BONE97

Bone Section
The following are True/False questions
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. 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.
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
*
Answer: 7. False 8. False 9. ?? True (BJ Manaster says that staph is still more
common than Salmonella in SCD) 10. True (immunosuppressed) 11. False (Although the
epiphysis is frequently involved too because some metaphyseal vessels in the infant cross to the
epiphysis. In the child, the epiphyseal plate becomes avascular and is a barrier to spread from
the metaphysis).
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
*
Answer: 12: False (DIP) 13: True (extensor mechanism) 14: True 15: True
1995, 1992
Fracture dislocations include:
16. Lisfranc (92)
17. Colles (95, 92)
18. Bennett (92)
19. Chauffeur (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 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 Chauffeur 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 dislocating up and back with
the distal fragment.
Galeazzi fracture: distal radial shaft fracture with distal radioulnar dislocation
Reference: Dahnert 1993, pp. 49-51
*
Answer: 16. True 17. False 18. True 19. False 20. True 21. True (22. True
(radial head dislocation)
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).
*
Answer: 23. True 24. True 25. True 26. True 27. False 28. True(esp if
medullary/intraarticular) 29. ???
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)
*
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 (increased in connective tissue disorders and ESRD)
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
*
Answer: 35. ??? 36. ??? 37. ??? 38. ??? 39. ???
1995
Regarding the skeletal manifestations 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
*
Answer: 40. False 41. ??? 42. False ?(skeletally immature children) 43. True
44. ???
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.
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)

*
Answers: 45. True 46. True 47. False 48. True 49. True
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
*
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. False 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???
*
Answer: 54. True 55. False (True in infant, adult) 56. True 57. False (avascular)
Reference: BJ Manaster Handbook of Radiology p 324. Dahnert 1996 p.76
1995
Regarding rupture of the quadriceps tendon:
58. most commonly occurs soon after the femoral physis has fused
59. associated with hemarthrosis 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
*
Answer: 58. ??? 59. True 60. True 61. True (can occur rarely in healthy person)
Ref: Baby Resnick 1996 p.859-860
1992
Which of the following are prominent features of seronegative spondyloarthropathy?
62. periostitis
63. dental ???
64. significant osteoporosis
*
Answer: 62. True (Reiter’s, psoriatic) 63. False 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
Ref: Baby Resnick 1996 p. 820
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
In general, oblique or spiral fractures of the malleoli are due to impacting (pushing) forces, while
transverse fractures are due to avulsing (pulling) forces.
Reference: Resnick 1989, pp. 857-859; BJM Handbook p. 259-260

*
Answer: 80. True 81. False 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; Baby Resnick 1996 p. 1141
*
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. pulmonary 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.
Histlogic 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.
*
Answers: 88. ??? 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
*
Answers: 92. False 93. True 94. True
“Psychiatry is the study of the id by the odd,” Salter of Salter-Harris fame.
1993
Concerning crystal deposition disease (CPPD):
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
*
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 (widened zone of provisional calcification). 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 (implies scurvy)
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 11-12 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. This is why the
frogleg view is helpful. 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
*
Answer: 111. True 112. False (malgrowth, such as in a Salter IV or V, but undergrowth due to
premature closure of physis).
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.
*
Answer: 119. True 120. True (only the Type 4, which may only be diagnosed by this view
121. True (useful, but internal rotation better for H-S deformity) 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 (internal) 126. False 127. False
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
*
Answer: 128. True 129. True (especially if the tumor produces sex hormones) 130. True
131. False (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
*
*
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.
References: Resnick 1989, p. 1049; Dahnert 1993, pp. 27, 87-88
*
Answer: 138. ??? 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.
*
Answer: 142. True 143. True 144. True 145. True (related to B2-microglobulin amyloid
deposition)
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. 879-880;
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. Thought to represent gaseous release into bony clefts within a
nonhealed fracture underneath endplate.
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 19963, pp. 153

*
Answers: 151. True 152. True 153. False? 154. True 155. False
1991
Epiphyseal overgrowth is seen in:
156. JRA
157. hemochromatosis
*
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.
*
Answers: 158. False??? 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.
*
Answer: 161. True 162. ??? 163. False (superior, internal rotation) 164. ??? 165.
False
1995 ITE
Causes of radiodense metaphyseal lines include:
166. hypervitaminoses
167. transplacental infections
168. treated leukemia
169. Paget’s disease
170. fluorosis
*
“Dense lines”
D-vitamin intoxication
Elemental arsenic, bismuth, phosphorus
Normal variant
Systemic illness
Estrogen to mother during pregnancy
Leukemia, lead poisoning
Infection (TORCH), idiopathic hypercalcemia
Never forget rickets
Early hypothyroidism
Scurvy, Sickle cell disease
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 infarctions. Radiographic features include:
1) Wimberger’s Ring
2) Pelkin’s Spur
3) Frankel’s Line
4) Trummerfeld’s Zone
5) Osteopenia
Answer: 166. True (vitamin D) 167. True (TORCH) 168. True 169. False 170. ???
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
preexisting lipomas. Well-differentiated liposarcomas can occasionally contain calcification or
ossification. the myxoid variety is most common (40-50%).
Reference: AFIP Notes, August, 1994 pp. J9-J10 (Kransdorf)
*
Answer: 171. False (although huge lesions likely sarcoma) 172. True 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 Psuedogout
1) weak positive birefringence
2) secondary to CPPD (calcium pyrophosphate dihydrate)
3) chondrocalcinosis: knee > symphysis pubis > TFC
4) associated with hemochromatosis and hyperparathyroidism
*
Answer: 176. False 177. ??? 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.
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
Dahnert 1996 p. 83
*
Answer: 181. True (13% vs. 2%) 182. ???? 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)
*
Answer: 186. True 187. False 188. False 189. True 190. True
Reference: Baby Resnick 1996 p. 916-921
1994
Which of the following can cause delayed healing of fractures?
191. dicumeral
192. corticosteroids
193. colchicine
194. diphosphonates
*
Drugs involved in delayed union of fractures:
colchicine, diphosphonates? I'll have to do a lit search.
steroids are definitely yes!
Search of the 1995 PDR did not list delayed union of fractures as a complication or side
effect with dicoumeral.
*
Answers: 191. False 192. True 193. ??? 194. ???
1994
Regarding a tear of the anterior cruciate ligament (ACL):
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.
References: Dahnert 1993, p. 48; Resnick 1989, pp. 808-813
*
Answers: 200. True 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
*
Answer: 204. True 205. True 206. ??? 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.
*
Answer: 209. False 210. False 211. True 212. False 213. True (inflammation and
infection give uniform loss)
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
*
Answer: 214. True 215. ??? 216. False??? 217. ??? 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
*
Answer: 219. True 220. False (more often) 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 = too skinny and gracile (e.g. OI);
Undertubulation = flaring of metaphyses (think anemias, storage diseases)
Carol Andrews does not think this tem applies to hyperemic disorders such as hemophilia or JCA
Answer: 224. True 225. False (undertubulated) 226. True 227. False 228. False
1993 ITE
The metacarpophalangeal joints are frequently involved in:
229. erosive osteoarthritis
231. gout
232. Wilson’s disease
233. acromegaly
*
Answer: 229. ??? 230. ??? 231. ??? 232. ??? 233. ???
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-99m-pertechnetate 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
*
Answer: 239. False (DDx includes synovial cell sarcoma) 240. False 241. False (knee)
242. ??? 243. False (no calcifications)
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%).
*
Answer: 244. False 245. False 246. False (pars) 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
253. synovial chondromatosis
*
Answer: 249. ??? 250. ??? 251. True 252. True (AFIP Notes, August, 1994) 253. ???
1995 my own
Which of the following are causes of disc space calcification?
254. CPPD
255. acromegaly
256. neurofibromatosis
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
Which of the following are associated with intra-articular cartilaginous and/or osseous loose
bodies?
259. synovial metaplasia
260. neuropathic joints
261. trauma
263. degenerative joint disease
*
Causes of neuropathic joint: syringomyelia, diabetes mellitus, leprosy, neurosyphilis,
myelomeningocele, spinal cord injury, congenital insensitivity to pain.
*
Answer: 259. ??? 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.
Answer: 264. False 265. False (AIIS) 266. False (greater troch) 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.
*
Answer: 269. ??? 270. False 271. ??? 272. True 273. ???
1992 ITE
A wide symphysis pubis is associated with:
274. cleidocranial dysostosis
275. extrophy of the bladder
276. Ehlers-Danlos syndrome
*
Answer: 274. True 275. True 276. ??? 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
*
Answer: 279. ??? 280. True 281. ??? 282. true 283. ???
1989
Regarding a Segond fracture:
284. fracture of the proximal fibula
285. represents avulsion fracture of the insertion of the tensor fascia lata (iliotibial band)
c. ???
*
Answer: 284. False 285. False
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.
*
Answer: 290. False 291. False 292. True 293. True 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
*
Answer: 300. True 301. False 302.True 303.True 304. False
Select the single best 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
Answer: a
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 slight 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
*
Answer: ???
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
*
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
*
Answer: d or b
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
*
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
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
*
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. I do not see supracondylar fracture quoted in my sources.
*
Answer: d
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
*
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.
- 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.
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
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, atlanto-occipital
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.
*
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
*
Answer: d
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
Answer: f. medial epicondyle in children, coronoid in adults
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
*
Segond fracture.
*
Answer: c
1992
25. Numerous low signal masses are seen in the joint space and synovium on T1-weighted
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)
*
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.
*
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
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.
*
Answer: b
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.
*
Answer: c. subcapital fracture
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
*
Answer: b. hyperparathyroidism is a cause
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.
facet arthrosis, shape of canal (congenital short pedicles), osteophytes, and disc bulge
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: c (RSD)
The following are matching questions:
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
*
Answer: ???
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.
*
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
*
Answer: 7. c 8. e 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 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 anterior midfemur. The
gracilis inserts in the pes anserinus.
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
*
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
*
Answer: 16. c 17. d 18. a 19. b
1995
20. aluminum toxicity
21. amyloid
a. tibial periostitis
b. AVN
c. carpal cysts
d. protrusio acetabuli
e. spontaneous fractures of the upper three ribs
*
Answer: 20. ??? 21. ??? 22. ???
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
*
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.
*
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.
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. c 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.
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.
Felty syndrome = rheumatoid arthritis, splenomegaly, and leukopenia
*
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) Resnick 1989, p. 890
The trochlea may have two ossification centers. (Fractures and Joint Injuries, p. 615)
*
Answers: 45. b 46. a 47. d 48. c (really medial epicondyle???)
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.)
Reference: Schulz 1990, p. 254
*
Answers: 49. b 50. d
1991
51. ankylosing spondylitis
52. Mining
53. radium dial painters
a. leukemia
b. lung cancer
c. thyroid cancer
d. bone cancer
e. renal cancer
*
Answer: 51. a 52. b 53. d
1991
54. tricompartmental DJD of the knee
a.. CPPD
*
Answer: ????
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. a 56. b 57. d
1994
58. aortitis
59. balanitis
60. ivory phalanx
61. involvement of the SI joints
62. periosteal reaction
63. osteoporosis
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
Ankylosing spondylitis - aortic insufficiency and conduction deficits
Psoriatic - ivory phalanx, periosteal reaction frequent
*
Answers: 58. a 59. a 60. b (less commonly a) 61. c (less commonly b and c) 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
2) 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
Answer: 64. ??? 65. b??? 66. b
1995 ITE
Matching regarding bone abnormalities:
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”)
*
Answer: 67. ? c 68. B (Rugger jersey) 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
*
Answer: 70. a 71. a 72. d
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.
*
Answer: 73. a??? 74. d??? 75. e
1994 ITE
76. disuse osteoporosis
77. osteomalacia
a. subchondral bone resorption

b. indistinct trabeculae
c. frayed metaphyses
d. biconcave vertebrae
e. metaphyseal lucent bands
*
Answer: 76. ??? 77. ??? 78. ???
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
*
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.
Also, see question 11
*
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
*
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
*
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. ???

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Bone Section

The following are True/False questions

1994, 1992, 1988

Reference: Resnick 1989, pp. 812-814

1993, 1992, 1991

Reference: Resnick 1989, pp. 857-859; BJM Handbook p. 259-260

“Psychiatry is the study of the id by the odd,” Salter of Salter-Harris fame.

1994, 1992, 1990

Do they mean Calve-Kummel-Verneuil disease? It sounds similar to regular ole’

Reference: Dahnert 19963, pp. 153

Reference: Baby Resnick 1996 p. 916-921

Whenever an abnormality of the anterior cruciate ligament is observed, it is always

Reference: MRI of the Body, Higgins 1992, p. 1106

1994 ITE, 1992 ITE

1993 ITE, 1990

Select the single best answer:

Also see similar question in True/False section

Answer: f. medial epicondyle in children, coronoid in adults

Match the following muscles with their origins/insertions:

a. medial epicondyle of the elbow

a. base of 5th metatarsal

1995, 1994, 1993, 1988

a. enlargement of the semimembranosogastrocnemius bursa

a. oral, ocular, and genital skin lesions

a. The last center to ossify

1994, 1992, 1990

a. exaggerated concavity of anterior margin

Answer: 64. ??? 65. b??? 66. b

a. round, sclerotic region abutting the endplate

a. lateral meniscus usually affected

a. radial head aligns with capitellum

a. subchondral bone resorption

a. thoracic curve convex to right

a. avascular necrosis of the lunate

a. most commonly fractured in associated with adult elbow dislocations

a. the least common of the congenital tarsal coalitions

a. bunk bed fracture

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