Musculoskeletal Radiology Practice Questions

Q: The X-ray and MRI findings given below point to the diagnosis of: (Recent NEET Pattern 2016-17)

Pigmented villonodular synovitis. ***Pigmented villonodular synovitis*** - The MRI image shows characteristic **low signal intensity foci** on T1 and T2 weighted images due to hemosiderin deposition, along with a nodular synovial mass, which are hallmarks of **pigmented villonodular synovitis (PVNS)**. - The presence of multiple nodular lesions within the joint capsule (indicated by arrows on MRI) and the soft tissue swelling visible on X-ray, without significant bone destruction typically seen in aggressive tumors, is consistent with PVNS. *Osteoid osteoma* - An osteoid osteoma typically appears as a **small lucent nidus** (<1.5 cm) with a sclerotic rim in the bone, often associated with a painful presentation relieved by NSAIDs. - The imaging findings here, particularly the large soft tissue mass and hemosiderin deposits on MRI, are not characteristic of an osteoid osteoma. *Osteoclastoma* - Osteoclastomas, also known as **giant cell tumors of bone**, are aggressive but benign tumors that appear as expansile **lytic lesions** originating in the epiphysis/metaphysis of long bones. - While they can be destructive, they typically don't present with the diffuse, hemosiderin-laden synovial proliferation seen in these images. *Osteosarcoma* - Osteosarcoma is a highly malignant bone tumor characterized by the production of **osteoid matrix** and often presents with features like cortical destruction, a soft tissue mass, and a sunburst or Codman's triangle appearance on X-ray. - The imaging features shown, particularly the T1/T2 hypointense foci on MRI due to hemosiderin, are not typical for osteosarcoma, which would instead show more features of bone destruction and aggressive periosteal reaction.

Q: The following X-ray of the pelvis shows:

Gas shadow artifact. ***Gas shadow artifact*** - The image shows a **dark, lucent area (gas shadow)** overlying the pelvic structures, particularly noticeable over the soft tissues and potentially obscuring parts of the bone. This indicates extraneous gas, likely from the bowel, that is projected onto the image. - Artefacts like gas shadows are common in X-rays and can sometimes mimic or obscure pathology, but their characteristic appearance helps differentiate them from true bone lesions or dislocations. This is an artifact. *Simple bone cyst* - A simple bone cyst (also known as a **unicameral bone cyst**) typically appears as a well-defined, lytic lesion with a sclerotic rim within the bone, often associated with a "fallen fragment sign" if a fracture has occurred. - The appearance in the image is not consistent with a true bone lesion within the bone itself but rather an overlying shadow. *Aneurysmal bone cyst* - An aneurysmal bone cyst is an expansile, lytic lesion that often presents with a **"soap bubble" appearance** and may contain fluid-fluid levels on MRI. - This lesion is typically intraosseous and causes bone expansion, which is not depicted by the observed gas shadow. *Posterior hip dislocation* - A posterior hip dislocation involves the **femoral head being displaced posteriorly and superiorly** relative to the acetabulum, leading to characteristic changes in the hip joint alignment. - The image does not show a change in the anatomical relationship between the femoral head and acetabulum; instead, it shows an external lucency.

Q: The given X-ray of the humerus shows:

Fibrous dysplasia. ***Fibrous dysplasia*** - The image shows a humeral lesion with a **ground-glass matrix** and areas of **cortical thinning** and expansion, consistent with fibrous dysplasia. - Fibrous dysplasia is a developmental anomaly where normal bone is replaced by **fibrous tissue** and immature woven bone, often appearing as a **shepherd's crook deformity** in long bones. *Aneurysmal bone cyst* - Aneurysmal bone cysts typically present as expansile **lytic lesions** with multiple **fluid-fluid levels** on imaging, which cannot be clearly discerned on this X-ray. - While they can be expansile like the lesion shown, they characteristically have a **"soap bubble" appearance** due to internal septations. *Ewing sarcoma* - Ewing sarcoma often presents with a destructive, infiltrative lesion and a characteristic **"onion-skin" periosteal reaction**, none of which are definitively seen here. - This highly malignant tumor typically causes **moth-eaten or permeative bone destruction**, which is distinct from the more uniform ground-glass appearance. *Posterior dislocation of shoulder* - A posterior dislocation of the shoulder would show the **humeral head displaced posteriorly** relative to the glenoid, often characterized by a "light bulb" sign or loss of true glenohumeral articulation. - The image exhibits an **intramedullary lesion** within the humeral shaft, not a displacement of the joint.

Q: A 65-year-old man presents with bone pains. X-ray Skull shows? (Recent NEET Pattem 2018-19)

Multiple myeloma. ***Multiple myeloma*** - The X-ray shows multiple, well-defined, lytic lesions (''**punched-out lesions**'') scattered throughout the skull, which is highly characteristic of multiple myeloma. - This condition is a **plasma cell malignancy** that commonly affects older adults and often presents with **bone pain** due to osteolytic activity. *Paget's disease* - Characterized by abnormal bone remodeling, leading to bone enlargement, thickening, and a **"cotton wool" appearance** on X-ray, which is not seen here. - While it can cause bone pain and skull involvement, the lytic pattern in the X-ray is not typical for Paget's disease. *Fibrous dysplasia* - This condition involves **normal bone marrow** being replaced by **fibrous tissue** and immature bone, often presenting as a **ground-glass appearance** or expansile lesions, usually in younger individuals. - The distinct "punched-out" lesions seen in the image are not characteristic of fibrous dysplasia. *Histiocytosis-X* - Also known as Langerhans cell histiocytosis, it can cause **lytic bone lesions**, particularly in the skull, described as a **"map-like" or "geographic" pattern**. - Although it causes lytic lesions, the pattern in the image, with its numerous small, widespread lytic lesions, is more indicative of multiple myeloma in an older adult.

Q: A 75-year-old female has chronic backache. X-ray spine is shown. What is the most likely diagnosis?

Osteoporosis. ***Osteoporosis*** - The X-ray shows diffuse **decreased bone density**, **vertebral body height loss** (compression fractures), and a **biconcave** (codfish) appearance of the vertebral bodies, all classic signs of osteoporosis. - The patient's age (75-year-old female) and chronic backache are consistent with **postmenopausal osteoporosis**, a common cause of such spinal changes. *Pott's spine* - Pott's spine, or **tuberculous spondylitis**, typically presents with **destruction of vertebral bodies** and **intervertebral discs**, often with an associated **paravertebral abscess**. - The X-ray imaging does not show signs of significant disc space narrowing, vertebral destruction, or soft tissue masses that would indicate an infectious process like Pott's spine. *Spondylolisthesis* - **Spondylolisthesis** involves the **anterior slippage of one vertebra over another**, which would be evident as a misalignment in the lateral spinal X-ray. - The image does not demonstrate any significant forward displacement of a vertebral body relative to the one below it. *Spondylodiscitis* - **Spondylodiscitis** is an **infection of the intervertebral disc space** and adjacent vertebral bodies, typically presenting with **erosions** and **destruction at the endplates** and **narrowing of the disc space**. - While there is some disc space narrowing due to degenerative changes, the prominent features of diffuse osteopenia and vertebral compression fractures are not typical of an acute or chronic infection.

Q: A 6-year-old boy presents with severe anemia and organomegaly. Peripheral smear was performed. The X-ray of hand shows:

Squaring of metacarpals. ***Squaring of metacarpals*** - The X-ray image shows **widening of the medullary space** and cortical thinning in the metacarpals, leading to a squared appearance. This is a classic finding in **beta-thalassemia major**, an inherited blood disorder characterized by severe anemia and organomegaly. - The associated microscopic image on the left likely shows **target cells**, which are also characteristic of thalassemia. *Hemarthrosis* - **Hemarthrosis** refers to bleeding into a joint space, which is typically seen in coagulopathies like **hemophilia**. - X-rays would show signs of joint distension, effusions, and eventually degenerative changes, but not the specific bone changes seen here. *Swan neck deformity* - A **swan neck deformity** is characterized by hyperextension of the proximal interphalangeal (PIP) joint and flexion of the distal interphalangeal (DIP) joint. - This deformity is classically associated with **rheumatoid arthritis** or other inflammatory arthropathies, not the described hematological disorder. *Subperiosteal resorption* - **Subperiosteal resorption** is a characteristic radiographic finding in **hyperparathyroidism**, often affecting the radial aspects of the middle phalanges. - It results from increased osteoclast activity and would not be the primary bone change seen in a young child with severe anemia and organomegaly.

Q: A middle-aged man presents with a lower jaw swelling. Clinically, there is expansion of the left ramus and the X-ray mandible shows soap bubble appearance. What is the clinical diagnosis?

Ameloblastoma. ***Ameloblastoma*** - Ameloblastoma is the most common odontogenic tumor, often presenting as a **slow-growing, expansile swelling** in the posterior mandible, as seen in this patient. - The classic **"soap bubble" or "honeycomb" radiographic appearance** is highly characteristic of ameloblastoma, reflecting its multilocular nature. *Aneurysmal bone cyst* - While an aneurysmal bone cyst can cause bony expansion, it typically presents with a **blood-filled lesion** and may not consistently show a "soap bubble" appearance unless it's very large and destructive. - Radiographically, it often appears as a **lytic lesion** rather than strictly multilocular. *Odontogenic myxoma* - Odontogenic myxoma can also cause jaw swelling and has a multilocular appearance, but it's often described as having a **"tennis racket" or "stepped ladder" trabeculation** pattern rather than clear "soap bubbles." - Its incidence is lower than ameloblastoma, making it less likely given the classic presentation. *Keratocyst* - An odontogenic keratocyst (OKC), now often referred to as a **keratocystic odontogenic tumor (KCOT)**, is primarily a cyst that can grow extensively and cause expansion. - Radiographically, it typically appears as a **well-defined, unilocular or multilocular radiolucency** but rarely has the classic "soap bubble" appearance as consistently as ameloblastoma.

Q: A man presents with back pain following a road traffic accident (RTA). There is no history of neurological deficit. An X-ray of the spine is done. What is the diagnosis based on the image?

Spinous process fracture. ***Spinous process fracture*** - The X-ray image reveals a **fracture of the spinous process** of one of the cervical vertebrae, characterized by a visible discontinuity or separation of this posterior bony projection. - This type of fracture, often caused by direct trauma or forceful hyperextension/hyperflexion, typically presents with localized back pain but often **without neurological deficit** as the spinal canal generally remains intact. *Chance fracture* - A **Chance fracture** (or seatbelt fracture) is a horizontal fracture of a vertebral body, usually in the thoracolumbar region, often caused by distractional forces (e.g., flexion over a seatbelt). - It involves all three columns of the spine (anterior, middle, and posterior) and is not seen in the cervical spine X-ray provided. *Compression fracture* - A **compression fracture** is characterized by the collapse of the vertebral body, often resulting in a wedge shape. - This typically appears as reduced height of the anterior vertebral body on an X-ray, which is not the primary finding in the image. *Fracture of base of vertebrae* - A **fracture at the base of the vertebrae** is a non-specific term; specific vertebral fractures are categorized based on the part of the vertebra affected (e.g., vertebral body, pedicle, lamina, spinous process). - The image distinctly shows a fracture in the **spinous process**, not the main body or base of the vertebra.

Q: A 35-year-old man presented with knee pain. The x-ray of his knee joint is given below. What is the probable diagnosis?

Paget's disease. ***Paget's disease*** - X-rays of Paget's disease show **thickened, sclerotic bone** with coarse trabeculae, often giving a cotton wool appearance, which is consistent with the image. - The disease involves increased bone turnover, leading to **disorganized bone remodeling** and enlarged, weakened bones. *Osteoarthritis* - Osteoarthritis typically presents with **joint space narrowing**, osteophytes, subchondral sclerosis, and cysts, which are not the predominant features in the given image. - It is primarily a degenerative joint disease affecting articular cartilage, rather than the extensive bone remodeling seen here. *Osteosarcoma* - Osteosarcoma is a malignant bone tumor characterized by a **destructive lesion** with associated soft tissue mass, sunburst periosteal reaction, or Codman's triangle. - The image does not show typical osteosarcoma features but rather diffuse bone remodeling. *Multiple myeloma* - Multiple myeloma usually presents with **punched-out lytic lesions** on X-ray, diffuse osteopenia, or generalized osteoporosis. - The image does not show lytic lesions characteristic of multiple myeloma.

Q: A patient with systemic mastocytosis undergoes skeletal survey. Which radiological finding is most characteristic of skeletal involvement?

Sclerotic bone lesions. ***Sclerotic bone lesions*** - **Sclerotic bone lesions** are the most characteristic radiological finding in systemic mastocytosis with skeletal involvement, appearing as numerous small, dense foci creating a classic **"polka dot pattern"** on skeletal survey. - This pattern results from **mast cell infiltration** with subsequent **osteoblast stimulation**, leading to increased bone density. - The sclerotic pattern is seen in approximately **70% of patients** with skeletal mastocytosis and is highly suggestive of the diagnosis. *Lytic bone lesions* - While mastocytosis can occasionally present with lytic lesions, they are **much less common** than sclerotic changes. - Pure lytic lesions are more characteristic of **multiple myeloma**, **metastatic disease**, or **Langerhans cell histiocytosis**. *Mixed lytic-sclerotic lesions* - **Mixed patterns** can occur in mastocytosis but represent a less common presentation compared to predominantly sclerotic lesions. - When mixed lesions are present, they typically show **more sclerotic than lytic** components. *Periosteal reaction* - **Periosteal reaction** indicates periosteal irritation and is typically seen in **osteomyelitis**, **trauma**, **aggressive tumors**, or **hypertrophic osteoarthropathy**. - This is **not a characteristic feature** of systemic mastocytosis and would suggest an alternative diagnosis or complication.

Question 1

The X-ray and MRI findings given below point to the diagnosis of: (Recent NEET Pattern 2016-17)

Accepted Answer

Pigmented villonodular synovitis

Answer

Osteoid osteoma

Answer

Osteoclastoma

Answer

Osteosarcoma

Question 2

The following X-ray of the pelvis shows:

Accepted Answer

Gas shadow artifact

Answer

Simple bone cyst

Answer

Aneurysmal bone cyst

Answer

Posterior hip dislocation

Question 3

The given X-ray of the humerus shows:

Accepted Answer

Fibrous dysplasia

Answer

Aneurysmal bone cyst

Answer

Ewing sarcoma

Answer

Posterior dislocation of shoulder

Question 4

A 65-year-old man presents with bone pains. X-ray Skull shows? (Recent NEET Pattem 2018-19)

Accepted Answer

Multiple myeloma

Answer

Paget's disease

Answer

Fibrous dysplasia

Answer

Histiocytosis-X

Question 5

A 75-year-old female has chronic backache. X-ray spine is shown. What is the most likely diagnosis?

Accepted Answer

Osteoporosis

Answer

Pott's spine

Answer

Spondylolisthesis

Answer

Spondylodiscitis

Question 6

A 6-year-old boy presents with severe anemia and organomegaly. Peripheral smear was performed. The X-ray of hand shows:

Accepted Answer

Squaring of metacarpals

Answer

Hemarthrosis

Answer

Swan neck deformity

Answer

Subperiosteal resorption

Question 7

A middle-aged man presents with a lower jaw swelling. Clinically, there is expansion of the left ramus and the X-ray mandible shows soap bubble appearance. What is the clinical diagnosis?

Accepted Answer

Ameloblastoma

Answer

Aneurysmal bone cyst

Answer

Odontogenic myxoma

Answer

Keratocyst

Question 8

A man presents with back pain following a road traffic accident (RTA). There is no history of neurological deficit. An X-ray of the spine is done. What is the diagnosis based on the image?

Accepted Answer

Spinous process fracture

Answer

Chance fracture

Answer

Compression fracture

Answer

Fracture of base of vertebrae

Question 9

A 35-year-old man presented with knee pain. The x-ray of his knee joint is given below. What is the probable diagnosis?

Accepted Answer

Paget's disease

Answer

Osteoarthritis

Answer

Osteosarcoma

Answer

Multiple myeloma

Question 10

A patient with systemic mastocytosis undergoes skeletal survey. Which radiological finding is most characteristic of skeletal involvement?

Accepted Answer

Sclerotic bone lesions

Answer

Lytic bone lesions

Answer

Mixed lytic-sclerotic lesions

Answer

Periosteal reaction

Musculoskeletal Radiology — MCQs

Musculoskeletal Radiology — MCQs

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