,
acid phos are normal.
References: Dahnert 1993, pp. 86-87; Resnick 1989, p. 603
*
Answer: a. elevated urine hydroxyproline or f. elevated serum alkaline phosphatase
1992
15. The best way to diagnose dislocation of the proximal femoral epiphysis in an infant
is:
a. CT
b. conventional tomography
c. nuclear medicine scan
d. PA and frog leg lateral
e. arthrogram
*
Of the choices given, arthrogram is the best choice (because the epiphyseal
ossification center may not yet be seen). However, in 1995 at most institutions MR is the
study of choice.
*
Answer: e. arthrogram (see above)
1992
16. The best view for assessing vertical diastasis of the sacroiliac joint is:
a. posterior oblique
b. inlet
c. outlet
d. AP
*
An outlet view is an AP view with 35-40 degrees of cephalic angulation.
Reference: Rogers, Radiology of Skeletal Trauma
*
Answer: c. outlet
1996, 1994, 1992
17. Which of the following comprise the pes anserinus?
a. sartorius, gracilis, rectus femoris
b. sartorius, gracilis, semitendinosus
c. sartorius, semitendinosus, semimembranosis
d. gracilus, semitendinosus, semimembranosus
*
Answer: b. sartorius, gracilus, semitendinosus
1993
18. A young man fractured his clavicle 8 days ago now presents with atrophy of the
deltoid muscle and loss of sensation of the shoulder. Which of the following nerves is
most likely injured? (This was also listed as a man with history of anterior shoulder
dislocation.)
a. musculocutaneous nerve
b. axillary nerve
c. ulnar nerve
d. median nerve
*
Axillary nerve damage (C5-C6) causes atrophy of the deltoid muscle. This can
occur with fracture of the clavicle, anterior dislocation of the shoulder, and may occur
with fracture of the surgical neck of the humerus. The lateral arm (C5) should also have a
patch of numbness proximally (basically, overlying the middle third of the deltoid - take
it from uncle Scott) in axillary nerve injury.
The coracobrachialis is supplied by the musculocutaneous nerve (C5-C6).
The radial nerve lies in the bicipital groove and this may be injured with proximal
humeral fracture.
References: Hoppenfield, “Physical Examination of the Spine and Extremities,” 1976, pp.
19-31; personal experience!
*
Answer: b. axillary nerve
1993
19. Contusion of the posterolateral tibia plateau and lateral femoral condyle is associated
with:
a. anterior cruciate ligament tear
b. PCL tear
c. tear of the lateral meniscus
d. tear of the medial meniscus
e. medial collateral ligament injury
f. lateral collateral ligament injury
*
Tear of the ACL is typically associated with contusion and/or occult fracture of
the lateral femoral condyle and of the posterolateral tibial plateau.
Collateral ligament tears may also produce contralateral bone injury.
Medial meniscal tears are associated with contusion of the lateral femoral
condyle.
References: Radiology 183: 835-838, 1992; Langer, et al, Rad. Clinics, Vol. 28, No. 5,
Sept. 1990.
*
Answer: a. anterior cruciate ligament tear
1993
20. Clinical history of a 20 y/o black man with hepatomegaly, diarrhea, and peripheral
edema. Dense bones are identified on X-ray: What is the most likely diagnosis?
A. lymphoma
B. mastocytosis
C. carcinoid
D. Gardner’s syndrome
*
Mastocytosis is a systemic disease with mast cell proliferation in the skin and
reticuloendothelial system (lamina propria of small bowel, bone, lymph nodes, liver,
spleen) associated with eosinophilia and lymphocytosis. Patients are often less than 6
months old when diagnosed (in 50%). Patients have nausea, vomiting, diarrhea
(steatorrhea), urticaria pigmentosa, abdominal pain, alcohol intolerance, and evidence of
histamine liberation. Small bowel exam shows a diffuse pattern of 2-3 mm sandlike
mucosal nodules. The liver and spleen are enlarged and there are sclerotic bone lesions
(in 70%). It is associated with leukemia.
Gardner syndrome is an autosomal dominant syndrome characterized by:
(1) osteomas (usually in head)
(2) soft tissue tumors, and
(3) colonic polyps (adenomatous)
See question 1 of the GI section for a more complete discussion.
Primary lymphoma of bone is usually a lytic lesion
Reference: Dahnert 1993, pp. 51, 67, 512, 525-526
*
Answer: b. mastocytosis
1993, 1992
21. The fracture most associated with a neurological defect:
a. fracture of the anterior and posterior arches of C1
b. fracture of the lateral masses of C1
c. fracture of the posterior elements of C2
d. clay shoveler’s fracture
e. fracture of the odontoid.
f. fracture of the lamina of C3
*
Fracture of the lamina of C3 is most likely to result in neurologic injury.
Fractures of C1 and C2 are relatively “infrequently” complicated by neurologic injury,
secondary to increased diameter of the canal at these levels.
This question was asked in a different manner on other tests. In those, atlantooccipital dislocation was the most common to cause neurologic deficit (it is almost
universally fatal! Luckily it is quite rare.).
Again, C1-2 injuries are unlikely to have acute neurologic sequela.
Type II fracture of the odontoid is associated with nonunion.
Reference: Resnick 1989, pp. 871-875
*
Answer: f. fracture of the lamina of C3
1992
22. Which of the following is the most likely cause of a vascular-appearing skin lesion
with lytic lesion in the forearm (+/- soft tissue swelling) in a homosexual male with
AIDS?
a. Kaposi’s Sarcoma
b. lymphoma
c. osteomyelitis
d. bacillary angiomatosis
*
Kaposi's consists of capillaries and fibrosarcoma-like cells. Cutaneous nodules
are present and can invade underlying bone. fig 85-17
ref: Resnick 1270
Answer: a
1992
23. What is the source of a bone fragment in the joint space in a relocated elbow?
a. radial head
b. coronoid
c. trochlea
d. capitellum
e. olecranon
f. medial epicondyle
*
Reference: Review of Radiology (Duke-Ravin) 1994, p. 126
depending on the magnitude and direction of the dislocation, posterior dilocation
may be associated with fx of the distal humerus, or coronoid process of the ulna. p 344
Harris and Harris.
In adults, the injury may be complicated by coronoid process fx or radial head fx.
In children or adolescents, the medial epicondylar ossicification center is frequently
avulsed and may become entraped during reduction. Complication include median and
ulnar n and brachial artery injury. p 838-40 Resnick
Answer: f. medial epicondyle in a child
b. in an adult.
1992
24. A bone chip is seen just lateral to the lateral tibial plateau. The injury is likely to the:
a. lateral collateral ligament
b. popliteus tendon
c. ACL
d. PCL
e. menisci
*
Segund fracture. Lateral collateral ligament complex includes the tensor fascia
lata, lateral collateral ligament- fibular collateral ligament, biceps femoris. Segund is
lateral capsular tear and associated with anterior cruciate tear and tibial bruise. It is an
avulsion fx of the tensor fasia lata. Lateral collateral attaches antero-laterally in Girdie's
tubercle which can create avulsion fx but NOT Segund.
ref: 7/12/95 Bone conference
*
Answer: c
1992
25. Numerous low signal masses are seen in the joint space and synovium on T1weighted images - they are lower in signal on gradient echo and T2-weighted images.
What is the diagnosis?
a. RA
b. hemophilia
c. PVNS
d. chondrosarcoma
*
High signal from highly vascular pannus in RA may be difficult to separate from
an effusion.
Hemosiderin-laden pannus in PVNS gets dark on gradient echo and T2.
Reference: MRI of the Body, Higgiins, 1992, pp. 1113-1114
*
Answer: c. PVNS
1993
26. What is the most likely diagnosis in an older woman with end-stage renal disease on
dialysis with radiographic findings including cervical subluxation and multiple carpal
erosions and carpal tunnel syndrome?
a. amyloid
b. crystal deposition disease
c. tenosynovitis
d. radial nerve injury
e. radial artery thrombosis
*
Radiographic findings of amyloid include: osteoporosis, lytic lesions, pathologic
fracture, osteonecrosis, soft tissue nodules and swelling, subchondral cysts and erosions,
neuroarthropathy, and joint subluxations and contractures. Amyloid deposition is a cause
of carpal tunnel syndrome. Other causes = PRAGMATIC (Pregnancy, Rheumatoid
arthritis, Amyloid, Gout, Myxedema, Acromegaly, Trauma, Idiopathic, Collagen vascular
disease)
Reference: Resnick 1989, pp. 683-684
Amyloidosis is associated with carpal tunnel syndrome and multiple carpal
erosions. Cervical spondyloarthropathy secondary to chronic renal disease is thought to
be secondary to amyloid.
ref: AFIP CC13-14
*
Answer: a. amyloid
1993
27. Which one of the following is true with regards to MR findings in spinal discitis?
a. bright disc and bright end-plate on T1
b. bright disc and bright end-plate on T2
c. susceptibility artifact involving the disc
d. bright end-plate and dark disc on T2
e. dark disc and dark end-plate on T2
*
You can also see loss of margin between the disc and the end-plate. In the acute
stage, the disc may appear expanded.
Reference: Atlas pp. 1001-1003
*
Answer: b. bright disc and bright end-plate on T2
1993
28. In a child with congenital hip dislocation, all of the below are true except:
a. there is dysplasia of the acetabulum
b. ultrasound is not useful in evaluating the neonate after one year of age
c. the dislocation is in the anterosuperior direction
d. it is more common in a first born child with oligohydramnios
e. there is a low risk of AVN
*
Sonography offers several advantages over other imaging techniques, particularly
in the first 6 months of life. The ability to see the femoral head and acetabulum when
they are composed of cartilage is a clear advantage. The multiplanar capability of
ultrasound is also useful. Finally, changes in hip position can be observed on a dynamic
basis.
The objective of dynamic hip assessment is to determine the following:
1. The position of the femoral head at rest in the neutral position and while
flexed with abduction/adduction.
2. The stability of the hip with motion and stress.
3. The development of the hip components. A deformed labrum becomes
echogenic.
the Barlow test determines if a hip can be dislocated - the hip is flexed and
adducted then pushed posteriorly. The Ortolani test is the reverse - the flexed hip is
abducted and the examiner feels the dislocated hip returning to the acetabulum.
Ultrasound is not useful after the age of one year because of shadowing secondary
to increased ossification.
Dislocations are superior, but lateral or posterior, not anterior. The acetabulum is
shallow.
CDH is more common in first borns, females (unlike slipped capital femoral
epiphysis), whites, breech delivery, or abnormal uterine position (such as that caused by
oligohydramnios). For whatever reason, the left side is more commonly affected. CDH
is believed to be related to high levels of maternal hormones which produce ligamentous
laxity in the infant.
The risk of AVN is >50% only after therapy and immobilization.
References: Resnick 1989, pp. 1000-1012; Rumack; Duke Review Manual
*
Answer: c. the dislocation is in the anterosuperior direction
1993 c PreTest
29. Anomalies of the radius are associated with ALL the following except:
a. Fanconi anemia
b. imperforate anus
c. duodenal atresia
d. thrombocytopenia
e. none of the above
*
Radial ray abnormalities, which include the thumb, occur as part of the Holt-Oram
and TAR (thrombocytopenia absent radius) syndromes, Fanconi anemia, Cornelia de
Lange syndrome, and trisomies 13 and 18. They are also part of the VACTERL
association (“L” is for limb anomalies) and frequently occur in conjunction with
imperforate anus.
Down syndrome (trisomy 21) is associated with duodenal atresia but usually does
not have an anomaly of the radius. Clinodactyly (widened space between the first two
digits of the hands and feet) is seen in 50% of patients with Down syndrome. There may
also be pseudoepiphyses of the 1st and 2nd metacarpals.
Reference: Dahnert 1993, pp. 40-41
*
Answer: c. duodenal atresia
1991
30. Which of the following views/modalities is best used to image sternoclavicular
dislocation?
a. CT
b. AP CXR
c. 40 degree cranial angulation
d. lateral CXR
*
Sternoclavicular joint injuries represent only about 2-3% of all shoulder
dislocations and result from direct or indirect force of great magnitude. Anterior
dislocations predominate over posterior (retrosternal) dislocations.
Although the Hobbs view (a superoinferior projection of the sternoclavicular
joint) is undoubtedlt helpful, CT is no doubt the best.
Reference: Resnick 1994, pp. 50, 833
*
Answer: a. CT
1992
31. The anterior compartment syndrome is most commonly seen following:
a. simple fracture of the tibia
b. open fracture
c. complex comminuted fracture
d. wide angulation of fracture fragments
e. high velocity injury with fractures of tibia and fibula
*
Reference: Emergency Orthopedics, p. 351
*
Answer: a. simple fracture of the tibia
1996, 1994
32. A pregnant woman is in the third trimester of pregnancy. She develops excruciating
debilitating hip pain with decreased range of motion. A hip film reveals osteopenia
without evidence of cortical destruction. What is the most likely diagnosis?
a. chondrolysis of pregnancy
b. osteoporosis
c. AVN
d. stress fracture
e. osteomyelitis
*
Pregnant patient in third trimester with hip pain/ decreased range of motion
and osteopenia:
Classic for transient osteoporosis of the hip. This entity was described in a middle
age male but also occurs commonly in pregnant females in the third trimester. It
causes pain, decreased range of motion and shows osteopenia diffusely in the
femoral neck/head and edema (hyperintense signal on T2 weighted images). It
resolves spontaneously in 6-9 months, although the Dick sez the Austrians core
them with instant relief of pain, though some question the long term sequella of
coring. AVN is in the differential diagnosis and is suspicious in "post-partum"
women after amniotic fluid emboli or DIC from puerperal sepsis. Stress fractures
tend to have calcar buttressing and sclerosis, though early I guess could appear
normal, though likely not osteoporotic. In osteomyelitis, one would expect
cortical destruction and joint space loss, though early on there may be osteopenia.
*
Answer: b. transient osteoporosis
1991
33. The displacement of a fat pad near which one of the following is not a harbinger of
underlying trauma?
a. pronator quadratus
b. iliopsoas
c. obturator internus
*
The pronator quadratus and its fat pad, when displaced in a volar direction,
indicates a subtle fracture of the distal radius or ulna.
Figure 10.7 p 699 in Harris, demonstrates prominence of the obturator internus m.
aponeurosis which suggests subperiosteal hemorrhage suggesting a superior ramus fx.
Fig. 10.8 Demonstrates the iliopsoas m shadow at the insertion on the lesser
trochanter. When the hip joint capsule is expanded by fluid or pus, the iliopsoas shadow
and gluteus min shadow become indistinct. p 700.
ref : Harris and Harris
*
Answer: ???
1994
34. The hip fracture which is most likely to result in AVN is:
a. intratrochanteric fracture
b. femoral shaft fracture
c. subcapital fracture
d. subtrochanteric fracture
*
Subcapital hip fractures are at greatest risk for AVN. The closer to the femoral head,
the greater the risk for AVN.(intracapsular)
ref: p 793 Harris and Harris
*
Answer: c. subcapital fracture
1996, 1994
35. Which of the following is most closely associated with volar plate avulsion fractures?
a. hyperextension
b. DIP
c. associated with volar dislocation
d. best seen on the AP view
*
Volar plate avulsion facture: according to Resnick only the MCP and PIP joints have
true "volar" plates at the base of the phalanges, not the DIP. Avulsion fracture at the PIP
occurs with hyperextension and subsequent retraction of the fracture fragment and
superficialis tendon proximally, the mid phalanx displaced dorsally. It is best seen on the
lateral view.
*
Answer: a. hyperextension
1994
36. All of the following regarding CPPD arthropathy are true except:
a. hemochromatosis is a cause
b. hyperparathyroidism is a cause
c. involves the first carpometacarpal joint
d. commonly affects the knee
e. similar to osteoarthritis
*
CPPD Arthropathy:
hematochromatosis, first MCP, knee, similar to osteoarthritis.
hyperparathyroidism - chondrocalcinosis but no CPPD
associated with hemochromatosis and primary hyperparathyroidism. Distribution
of changes involves the radial-carpal, capitate-lunate, MCP, elbows, shoulders,
patellofemoral, hip. Get radiographic changes of OA.
AFIP notes L2, Brower, 1995
First carpometalcarpal jt productive changes are usually seen in degenerative joint
disease. Radiocarpal change is more common in CPPD. Resnick p 495
*
Answer: c.
1991
37. Which of the following is the likely cause in a patient who has central cord syndrome
and prevertebral soft tissue swelling in a patient s/p MVA?
a. hyperextension dislocation
b. Jefferson fracture
c. burst fracture
*
Answer: a. hyperextension dislocation
1994
38. Which of the following is least important in the evaluation of spinal stenosis?
a. shape of the spinal canal
b. dentate ligament hypertrophy
c. osteophytes
d. disc bulge
e. facet joint degenerative disease
*
Least important in spinal stenosis:
dentate ligament - holds cervical spine in place, not involved in stenosis. The
denticulate ligament in Clemente holds the cervical cord to the vertebral body. Couldn't
find dentate ligament. p 571
facet arthrosis, shape of canal (congenital short pedicles), osteophytes, and disc
bulge , ligamentum flava hypertrophy, all commonly contribute to stenosis.
*
Answer: d. dentate ligament hypertrophy
1993
39. A 40 year-old man is two months S/P MI. He has chronic left arm pain associated
with soft tissue swelling and decreased range of motion. The patient’s symptoms are
most likely due to:
a. myocardial ischemia
b. arterial insufficiency
c. a bone scan which is hot on all 3 phases
d. degenerative joint disease
e. Dressler’s syndrome
*
Answer: ???d
endhere
Bone Section
The following are matching questions:
1996
In reference to shoulder dislocations:
a. avascular necrosis of the humeral head
b. avulsion of the lesser tuberosity
c. brachial plexus injury
d. median nerve injury
e. radial nerve injury
1. anterior dislocation
2. posterior dislocation
1???
2???
1996
The following injuries are associated with:
a. lateral capsular sign
b. patellar dislocation
c. compression fx of L1
d. glenoid labral tear
1. calcaneal fracture
2. torn ACL
1???
2???
1996
a. femur
b. tibia
c. talux
d. calcaneus
e. phalanx
1.plafond
2. sustentaculum tali
3. adductor tubercle
1. ??
2???
3???
1996
a. involves the patellofemoral joint
b. needle like crystals best seen on electron microscopy
c. most commonly involves the hip joint
d. periarticular osteopenia
e???
1. CPPD crystals
2. urate
3. hydroxyapatite
1???
2???
3???
1996
The following lesions have a similar appearance to which type of osteosarcoma?
a. classic osteosarcoma
b. teleangiectatic osteosarcoma
c. periosteal osteosarcoma
d. cortical osteosarcoma
e. cental osteosarcoma
1. aneurysmal bone cyst
2. parosteal osteosarcoma
3. chondrosarcoma
1???
2???
3???
1996
Marrow dose for the following are:
a. < 1 mrad
b. 16 mrad
c. 160 mrad
d. 490 mrad
e. 1500 mrad
1. PA and Lat CXR
2. UGI
3. CT
4. mammo
1???
2???
3???
4???
1995
Match the following muscles with their origins/insertions:
1. Volkmann’s contracture
2. fragment commonly displaced into the joint space
3. nonunion
a. medial epicondyle of the elbow
b. lateral epicondyle of the elbow
c. supracondylar fracture of the humerus
d. proximal fracture of carpal scaphoid
e. fracture of tibial midshaft
*
Volkman's contracture is a result of ischemic compromise secondary to a
supracondylar fracture. There is interruption of the normal circulation of the brachial
artery. Get resultant ischemia of the flexor muscles and nerves with resultant flexion
contractures of the hand and wrist and impaired sensation.
ref: p 201 Schwartz, Lang of Fx.
In elbow dislocation in children or adolescents, the medial epicondylar
ossification center is frequently avulsed and may become entrapped during reduction. p
838 Resnick
Nonunion is failure of fx healing completely during a period of 6-9 months.
Nonunion of tibial or femoral fx is encountered most commonly, whereas humeral, radial,
ulnar, clavicular nonunion is less frequent. p 806 Resnick
Answer:
1. c
2.a
3.e
1991, 1990
Insertion of:
4. peroneus brevis
5. peroneus longus
6. plantaris
a. base of 5th metatarsal
b. base of 1st metatarsal and cuneiform
c. calcaneus
d. cuboid
*
Plantaris tendon arises from the lateral epicondylar ridge of the femur and travels
between the lateral head of the gastrocnemius and soleus. It inserts on the medial side of
the calcaneal tuberosity.
The peroneus longus arises from the lateral condyle of the tibia and the proximal
two thirds of the fibula and hooks around the lateral malleolus and passes through a
groove in the cuboid bone to insert on the lateral aspect of the 1st cuneiform and the base
of the 1st metatarsal.
Snell, anatomy for med students
*
Answer: 4. a
5. b
6. c
1995, 1988
7. at pathology resembles an aneurysmal bone cyst
8. centrally contains mature bone
9. resembles chondrosarcoma histopathologically
a. parosteal osteosarcoma
b. periosteal osteosarcoma
c. telangiectatic osteosarcoma
d. classic osteogenic osteosarcoma
e. Pagets disease which degenerated into osteogenic osteosarcoma
*
Teleangietatic Osteosarc is ABC-like on radiograph and is frequently misdx. The
tumor is largely composed of cystic cavities containing necrosis and hemorrhage. An
ABC on path, is blood filled spaces with fibrous walls. Possible that ABC is a secondary
lesion-- one of the possible sources is teleangietatic osteosarc.
ref: p HH9, p FF20 and p 1122 Resnick.
Juxtacortical /periosteal chondrosarcoma and periosteal osteosarcoma have a
clinically and radiologically similar appearance. Many investigators believe that they are
the same disease.
ref:p 1141 Resnick.
Parosteal osteosarcoma is dense with tumor bone in the center. It usually grows
on a stalk. With myositis ossificans, there is calcification in the periphery.
Answer: 7. c
8. ?a 9. b
1995, 1994, 1993, 1988
Match the following muscles with their origin/insertion:
10. hamstrings
11. rectus femoris
12. adductors
13. sartorius
14. iliopsoas
a. anterosuperior iliac spine
b. anteroinferior iliac spine
c. ischial tuberosity
d. pubic symphysis
e. lesser trochanter
*
Origins - insertions:
sartorius: anterior superior iliac spine - pes anserinus (sartorius, gracilis,
semitendinosis) on proximal medial tibia
rectus femorus: anterior inferior iliac spine - patella
iliopsoas: iliac fossa/transverse processes - lesser trochanter
hamstrings: ischial tuberosity - medial proximal tibia
The origin of the sartorius is the anterior superior iliac spine (inserts on the
proximal medial tibia). The sartorius is the longest muscle in the body.
The origin of the rectus femoris is the anterior inferior iliac spine (inserts on the
patella as part of the quadriceps tendon along with the Vastus medialis, intermedius, and
lateralis).
The origin of the hamstrings (semimembranosus, semitendinosus) (in medial
head) and the biceps femoris (lateral head)) is the ischeal tuberosity. Semitendinosus
inserts on the pes anserinus; semimembranosus inserts on the medial tibial condyle;
biceps femoris inserts on the fibular head.
The origin of the adductors (adductor brevis and longus and the gracilis) is the
pubic symphysis and inferior pubic ramus for the gracilis. The adductor brevis inserts on
the linea aspera of the proximal medial femur. The adductor longus inserts on the
posterior midfemur. The gracilis inserts in the pes anserinus(medial prox tibia)..
The lesser trochanter is the insertion of the psoas major muscle. The origin of the
psoas major muscle is T12-L3. The lesser trochanter may be avulsed with rapid hip
flexion.
Reference: Dahnert 1993, p. 20 Snell, Anatomy for med stud.
*
Match the following muscles with their origin/insertion:
10. hamstrings
11. rectus femoris
12. adductors
13. sartorius
14. iliopsoas
a. anterosuperior iliac spine
b. anteroinferior iliac spine
c. ischial tuberosity
d. pubic symphysis
e. lesser trochanter
Answers: 10. c
11. b
12. d
13. a
14. e
1995
Match the following muscles with their origins/insertions:
16. brachialis
17. biceps
18. wrist flexors
19. wrist extensors
a. medial epicondyle
b. lateral epicondyle
c. coronoid process of the ulna
d. proximal radius
e. trochlea
*
Brachialis originates at the front distal half of the humerus and inserts at the
coronoid process of the ulna.
Biceps origin is the supraglenoid tubercle of the scapula for the long head, and
coracoid process for the short head. It inserts at the tuberosity of the radius.
The flexors of the wrist( flexor carpi ulnaris, flexor carpi radialis,) orginate at the
medial epicondyle of the humerus. Fl. carpi ulnaris inserts at the pisiform and hook of
the hamate, base of the 5th MC. Fl carpi radialis inserts at the base of the 2nd and 3rd
MC. Flexor digitorum profundus primarily flexes the distal phalanges,but assists in wrist
flexion-- originates at the anteromedial ulna shaft. and inserts distal phalanges of the
medial four fingers.
Wrist extensor include the extenor carpi radialis brevis and the extensor carpi
ulnaris. and they originate at the lateral epicondyle of the humerus. Radialis brevis inserts
at the posterior base of the 3rd MC. Ulnaris inserts at the base of the 5th MC.
p. 485, 462 Snell. Anatomy for med stud.
Answer: 16. c 17. d
18. a 19. b
1995
20. aluminum toxicity
21. amyloid
22. hyperparathyroidism
a. tibial periostitis
b. AVN
c. carpal cysts
d. protrusio acetabuli
e. spontaneous fractures of the upper three ribs
*
The primary cause of progression of skeletal abnormalities in pt on chronic HD is
osteomalacia attributable to aluminum toxicity. Clinical characteristics of Al toxicity
include bone pain, myopathy, fx, dialysis encephalopathy. p 643 Resnick In more than 3
atraumatic fx - ribs, vertebrae, hips, pelvis, clavicles, extremites, is Al toxicity until
proven otherwise. CC12 AFIP Murphey 1995.
Amyloid is secondary to deposition of b2-microglobulin amyloid. Get carpal
tunnel syndrome, destructive spondyloarthropathy, osseus and intrarticular deposition e.g.
cystice lytic areas, endosteal scalloping from erosion from soft tissue mass. CC AFIP ntes
1995, Murphey
Features of hyperparathyroidism include subperiosteal, intracortical, endosteal,
subchondral, subligamentous, and trabecular bone resorption, brown tumors, bone
sclerosis, chondrocalcinosis. Periostitis is rarely found in primary hyperpara but not
infrequently( 8-25% in AFIP notes) found in secondary. p 631 Resnick. Causes of
protrusio include RA, Ank spond, OA, Infection, pagets, osteomalacia, XRT, trauma. p
286 Resnick
AVN is seen in pt w/ renal disease post transplant and is secondary to steroids. CC
, AFIP notes.
Answer: 20. e
21. c 22. d ?
1993
23. Sjogren’s syndrome
24. sarcoidosis
a. uveitis
b. retinitis
c. keratoconjunctivitis
*
Answer: 23. c (keratoconjunctivitis sicca, xerostomia, RA)
24. a
1993, 1991
25. subluxation
26. involves the 2nd and 3rd metacarpals
27. 37 y/o with carpal tunnel syndrome
a. hemochromatosis
b. SLE
c. amyloid
*
SLE is associated with multiple joint subluxations (also periarticular osteoporosis
and erosions). Clinical features suggesting muscle involvement have been observed in
30-50% of patients with SLE. Other musculoskeletal abnormalities seen in lupus are
symmetric polyarthritis, spontaneous tendon rupture, and osteonecrosis (5-6%, most
common in the femoral head). Acral sclerosis has also been reported.
Hemochromatosis can be either primary or secondary (due to alcoholic cirrhosis,
multiple blood transfusions, refractory anemia, or chronic excess oral iron ingestion).
The disorder is 10-20 times more frequent in men. The classic triad is cirrhosis, skin
pigmentation, and diabetes. The arthropathy of hemochromatosis is a noninflammatory
condition which initially involves the small joints of the hands, especially the 2nd and 3rd
metacarpals. It also results in osteoporosis (of vertebral bodies may produce biconcave or
“fish” vertebrae similar to those occurring in other forms of osteoporosis), subchondral
cyst formation, and iron deposition in the synovium. Chondrocalcinosis occurs in up to
30%. Bone eburnation and cysts and the absence of osteophyte formation are associated
findings.
Amyloidosis is either primary (no coexistent or antecedent disease) or secondary
(associated with various chronic diseases). The diagnosis can be substantiated with the
Congo red test. The reported frequency of amyloidosis in rheumatoid arthritis has varied
from 5 to 25%. Osteoporosis, lytic lesions of bone (simulating appearance of myeloma),
and pathologic fractures may be observed. Articular lesions are characterized by bulky
soft tisue masses, well-defined erosions and cysts, and preservation of joint space.
Mnemonic for carpal tunnel syndrome: PRAGMATIC, Pregnancy, Rheumatoid
arthritis, Acromegaly, Gout, Myxedema, Amyloid, Trauma, Idiopathic, Collagen
vascular disease.
References: Dahnert 1993, p. 43; Resnick 1989, pp. 347-351, pp. 510-514, pp. 683-684
*
25. subluxation
26. involves the 2nd and 3rd metacarpals
27. 37 y/o with carpal tunnel syndrome
a. hemochromatosis
b. SLE
c. amyloid
Answers: 25. b
26. a
27. c
1993
28. median nerve
29. ulnar nerve
30. posterior tibial nerve
a. tarsal tunnel
b. sinus tarsi
c. Guyon tunnel
d. carpal tunnel
*
The ulnar nerve (and ulnar artery) goes through the Guyon tunnel - the bony
boundaries are the pisiform medially and the hook of the hamate laterally. The floor of
the canal is the flexor retinaculum and the origin of the hypothenar muscles. The most
frequent causes of ulnar nerve entrapment are ganglia and trauma.
The sinus tarsi is on the lateral aspect of the foot and contains the interosseous
ligament.
The tarsal tunnel is located behind and below the medial malleolus, its floor is
osseous and its roof is formed by the flexor retinaculum. The posterior tibial nerve runs
through it.
Reference: Resnick 1989, p. 940
*
Answers: 28. d
29. c 30. a
1992, 1989
31. 2nd and 3rd metacarpal
32. DJD of unusual joints
33. multiple joints with periarticular soft tissue swelling
a. amyloid
b. CPPD
c. synovial chondromatosis
d. PVNS
*
Synovial (osteo)chondromatosis is secondary to cartilage metaplasia in the
synovium. The knee is the most common joint affected (50%), followed by the hip and
elbow. It is twice as common in males. The cartilage hypercellularity and nuclear atypia
may simulate cartilage maligancy (but they rarely degenerate into chondrosarcoma). The
bodies calcify 70-75% of the time. Even if not ossified, the bodies may cause erosions
and osteoarthritic-appaering changes. There are numerous rounded filling defects on
arthrography. On MR there is variable signal with some hyperintensity on T2-weighted
images. Treatment is surgical synovectomy - recurrences are common.
Amyloid is characterized by juxtaarticular osteoporosis, multiple subchondral
cysts, soft tissue swelling, multiple subchondral cysts, soft tissue swelling, and
preservation of the cartilage space. Clinical findings of amyloid are hard to distinguish
from RA. Get asymmetric soft tissue masses and swelling. Articular lesions in amyloid
are characterized by bulky sot tissue masses, well-defined erosions, cysts and preservation
of joint spaces. p 684 Resnick.
Although “2nd and 3rd metacarpophalangeal joints” is the buzz word for
hemochromatosis, it can also be seen in CPPD and other arthritides.
*
Answers: 31. b 32.b 33. a
1992, 1990
34. popliteal cyst
35. meniscal cyst
36. ganglion
a. enlargement of the semimembranosogastrocnemius bursa
b. associated with meniscal tear
c. not associated with meniscal tear
d. bilateral
e. low signal on T2 images
*
A popliteal cyst (also called a Baker cyst) results from communication between
the knee joint and the gastrocnemius-semimembranosus bursa - its incidence increases
with age.
Meniscal cysts are cystic masses related to meniscal tears (1-2% incidence). Fluid
enters from the joint through the tear. Pain is often worse at night and after exercise.
Lateral meniscal cysts are 3-10 times more common than medial cysts. The tear must be
repaired and the cyst must be resected to alleviate symptoms.
Ganglion cyst is a cystic space uni/multi locular with myxoid material. It arises
wherever there is synovium( tendon sheath, fascial planes) Not lined with synovium and
occasionally communicates with the joint. D18 AFIP notes 1995 Kaplan. They rarely
communicate with the synovium of a tendon sheath or joint. p 1187 Resnick.
References: AFIP Notes, 8/94, Bone, pp. JJ10-JJ13; MR of the Musculoskeletal System,
Thomas Berquist, ed.
*
Answers: 34. a 35. b
36. c
1992
37. Behcet’s
38. adult Still disease
39. Felty syndrome
a. oral, ocular, and genital skin lesions
b. rapid destruction of the MCP joints and carpal joints
c. destruction and ankylosis
d. HLA B27 positive
e. infections
*
In Behcet’s disease, the skeletal changes are: sacroileitis, occasionally
osteoporosis, soft tissue swelling, and spontaneous atlantoaxial subluxations. Classic triad
of Behcet syndrome is recurrent oral and genital ulceratin and ocular inflammation.
Felty syndrome = rheumatoid arthritis, splenomegaly, and leukopenia. p 260
Adult onset Stills is characterized by rash, fever, involvement of the C-spine and
peripheral and S-I jts. The course to the joint disease is mild. Xray changes include
carpal ankylosis, apophyseal joint fusion in the c-spine, patchy sclerosis about the S-I
joint. Get narrowing of the Carpometacarpal and midcarpal joint w/o osseous erosions
and may culminate in ankylosis. MCP jt are typically spared. p 297
ref: Resnick 345-6
*
Answers: 37. a
38. c
39. b
1994
40. vastus medialis
41. semimembranosis
42. popliteus
43. pectineus
44. peroneus brevis
a. hamstrings
b. quadriceps
c. neither
*
Answers: 40. b
41. a 42. c
43. c
44. c
1993, 1990v
45. Medial epicondyle
46. Lateral epicondyle
47. Trochlea
48. Capitellum
a. The last center to ossify
b. Associated with an isolated avulsion
c. an infrequently entrapped fragment
d. ossifies in multiple centers
*
Separation of the medial epicondyle represents 10% of all elbow injuries. It may
become entrapped within the joint. (Resnick 1989, p. 891)
The lateral epicondyle is the last center to ossify. Mnemonic to remember this:
C - capitellum (age 1)
R - radial head (age 5)
I - internal (medial) epicondyle (age 6)
T - trochlea (age 9)
O - olecranon (age 6-10)
E - external (lateral epicondyle) (age 11)
lesser minds "Come Rub My Tree Of Love"
Resnick 1989, p. 890 or for
The trochlea may have two ossification centers. (Fractures and Joint Injuries, p.
615)
*
Answers: 45. b
46. a
47. d
48. c
1991
49. comminuted fracture at the base of the thumb
50. radial neck fracture and distal radioulnar joint dislocation
a. Bennett
b. Rolando
c. Essex-Lopresti
d. Galeazzi
*
The Essex-Lopresti fracture (one dude, two names) is a rare condition produced by a
violent longitudinal compression force in the long axis of the radius. It is a comminuted
fracture of the radial head associated with dislocation of the distal radioulnar joint. (Note
at least superficial resemblance to a Galeazzi fracture.)
Bennet fx is a fracture of the base to the 1st MC. Rolando fx is y-shaped fx of the
base the the 1st MC.
Reference: Schulz 1990, p. 254, 267, 241.
*
Answers: 49. b
50. d
1991
54. tricompartmental DJD of the knee
a.. CPPD
*
Answer: a
1996, 1994, 1992, 1990
55. plafond
56. sustentaculum tali
57. volar plate
a. tibia
b. calcaneus
c. talus
d. phalanx
e. femur
*
The sustentaculum tali is a horizontally projecting shelf located at about the level
of the junction of the anterior and middle third of the os calcis - it contains an articular
facet and acts to support the talus.
*
Answers: 55. c 56. b 57. d
1994
58. aortitis
59. balanitis
60. ivory phalanx
61. involvement of the SI joints
62. periosteal reaction
63. osteoporosis
xx
a. Reiter’s disease
b. Psoriatic arthritis
c. ankylosing spondylitis
*
Reiter's - "balanitis circinitis sicca" and “keratosis blennorrhagia” (both mucocutaneous
lesions); “fluffy” periosteal reaction; aortic incompetence; juxtaarticular osteoporosis
(rare in acute stage); is an STD, also acquired from a certain type of Shigella dysentary;
classic triad = arthritis, urethritis, uveitis. Aortitis is associated with Reiter's, RA,
psoriatic, behcet, IBD. p 1018. Harrison's 12th ed.
Ankylosing spondylitis - aortic insufficiency and cardiac conduction deficits, uveitis,
aspergillous ref: Harrisons'
Psoriatic - ivory phalanx, periosteal reaction frequent
Reference: Dahnert 1993, pp. 89-90
*
Answers: 58. a ,b 59. a
60. b (less commonly a)
61. c (less commonly b and a)
62. a and b
63. a
1995 ITE
Matching regarding vertebral body:
64. notochord remnant
65. normal variant
66. acromegaly
a. exaggerated concavity of anterior margin
b. exaggerated concavity of posterior margin
c. exaggerated concavity of lateral margin
d. midline defect (butterfly vertebra)
e. inferior endplate concavity on either side of midline
*
Differential diagnosis of posterior vertebral body scalloping:
1) Normal variant L4-6- only mild scalloping2) neurofibromatosis
3) tumor/ increased intraspinal pressure
4) achondroplasia (look for narrowing of space between the pedicles)
5) acromegaly
6) Ehlers-Danlos, Marfan’s, Osteogenesis Imperfecta
7) Mucopolysaccharidosis
Anterior scalloping in children is usually due to NF, lymphadenopathy,
leukemia/lymphoma.
Kirks, p 209
The central nucleus pulposus ( part of the intervetebral disc is also the external annulus
fibrosis) is a remnant of the notochord.p 206 Kirks.
Common normal variants on table 3-9 Kirks.p 210.
Spina bifida occulta is secondary to lack of ossification of the cartilaginous cleft
in the midline.and is a normal variant. Butterfly vertebra (p 214) is secondary to lack of
fusion of the two cartilaginous centers of a vertebral body.
Answer: 64. e 65. b???
66. b
1995 ITE
Matching regarding bone abnormalities:
67. Paget’s disease
68. renal osteodystrophy
69. discogenic sclerosis
a. round, sclerotic region abutting the endplate
b. linear, sclerotic regions abutting the endplates
c. linear, sclerotic peripheral margins of vertebral bodies
d. round, sclerotic region in center of vertebral body (“bone in bone”)
*
renal osteodystrophy is associated with "Rugger jersey" spine which has sclerotic
endplates
Pagets spine give "picture frame" appearance, ivory vertebral body, posterior
elements may be involved. LL-4 AFIP 1995
?? Discogenic sclerosis-- is it the same as benign vertebral sclerosis which is
associated with degenerative disc disease with loss of disc height. usually involves the
inferior endplate. bone conference 7/5/93
Answer: 67. ?c
68. ?b
69. ???a
1995 ITE
Matching regarding the knee:
70. meniscal cyst
71. discoid meniscus
72. myxoid degeneration of meniscus
a. lateral meniscus usually affected
b. medial meniscus usually affected
c. women usually affected
d. asymptomatic
e. anterior cruciate ligament tear associated
*
Discoid mesniscus is usually lateral and is predisposed to tears.
Meniscal cyst
is usually lateral and is associated with a meniscal tear. Medial cysts when present are
larger than lateral cysts.
ref:p D6-7 Kaplan, AFIP 1995
Answer: 70. a
71. a
72. ???
1994 ITE
73. Salter I fracture of distal humeral epiphysis
74. Posterior elbow dislocation
75. Monteggia fracture/dislocation complex
a. radial head aligns with capitellum
b. olecranon fracture
c. avulsed lateral epicondyle of humerus
d. avulsed medial epicondyle of humerus
e. disruption of proximal radioulnar joint
*
In a Monteggia fracture, there is a displaced fracture of the proximal ulna and
dislocation of the radial head.
Fractures of the elbow in children include supracondylar, lateral condylar ( Salter
IV because split epipysis and adjacent metaphysis), medial epicondyle, and the remaining
15% include diloc, olecranaon/coronoid fx, monteggia.p 353 Kirks
Elbow dislocation in adults can be complicated by fx of the coronoid or the radial
head. In children, the medial epicondylar ossification center is frequently avulsed. p 838
Resnick
*
Answer: 73. a??? d
74. d 75. e
1994 ITE
76. disuse osteoporosis
77. osteomalacia
78. hyperparathyroidism
a. subchondral bone resorption
b. indistinct trabeculae
c. frayed metaphyses
d. biconcave vertebrae
e. metaphyseal lucent bands
*
hyperpararthyroidism manifests in subperiosteal, cortical, endosteal, subchondral,
subligamentous resorption, brown tumors, periosteal new bone formation. CC4-6, AFIP
Murphey 1995
Characteristic changes of rickets are in immature bone and seen in the gowth
plates prior to closure. Osteomalacic changes are seen in mature areas of trabecular and
cortical bone. p 591 Resnick. Findings of osteomalacia include, osteopenia, loss of
trabeculae with prominence of the remaining trabeculae- which are unsharp on close
examination, pseudofx/ Looser's zones (may be secondary to mechanical erosive process
of adjacent blood vessel). Looser's zones typically appear at the axillary margin of the
scapula, ribs, inf and sup rami, inner margin of the prox femora, post margin of the
proximal ulna. p 593
After immobilization, osteoporosis appears w/ion 2-3 months. Patterns include:
speckled or spotty osteoporosis, band like osteoporosis in the subchondral or metaphyseal
regions, cortical lamellation/scalloping. p 574
Biconcave vertebra are seen in age-related osteoporosis. p 571
ref: Resnick, p 593,574, 571. AFIP Murphey, 1995
Answer: 76. e 77. b
78. a
1994 ITE
Matching regarding intrinsic osseous abnormalities:
79. congenital scoliosis
80. idiopathic scoliosis
81. neuromuscular scoliosis
a. thoracic curve convex to right
b. male predominance
c. curve progression after skeletal maturity
d. osseous anomalies
e. long thoracolumbar curve
*
Idiopathic scoliosis is most common and is usually in adolescents. Infantile
idiopathic scoli is more common in boys and has a curve convex to the left in the thoracic
region and resolves spontaneously. Progressive infantile scoli is more common in boys
and is convex to the left and has a poor px. Juvenile scoli is in girls and has a convex
thoracic curve to the right and also has a poor px. MOST common is adolescent scoli and
is more frequent in girls with a convex to the right thoracic curve. The higher the level of
the curve, the worse the px. Compensatory curves are present from the onset of the
deformity.
Congenital scoli is due to abnormal neural or bone development. Usually have
progressive curve. Most common site is the thoracic. Diastematomyelia is present in 5%.
Neuromuscular scoli had a classic C shaped curve. Etiologies are listed on p 255
Kirks, table 3-14. It extends from the upper thoracic to the pelvis. Pelvic obliquity is
characteristic. p 1069 Resnick
ref: Kirks p 254-5
Answer: 79.d
80. a
81. e
1993 ITE
82. ulna plus variance
83. ulna minus variance
84. Madelung’s deformity
a. avascular necrosis of the lunate
b. triangular fibrocartilage tears
c. extensor carpi ulnaris tendinitis
d. triangular configuration of carpus
e. scapholunate ligament rupture
*
Madelung’s deformity is chondrodysplasia of the distal radial epiphysis. It
represents a bowing of the distal end of the radius. Typically, the radial bowing occurs in
a volar direction while the ulna continues to grow in a straight fashion. there is wedging
of the carpus between the deformed radius and protruding ulna, resulting in a triangular
configuration with the lunate at the apex.
Also, see question 11
Reference: Resnick 1989, pp. 1083-1084
*
Answer: 82. b (and e)
83. a
84. d
1993 ITE
85. medial epicondyle
86. supracondylar humerus
87. coronoid process
a. most commonly fractured in associated with adult elbow dislocations
b. affected in “little leaguer’s elbow
c. affected in “tennis elbow”
d. involved in the Monteggia fracture
e. most commonly fractured in children
*
Little leaguer's elbow is severe avulsion of the medial epicondyle. Supracondylar
fx account for 60% of elbow injuries in children and is the most common elbow injury. p
353. Kirks
Coronoid process is frequently injured in adults with elbow dislocation.
?? Tennis elbow is lateral epicondylitis.
Answer: 85. b
86. e
87. a
1993 ITE
88. talocalcaneal coalition
89. calcaneonavicular coalition
90. talonavicular coalition
a. the least common of the congenital tarsal coalitions
b. optimally identified on an oblique view of the foot
c. more common in girls
d. an increased plantar angle is characteristic
e. bilateral in 25% of affected patients
*
Tarsal coalition may be fibrous, cartilagionous, or osseous, can be congenital
/acquired.
Calcanealnavicular coalition is the most common. Can be bilateral, aSx or
associated with a rigid foot. Best ID on a 45 degree medial oblique view of the foot. A
secondary sign is hypoplasia of the head of the talus. Talar beaking is uncommon.
Talocalcaneal coalition is second most common. Almost all occur between the
talus and the sustentaculum tali. More common in boys and is bilateral in 25%. ID
through a penetrated axial film. Secondary signs include talar beaking, broadening of the
lateral process of the talus, narrowing of the posterior subtalar jt, concave undersurface of
the talar neck, failure of the visualization of the middle subtalar joint.
Talonavicular coalition is uncommon. Pt may be aSx or may have peroneal
spasm. Usually see osseous bridge.
ref: Resnick 1079-81
Answer: 88. e
89. b
90. a
1990
91. distal humerus
92. tibia
93. 1st metatarsal
94. 5th metatarsal
a. bunk bed fracture
b. toddler’s fracture
c. Volkman’s contracture
*
When the increased pressure of progressive edema within a rigid osteofascial
compartment of either the forearm or the leg threatens the circulation to the enclosed
(intracompartmental) muscles and nerves, the phenomenon is called a compartment
syndrome (formerly known as Volkman’s contracture). Compartment syndromes most
frequently involve the flexor compartment of the forearm and the anterior tibial
compartment of the leg. Muscle can survive up to 6 hours of ischemia but cannot
regenerate. Necrotic muscle is replaced by scar that shortens producing a compartmental
contracture. The injuries that are most commonly complicated by a compartment
syndrome:
1. displaced supracondylar fracture of the humerus with damage to the brachial
artery in children
2. excessive longitudinal traction in the treatment of fractures of the femoral shaft
in children with resultant arterial spasm
3. fractures (as well as surgical osteotomies) of the proximal third of the tibia
4. drug-induced coma with resultant pressure on major arteries from lying on a
hard surface in an awkward position for a prolonged period.
*
Answer: 91. c 92. b
93. ??? 94. ???