Musculoskeletal Radiology Practice Questions

Q: Which of the following is the most probable diagnosis of the patient with the given X-ray?

Pott's spine. ***Pott's spine*** - X-ray shows characteristic **disc space narrowing** and **vertebral collapse** with **paravertebral shadow**, pathognomonic of tuberculous spondylitis. - May demonstrate **gibbus deformity** (angular kyphosis) due to anterior vertebral body destruction with relative disc space preservation initially, then progressive narrowing. *Osteoporosis* - Presents with **generalized bone demineralization** and **compression fractures** but **disc spaces remain preserved**. - Lacks the **paravertebral soft tissue shadow** and focal destructive changes seen in infectious processes. *Metastatic bone disease* - Typically shows **multiple lytic or sclerotic lesions** throughout the skeleton with **preserved disc spaces**. - **Pedicle destruction** ("winking owl sign") is common, but disc involvement is rare unlike infectious spondylitis. *Multiple myeloma* - Characterized by **multiple punched-out lytic lesions** in vertebral bodies with **normal disc spaces**. - Often associated with **pathological fractures** but lacks the paravertebral soft tissue involvement typical of Pott's spine.

Q: Wimberger ring sign is present in which condition?

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

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

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

Q: Based upon this PA ulnar deviation view of the wrist, what is the MOST likely diagnosis?

De Quervain tenosynovitis. ***De Quervain tenosynovitis*** - **Soft tissue swelling** at the **radial styloid** is characteristic of De Quervain tenosynovitis on PA ulnar deviation views. - **Periostitis** along the first extensor compartment creates a typical appearance in this specific radiographic projection. *Osteomyelitis* - Would show **cortical destruction** and **intramedullary changes** rather than isolated soft tissue swelling. - Typically presents with **bone marrow edema** and **sequestra** formation on advanced imaging. *Hypertrophic osteoarthropathy* - Characterized by **symmetric periosteal new bone formation** along multiple long bones, not localized to radial styloid. - Associated with **clubbing** and **underlying pulmonary or cardiac disease**, presenting bilaterally. *Rheumatoid arthritis* - Shows **joint space narrowing** and **erosions** at multiple articulations, particularly **radiocarpal** and **midcarpal** joints. - Demonstrates **ulnar deviation** deformity but with **bone destruction** rather than isolated soft tissue changes.

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

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

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

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

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

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

Q: A hand radiograph of a child suggests which diagnosis?

Rickets. ***Rickets*** - Hand radiographs show **widened, frayed, and cupped metaphyses** at the distal radius and ulna, which are pathognomonic for rickets. - Additional findings include **widened growth plates**, **osteopenia**, and **delayed ossification** of carpal bones in children. *Scurvy* - Radiographic features include **dense metaphyseal lines** (Trümmerfeld zones) and **cortical thinning**, not the frayed appearance seen in rickets. - Often shows **subperiosteal hemorrhages** and **pencil-thin cortices**, which are distinct from rickets findings. *Hyperparathyroidism* - Hand X-rays typically show **subperiosteal bone resorption** along the radial aspects of middle phalanges and **salt-and-pepper skull** appearance. - **Brown tumors** and **generalized osteopenia** may be present, but metaphyseal changes are not characteristic. *Osteogenesis imperfecta* - Characterized by **multiple fractures**, **thin cortices**, and **gracile bones** with poor bone quality. - Shows **osteopenia** and **deformities** from repeated fractures, but lacks the specific metaphyseal changes of rickets.

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

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

Question 1

Which of the following is the most probable diagnosis of the patient with the given X-ray?

Accepted Answer

Pott's spine

Answer

Osteoporosis

Answer

Metastatic bone disease

Answer

Multiple myeloma

Question 2

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

Accepted Answer

Lead poisoning

Answer

Rickets

Answer

Metaphyseal dysplasia

Answer

Hypophosphatasia

Question 3

Wimberger ring sign is present in which condition?

Accepted Answer

Scurvy

Answer

Rickets

Answer

Secondary syphilis

Answer

Tuberculosis

Question 4

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

Accepted Answer

Oblique view

Answer

Anteroposterior (AP) view

Answer

Posteroanterior (PA) view

Answer

Lateral view

Question 5

Based upon this PA ulnar deviation view of the wrist, what is the MOST likely diagnosis?

Accepted Answer

De Quervain tenosynovitis

Answer

Osteomyelitis

Answer

Hypertrophic osteoarthropathy

Answer

Rheumatoid arthritis

Question 6

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

Accepted Answer

Calcific tendinitis

Answer

Shoulder dislocation

Answer

Acromioclavicular dislocation

Answer

Hill-Sachs lesion

Question 7

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

Accepted Answer

Osgood-Schlatter disease

Answer

Pellegrini-Stieda lesion

Answer

SLAP tear

Answer

Segond fracture

Question 8

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

Accepted Answer

MRI

Answer

Clinical examination

Answer

X-ray

Answer

CT scan

Question 9

A hand radiograph of a child suggests which diagnosis?

Accepted Answer

Rickets

Answer

Scurvy

Answer

Hyperparathyroidism

Answer

Osteogenesis imperfecta

Question 10

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

Accepted Answer

Scurvy

Answer

Rickets

Answer

Battered baby syndrome

Answer

Sickle cell disease

Musculoskeletal Radiology — MCQs

Musculoskeletal Radiology — MCQs

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