image Q. 124 - House of pain

Q.    Which of these has highest constituent of prostaglandins?


a. Synovial sarcoma
b. Subungual glomus tumor
c. Malignant Fibrous histiocytoma
d. Osteoid osteoma
e. Bone infarcts

Answer -
d

 Osteoid forming benign bone tumor osteoid osteoma has small foci and radiologically presents as small nidus with reactive sclerosis around.

Thin slice CT or bone scan may be additional imaging modalities.

Night pain with dramatic relief on taking NSAIDS is characteristic feature and is due to high prostaglandins present in the lesion especially PGE2 and PGI2.

image Q . 123 - Teething trouble

Q.     'Tooth sign' is not related to teeth but is found in ?


a. Carpal bones
b. Upper cervical vertebrae
c. tarsal bones
d. Patella
e. Skull bones

Answer -
d

Tooth sign is radiological sign suggestive of quadriceps insertional degeneration, tendinopathy or enthesopathy.

The resulting picture is of vertical ridging or spurring and osteophyte over patella at insertion site of quadriceps tendon (schematic image below )

Better seen in skyline patella views.

image Q. 122 - Under tension

Q.  Tension band injuries is commonly found in?

a. Patella
b. Greater trochanter
c. Spine
d. Pelvis
e. Ankle

Answer -
c

The posterior column of spine behaves like tension band against injury forces and thus acts as posterior restraining structure.

Eg. in thoracic injuries posterior facet and posterior ligamentous structures.

Thus in thoracic spine these injuries are also called 'tension band injuries' as these affect posteroligamentous complex (PLC) or tension band of the normal spine.




Link:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804719/

image Q. 121 - Emergency acronyms

Q.   Below are all common acronyms used in the settings of emergency care except?

a. AVPU
b. FAST
c. SALT
d. DAIR

Answer -
d

A classic scale to assess consciousness of patient in emergency settings is AVPU. It stands for
Alert
responds to Voice
responds to Pain
Unresponsive
This was initial scale used by ATLS. ( Advances trauma Life Support).

Focused Abdominal Sonography for Trauma is for rapid diagnosis of intrabdominal haemmorhage used in all unstable patients with risk of abdominal injury.
Additional views to assess pleural spaces for pleural effusion is termed E- FAST (extended FAST).


There are several mass casuality triage systems. SALT is one algorithm.
Sort
Assess
Life saving interventions
Treatment/ Transport
 This helps patients to be grouped into 4 categories of minimal, delayed, immediate and dead/ expectant to prioritize treatment or transfer.

DAIR is an acronym for Debridement, Antibiotics and Implant Retention. This is practiced in early periprosthetic infection usually within 4-12 weeks of surgery.

image Q. 120 - The shape of it

Q.   Which of these constitute largest proportion of articular cartilage?

a. Cells
b. Collagen
c. Water
d. Proteoglycan
e. Hyaluronic acid

Answer -
c

Water constitutes the largest part of hyaline articular cartilage.

Water - 70-80% followed by Collagen 10-20%.
Rest are Proteoglycan and cells(chondrocyte as only cells).

Most if collagen is type 2

Cartilage acts as biphasic material with water and solid phase.

Type 2 collagen has least reparative quality.
It is like hyoerhydrated sponge with viscoelastic properties.
In normal activities (like walking) it behaves more as viscous and while in running it behaves in elastic manner to protect the joints.

image Q. 119 - Index case

Q.    The first arthroscopic surgery was done for?

a. Loose body removal from joint
b. Drainage of effusion
c. Baker's cyst
d. Synovial biopsy
e. Villonodular synovitis

Answer -
e

First arthroscopic surgery was done for removal of  PVNS (Pigmented VilloNodular Synovitis) from knee in 1969 by Masaki, Watanabe and colleagues.

image Q.118 - Inheritance of flaws

Q.  Which of these is commonest inherited neurological disorders ?

a. Cerebral palsy
b. Neurofibromatosis
c. Down's syndrome
d. Charcot- Married - Tooth disease
e. Multiple sclerosis

Answer -
d

Charcot -Marrie-Tooth is the most common inherited neurological disorder affecting nerves. It results in muscle imbalance.

It is also called Hereditary Motor Sensory Neuropathy (HMSN).

It's incidence on 1 in 2500 in U.S.

Common features include family history and features like cavovarus feet, scoliosis, hammer toe etc.

Down syndrome is common genetic disorder and cerebral palsy is caused mostly by birth related complications.

image Q. 117 - Elbow room

Q.    Which of the bony structure should be assessed in a child with elbow dislocation?

a. Lateral condyle
b. Trohlea
c. Capitellum
d. Medial epicondyle
e. Radial neck

Answer -
d

Medial epicondyle is the most common fracture associated with elbow dislocation in children.

Sometimes the medial epicondyle is displaced and incarcerated into elbow joint blocking the reduction.

So, if the medial epicondyle is not visible in radiograph then we must suspect displacement of it into elbow joint.

So the answer is medial epicondyle that should be assessed in radiograph.

image Q. 116. - Namesake

Q.  All of these are synonyms that are interchangeably used except?

a. Cotyloid fossa AND acetabular fossa
b. Caput collum diaphysis angle AND neck shaft angle
c. Scarpa's triangle AND femoral triangle
d. Promontory AND ala
e. Plafond AND dome

Answer -
d and e

Cotyloid fossa is found in acetabulam and is synonymous with acetabulam fossa.

CCD ( caput collum diaphysis angle) is nothing but another name for neck shaft angle of proximal femur.

Scarpa's triangle is femoral triangle. Pain and tenderness over this triangle suggests hip joint or femur neck pathology.

Promontory and ala are part of sacrum but they are not the same ( see image below first)

Plafond is distal tibia articular surface that is like roof of ankle joint over the dome of talus  and thus are not the same ( image second).

image Q. 115 - Test of curves

Q.  The radiograph of spine below displays slight abbormal curve. Which if the clinical test below will confirm benign nature of the curve?

a. Allen's test
b. Adam's test
c. Adson's test
d. Anderson's test
e. Eden test

Answer -
b

The abnormal curve mentioned in the question is scoliosis as the radiograph is an anteroposterior view.

The question intends to ask about the test that suggests that the deformity is benign or not structural.
The test to ensure that the scoliosis is functional ( benign) and not structural is the one that is asked here.

The patient is asked to bend forward upto ninety degrees and the back is inspected from behind of patient. If there is improvement and there is no bump visible then the deformity is non-structural and if a bump or rib hump is seen then the deformity is fixed and structural.
This is called Adam's forward bending test.

Adson's test is for thoracic outlet syndrome. It is provocative test to create posture that puts pressure over neurovascular bundles in neck in conditions like cervical rib (cervical rib syndrome) or between scaleneus muscles ( scaleneus anticus syndrome)

Eden test is also for a variant of thoracic outlet syndrome symptoms. It is called costoclavicular syndrome as the compression site is between firts rib and clavicle.

Allen test is used to measure patency of radial and ulnar arteries before many procedures like hand surgeries, radial artery bypass graft or cannulation or arterial blood gas analysis etc.

image Q. 114 - Real Steel

Q.   Orthopaedic implants usually are  made of stainless steel 316 L. The letter 'L'  stands for  which of these?

a. Lightweight
b. Longevity
c. Lead content
d. Large molecular weight
e. Low carbon content

Answer -

e

The stainless steel grade 316L is used in steel implants. The L stands for low carbon. Lesser carbon makes inplant better resistant to corrosion.
Another variant of it is 316 LVM that is 316 L Vacuum Melted.

image Q. 113 - Tilted

Q.   Lateral tilt of the spine is called ?

a. Lumbago
b. Scoliosis
c. List
d. Listhesis
e. Pisa syndrome

Answer -
c


List is a lateral tilt of the spine.

 A plumb line dropped from the spinous process of T1
falls to one side of the gluteal cleft.
Thus attitude may follow a symptomatic herniated disk and painful
spasms of the paravertebral muscles.

Lumbago is lower back pain.

Listhesis is displacement of one vertbra over the other in front ( anterolisthesis) or back (retrolisthesis). This is identified in lateral or oblique radiograph. Common site is lumbosacral junction.

Pisa syndrome is involuntary flexion muscular dystonia and lateral flexion of trunk with some rotational element. It may be complication of long term drugs like  antipsychotic treatment.

image Q. 112 - Healed by bug

Q.    Localised administration of Collagenase injection is sometimes used to treat Dupuytren's contracture. Which of these is usual source of it?

a. Clostridium histolyticuml
b. Botilunum toxin
c. Vibrio species
d. Sachomyces boulardii
e. Lactobacillus acidophilus

Answer -
a

Collagenase derived from  is one of the option to treat Dupuytren's contracture as it is given as intralesional injection over diseased cords.

Botulinum toxin extracted from Clostridium botulinum is another matter that is used in various piroses in musculoskeletal care like in spasticity management etc.

Last two options are used as probiotics.

image Q. 111 - Curvaceous

Q.   Primary curve of the spine is ?

a. Straight
b. Kyphosis
c. Scoliosis
d. Lordosis
e. Circular

Answer -
b

The primary curve if the spine is one which is in the beginning and in newborn the spine is overall kyphosis.

The lordosis is later developed.

As the newborn has head holding the cervical lordosis develops.

 As the child starts standing then lumbar lordosis develops.
 Thus at only thoracic level, the primary curve persists as normal thoracic kyphosis.

image Q. 110 - Testing times

Q.   Which among these is least helpful to diagnose any musculoskeletal disorder ?

a. Slocum test
b. Yocum test
c. Bolam test
d. Fulcrum test

Answer -
c

Slocum test is used in knee ligamentous injury.

It is a mofdification of anterior drawer test, it measures antrromedial and anterolateral rotatory instabilities (AMRI and ALRI).

Yocum test is atest for shoulder examination for rotator cuff injury.

Fulcrum test is used to test for stress fracture of hip and thigh.

Bolam test , on the other hand, is a medicolegal entity. Used for evaluation of medical negligence.

It states "The test is the standard of the ordinary skilled man exercising and professing to have that special
skill. A man need not possess the highest expert skill, it is well established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising' that particular art (a health care professional), is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical man skilled in the particular act"

image Q. 109 - 'When going gets 'tuft'....

Q.  Tuft fractures are related to ?

a. Pelvis
b. Sacrum
c. Hand
d. Ankle
e. Foot

Answer -
c

Distal phalanx fracture of fingers or digits is called tuft fracture (see image below)


It can be associated with nail bed injuries.

image Q. 108 - Coming of 'age'

Q.  Which if these is least valid procedure for joint or bone disorder?

a.  Forage
b. Circlage
c. Lavage
d. Remplissge
e. Barbotage

Answer -
e

Forage is core decompression procedure for relieving pressure from femoral head by bone drilling in cases of osteonecrosis.

 Circlage is procedure of fixing bones with the help of stainless steel wire or fibre wire etc. to secure them together. Commonly done in cases of periprosthetic fractures, patella fracture etc.

Lavage is washout with copius amount of fluid or daline. It is done for open injuries but intraarticular lavage can be done for joint pathologies with arthroscopic method. Also an option in osteoarthritis knee.

Remplissage is surgical procedure for management of shoulder instability with large and engaging humeral defect ( Hill Sach lesion) which is covered to avoid contact with glenoid and treated in this manner.

Barbotage involves multiple repeated injection of fluid or aspiration in various pathologies like spinal anasthesia, surgical biopsies, gastric lavage or calcific musculoskeletal lesions. This is not specific, thus the best option here

image Q. - 107 - Bad dish

Q.    'Dishwater fluid' is found in ?

a. Tubercular sinus
b. Gonococcal arthritis
c. Chronic osteomyelitis
d. Necrotising fasciitis
e. Morel Lavallee lesion

Answer -

d

Dishwater is the water after the dishes  have been washed in it.

Murky grayish colored fluid from soft tissue is suggestive if underlying necrosis and is characteristic feature of necrotising fasciitis.

Chronic osteomyelitis and tubercular in late stagfes show clear serious discharge.

Morel Lavallee lesion is internal degloving injury found after traumatic injury. This is associated with collected blood, lymph, and local debris.

image Q. 106 - 'Out'standing

Q.   Which of these is not a part of WHO safe surgery checklist ?

a. Time out
b. Pull out
c. Sign in
d. Sign out

Answer -

b

WHO safe surgery checklist has three broad categories ( refer to the image below the text)

Sign in -  Basic patient and surgical site identification along with anasthesia related  information.

Sign out -
Recall of relevant details after the procedure.

Time out -
Intraoperative confirmation of key details.

Pull out, on the other hand is related to screws. Pull out strength of screw is measure of its strength of  purchase inside bone and effort of its removal.

image Q. 105 - In fragments

Q.   All of these are associated with traumatic injuries except ?

a. Butterfly fragment
b. Thurston - Holland fragment
c. Free fragment
d. Constant fragment

Answer -
c

Comminuted fractures especially short oblique fractures are usually associated with a broken separate piece of bone on radiographs and it is called the butterfly fragment.

Physeal injuries in children if associated with a part of metaphyseal are fractured is classified as Salter Harris type 2 in the classification of same name. This small metaphyseal part is called Thurston - Holland fragment or sign.

Constant fragment is related to calcaneal fractures in which one broken part is considered constant and surgery was done to put together other parts to this one. This ,however, was an older concept.

Free fragment is extruded fragment of intervertebral disc that is broken and now lies free inside spinal canal.

image Q. 104 - Spare the spur

Q.  ' Butress' or 'spur' formation is a feature of

a. Periosteal chondrosarcoma
b. Periosteal osteosarcoma
c. Periosteal Chondroma
d. Parosteal osteosarcoma

Answer -
c


The 'Butress' refers to the part of the bone that is elevated at the base of the tumor looking like a spur and the saucer- shaped erosion of the bone above it (see image below)

This is characteristic feature of periosteal Chondroma.

Periosteal Chondroma ( or Juxtacortical Chondroma or ecchondroma) is rare benign cartilage growth beneath periosteum and mostly at tendon insertion sites.

Proximal humerus is common site.