Musculoskeletal Radiology Practice Questions

Q: Based on the provided X-ray image, identify the most likely diagnosis.

Osteosarcoma. ***Osteosarcoma*** - The X-ray demonstrates a classic **"sunburst"** or **"sun-ray"** appearance, which is a periosteal reaction caused by tumor spicules radiating outwards. This is a hallmark sign of osteosarcoma. - This malignant tumor typically arises in the **metaphysis** of long bones, such as the distal femur, proximal tibia, and proximal humerus, and is often associated with a soft tissue mass and aggressive bone destruction. *Ewing sarcoma* - Radiographically, Ewing sarcoma more commonly presents with a lamellated or **"onion-skin"** periosteal reaction or a destructive, **"moth-eaten"** appearance. - It is a **small round blue cell tumor** that typically affects the **diaphysis** of long bones in children and young adults. *Chondrosarcoma* - This is a malignant tumor of cartilage-producing cells, characterized by **"popcorn"** or **"ring-and-arc"** calcifications on X-ray, which are not seen in this image. - Chondrosarcoma typically affects older adults (over 40) and commonly involves the bones of the pelvis and trunk. *Gout* - Gout is a form of inflammatory arthritis, not a tumor. Its classic radiographic finding is **"punched-out"** erosions with sclerotic margins and overhanging edges, often called **"rat-bite"** erosions. - It does not cause a sunburst periosteal reaction and commonly affects the first metatarsophalangeal joint.

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

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

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

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

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

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

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

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

Q: The following view of the knee joint is known as:

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

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

AP shoulder view with anterior dislocation. ***AP shoulder view with anterior dislocation*** - The humeral head is displaced **inferiorly and medially** relative to the glenoid, which is the characteristic finding of **anterior shoulder dislocation** on an AP radiograph - Anterior dislocations account for **95% of all shoulder dislocations** and typically result from a fall on an outstretched arm with the shoulder in abduction and external rotation - The AP view clearly shows loss of normal glenohumeral articulation with the humeral head positioned **anterior and inferior** to the glenoid fossa *AP shoulder view with posterior dislocation* - Posterior dislocations show the humeral head fixed in **internal rotation** with the characteristic **"light bulb" sign** (symmetric rounded appearance) - The humeral head typically appears **medially positioned** but not inferiorly displaced as seen in anterior dislocations - This represents only 2-5% of shoulder dislocations and is often associated with seizures or electrocution *Lateral view with anterior dislocation of shoulder* - This is an **AP view**, not a lateral view - A lateral view (Y-scapular view) would show the scapula in a **Y-shaped configuration** with the humeral head positioned anterior to the glenoid in cases of anterior dislocation - The lateral view is useful for confirming the direction of dislocation seen on AP radiographs *Lateral view with posterior dislocation of shoulder* - This is an **AP view**, not a lateral view - On a true lateral (Y-scapular) view, posterior dislocation would show the humeral head displaced **posteriorly** relative to the glenoid - Posterior dislocations are frequently missed on AP views alone, making lateral views essential for complete evaluation

Q: What is the correct diagnosis for the image shown?

Fish vertebra. ***Fish vertebra*** - The image indicates **biconcave vertebral bodies** with a central depression, mimicking the appearance of a **fish vertebra**. This shape results from bone softening conditions, leading to compression of the vertebral body by the turgid intervertebral discs. - This finding is classically associated with **osteoporosis** or **osteomalacia**, where the bone mineral density is reduced making the vertebrae more susceptible to this type of deformation. *Hemivertebra* - A hemivertebra is a **congenital anomaly** where only half of a vertebral body forms, causing a wedge-shaped vertebra and often leading to **scoliosis**. - The image does not show a malformed, wedge-shaped vertebral body; instead, it shows a **biconcave deformity** of a fully formed vertebra. *Rugger jersey spine* - Rugger jersey spine refers to the appearance of alternating lucent and sclerotic bands on the superior and inferior endplates of vertebral bodies, resembling the stripes on a rugby jersey. - This finding is characteristic of **renal osteodystrophy** due to secondary hyperparathyroidism, which is not depicted in the given image. *Block vertebra* - A block vertebra is a **congenital or acquired fusion** of two or more adjacent vertebral bodies, resulting in a single, enlarged vertebral segment with rudimentary or absent intervertebral discs. - The image clearly shows distinct vertebral bodies with intervening discs, albeit distorted, and no evidence of fusion.

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

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

Question 1

Based on the provided X-ray image, identify the most likely diagnosis.

Accepted Answer

Osteosarcoma

Answer

Chondrosarcoma

Answer

Gout

Answer

Ewing sarcoma

Question 2

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

Accepted Answer

Sacral insufficiency fracture

Answer

Multiple myeloma

Answer

Acute osteomyelitis

Answer

Bone marrow edema

Question 3

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

Accepted Answer

Spondylolisthesis

Answer

Spondylitis

Answer

Vertebral fracture

Answer

Osteosarcoma

Question 4

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

Accepted Answer

MRI sacroiliac joint

Answer

X ray

Answer

Bone scan

Answer

CT sacroiliac joint

Question 5

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

Accepted Answer

A= Giant cell tumour, B= Aneurysmal bone cyst

Answer

A= Simple bone cyst, B= Aneurysmal bone cyst

Answer

A= Aneurysmal bone cyst, B= Simple bone cyst

Answer

A= Osteochondroma, B= Aneurysmal bone cyst

Question 6

The following view of the knee joint is known as:

Accepted Answer

Sunset view

Answer

Merchant's view

Answer

Tunnel view

Answer

Rosenberg view

Question 7

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

Accepted Answer

AP shoulder view with anterior dislocation

Answer

AP shoulder view with posterior dislocation

Answer

Lateral view with anterior dislocation of shoulder

Answer

Lateral view with posterior dislocation of shoulder

Question 8

What is the correct diagnosis for the image shown?

Accepted Answer

Fish vertebra

Answer

Hemivertebra

Answer

Rugger jersey spine

Answer

Block vertebra

Question 9

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

Accepted Answer

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

Answer

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

Answer

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

Answer

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

Question 10

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

Accepted Answer

Multiple myeloma

Answer

Histiocytosis X

Answer

Hyperparathyroidism

Answer

Sickle cell anemia

Musculoskeletal Radiology — MCQs

Musculoskeletal Radiology — MCQs

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