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84. A. B. C. D. You are shown a single lateral radiograph (Figure 1). What is the MOST likely diagnosis? Klippel-Feil syndrome Chronic juvenile arthritis Ankylosing spondylitis Diffuse idiopathic skeletal hyperostosis (DISH)
Diagnostic In-Training Exam 2006
Section IV – Musculoskeletal Radiology
Question 84 Rationales: A. Incorrect. Klippel-Feil syndrome includes any congenital fusion of the cervical vertebra which may involve one or more levels. This fusion may be partial or complete affecting the anterior and/or posterior elements. The original syndrome, consisting of short neck, low posterior hairline and limited neck mobility, is present in less than half of such cases. Approximately 20-25% of cases are associated with Sprengel’s deformity. The diffuse ankylosis in the test case is NOT associated with hypoplastic intervertebral discs with a constricted appearance which is typical of fusion that occurs on a congenital basis. B. Incorrect. Ankylosis of the apophyseal joints typically involves the upper cervical spine, usually C2 C3 and C3 C4. The associated vertebra and intervertebral discs do not develop normally and appear hypoplastic. C. Correct. Diffuse, uniform ankylosis is typical of advanced ankylosing spondylitis. There is extensive syndesmophyte formation and facet joint fusion. The vertebra and intervertebral discs are mature, without hypoplasia. Because the discs and facet joints are fused, trauma results in atypical fracture patterns as in the test case where “pseudarthrosis” is present at the C6 7 level. There is osseous fusion at the interverbral discs and facet joints. Fine, vertical syndesmophytes are evident. Subsequent fracture is also present at the lower cervical region D. Incorrect. Diffuse idiopathic skeletal hyperostosis involves ossification of numerous ligaments throughout the body, typically the anterior longitudinal ligament (Forrestier’s Disease). Lateral radiographs show flowing, ribbon like ossification anterior to the vertebra with relative preservation of disc space height.
American College of Radiology
Section IV – Musculoskeletal Radiology
85. You are shown sagittal proton density and coronal proton density fat-suppressed MR images (Figures 2A and 2B). What is the MOST likely diagnosis? A. B. C. D. Meniscal flounce Bucket-handle tear Myxoid degeneration Discoid meniscus
American College of Radiology
Section IV – Musculoskeletal Radiology Figure 2B Diagnostic In-Training Exam 2006 4 .
Normal menisci are semilunar fibrocartilage structures at the periphery of the medial and lateral joint compartments. 5 American College of Radiology . presumably due to traction related to positioning.Section IV – Musculoskeletal Radiology Question 85 Rationales: A. like a disc between two adjacent vertebrae. Correct. Meniscal flounce refers to a physiologic change in the shape of the meniscus. The undulating appearance may mimic a tear. which may be observed during routine MR imaging. Such menisci are usually not torn. B. degeneration and perhaps intrasubstance tear. Incorrect. or there is an associated meniscal cyst. There is excessive meniscal tissue occupying the lateral joint compartment. The lateral meniscus is almost always involved. usually the medial. C. The etiology of the discoid meniscus is unknown. D. with displacement of the more central meniscal tissue (the bucket handle) to the intercondylar notch. indicative of cavitation. The bucket-handle tear involves a longitudinal tear at the periphery of the meniscus. Incorrect. Prominent areas of increased signal intensity within the substance of a meniscus are more significant when the meniscus is discoid in nature. Increased signal within the substance of the meniscus that does not extend to its superior or inferior articular surface may represent several phenomena including peripheral neurovascular structures. Incorrect.
C. B. Brodie’s abscess Osteoid osteoma Stress fracture Non-ossifying fibroma 6 American College of Radiology . What is the MOST likely diagnosis? A.Section IV – Musculoskeletal Radiology Figure 3A 86. You are shown AP and lateral radiographs (Figure 3A and 3B) of a 24-year-old man with chronic leg pain. D.
Section IV – Musculoskeletal Radiology Figure 3B Diagnostic In-Training Exam 2006 7 .
Most are cortically based and surrounded by exuberant reactive uniform sclerosis. The lucency itself usually demonstrates an elongated appearance with the suggestion of loculations and tracts or channels. There is an elongated. D. Incorrect. It is cortically based and is usually surrounded by a thin. lobulated sclerotic margin. C. They are characteristically 1-4 cm lucent subcortical lesions surrounded by spongy bone eburnation and periosteal reaction. A Brodie’s abscess may be evident during the subacute or chronic stages of osteomyelitis. The nidus of osteoid osteoma is generally smaller than 1. 8 American College of Radiology . well-defined.5 cm. B. Correct. channel-like. Incorrect. Incorrect.Section IV – Musculoskeletal Radiology Question 86 Rationales: A. with surrounding sclerosis and chronic periosteal reaction. Periosteal reaction without fracture is rare. multilculated lytic lesion at the proximal tibia adjacent to the anterior cortex. The lucency of a stress fracture is linear and intracortical in location. A Nonossifying fibroma is a benign geographic lesion that occurs most frequently in a metadiaphyseal location.
C.Section IV – Musculoskeletal Radiology Figure 4A 87. You are shown an AP radiograph and coronal fast spin-echo proton density image of a 13-yearold boy with knee pain (Figures 4A and 4B). 9 Enchondroma Chondromyxoid fibroma Clear cell chondrosarcoma Chondroblastoma American College of Radiology . D. B. What is the MOST likely diagnosis? A.
Section IV – Musculoskeletal Radiology Figure 4B Diagnostic In-Training Exam 2006 10 .
Incorrect. Conventional radiographs show an eccentric lesion with a sclerotic inner margin and some degree of expansile remodeling. Most are asymptomatic until pathologic fracture. CMF is a rare metaphyseal lesion. usually with a sclerotic border. Most patients are between 10 and 20 years of age. Clear cell chondrosarcoma. D. Conventional radiographs demonstrate cartilaginous calcification and periosteal reaction in less than half the cases. In long tubular bones. Chondroblastoma is a benign cartilaginous tumor of childhood that occurs in the epiphysis or apophysis. is an end-of-thebone lesion occurring in middle age and young adults. with or without cartilaginous calcification. Enchondroma is a common lesion characterized by the formation of mature hyaline cartilage. most common about the knee. 11 American College of Radiology . These lesions are usually small and well defined. though usually larger. well-defined. Conventional radiographs show a lytic lesion. About one third of cases show calcification within the lesion. it is most common at the proximal femur and humerus. Associated bone marrow edema may be noted with MR imaging. most commonly about the knee.Section IV – Musculoskeletal Radiology Question 87 Rationales: A. usually in young adults. enchondromas are most often metaphyseal. Conventional radiographs show a lytic lesion with well-defined sclerotic borders. Correct. like chondroblastoma and giant cell tumor. There is a small. well defined lesion at the proximal tibial epiphysis. It is the least common benign cartilage neoplasm. Patients may present after reaching skeletal maturity. similar in appearance to chondroblastoma. Lesions may also have poorly defined margins. Incorrect. A rare. Endosteal scalloping may be present with larger lesions. with a lobulated border. They are most common at the metacarpals and phalanges. C. Patients are adolescents and young adults. Incorrect. low grade malignancy. B. It is seen throughout life.
Malignant transformation B.Section IV – Musculoskeletal Radiology Figure 5 88. Which one of the following is associated with this disorder? A. Renal disease 12 American College of Radiology . You are shown an AP radiograph (Figure 5) of a 20-year-old woman. Multiple fractures D. Sexual precocity C.
Incorrect. Incorrect. Renal osteodystrophy is characterized by osteomalacia and secondary hyperparathyroidism. brown tumors. and renal osteodystrophy. Malignant transformation to chondrosarcoma is a well known complication of multiple hereditary exostoses. 2-5% more likely. the McCune-Albright syndrome. Bone that is more prone to fracture is seen with many congenital/developmental and metabolic disorders including osteogenesis imperfecta. Correct. The literature describes an incidence ranging from 1-25%. Incorrect. Radiographic findings include subperiosteal resorption. D. Multiple sessile osteochondromata about the hips characterize this case of multiple hereditary exostoses. osteopenia and osteosclerosis.Section IV – Musculoskeletal Radiology Question 88 Rationales: A. Sexual precocity or precocious pseudopuberty is associated with fibrous dysplasia. osteopetrosis. Diagnostic In-Training Exam 2006 13 . insufficiency fractures. B. C. Patients with multiple hereditary exostoses are not more prone to fracture.
Sartorius Rectus femoris Tensor fasciae latae Iliopsoas 14 American College of Radiology .Section IV – Musculoskeletal Radiology Figure 6A Figure 6B 89. What tendon is avulsed? A. You are shown coronal inversion recovery and axial fat-suppressed T2-weighted images (Figures 6A and 6B) of a 43-year-old woman with hip pain. D. C. B.
The sartorius. Incorrect. originates at the anterior superior iliac spine. crosses the hip and inserts at the lesser trochanter. Correct. The iliopsoas originates as the iliacus and psoas musculature at the anterior iliac wing and paravertebral lumbar spine respectively. the longest muscle in the body. B. C. Incorrect. semitendinosus) at the proximal medial tibia. The rectus femoris originates at the anterior inferior iliac spine where the abnormality is present in the test case. The tensor fasciae latae originates at the posterolateral margin of the iliac crest and crosses the hip and knee and inserts as the iliotibial band at Gerdy’s tubercle at the proximal lateral tibia. vastus medialis. gracilis. vastas lateralis.Section IV – Musculoskeletal Radiology Question 89 Rationales: A. It crosses the hip and inserts as a component of the quadriceps tendon (rectus femoris. D. crosses the hip and knee and inserts as a component of the pes anserinus (sartorius. vastis intermedialis) at the patella which continues distally as the patella tendon. Incorrect. Diagnostic In-Training Exam 2006 15 .
B. D. including Down’s. scoliosis is common. Joints may be deformed but are stable. Ligament laxity is not a feature of NFBT. 16 American College of Radiology . C. short segment curve is virtually diagnostic. Correct. scalloping. overgrowth. Eventual fracture is difficult to treat with repeated episodes of non-union hence the term “congenital pseudarthrosis of the tibia and fibula. Incorrect. multiple non-ossifying fibromas have all been described. Multiple exostoses are not a manifestation of the mesodermal dysplasia. D. idiopathic like. and Ehlos-Danlos Syndrome. C. sharply angulated. Scoliosis and /or kyphosis are one of the most common problems of patients with Type I NFBT. Atlanto-axial subluxation is not a complication. The bow spontaneously straightens over time and any limb length discrepancy is easier to treat. A. which one of the following is associated? S-shaped scoliosis Posteromedial bowing of the tibia Multiple exostoses Atlanto-axial subluxation Question 90 Rationales: A.Section IV – Musculoskeletal Radiology 90. Bony defects. Numerous bony lesions/deformities are typical of Type I NFBT. Concerning Type I Neurofibromatosis. Anterolateral bowing of the infant tibia and fibula is characteristic of Type I NFBT. Incorrect. Marfans. a typical S-shaped.” Posteromedial bowing of the tibia and fibula is rare and more benign. Numerous congenital disorders are associated with ligament laxity and scoliosis. Incorrect. Although a dysplastic. B.
This is the most common complication. Skeletal dysplasias may be classified according to the type of bone formation. Concerning osteopetrosis. Cortical or periosteal bone formation is intramembranous. Incorrect. Correct. infantile osteopetrosis being the most studied entity in this regard. intramembranous or both. bone is more resistant to fracture and undergoes bone marrow suppression. A. Diagnostic In-Training Exam 2006 17 . Defective osteoclastic activity and subsequent diminished bone resorption is felt to be the primary abnormality of the sclerosing dysplasias. which one is TRUE? In the adult. endochondral .Section IV – Musculoskeletal Radiology 91. Incorrect. D. The degree of abnormal diminished osteoclastic activity varies during skeletal growth and development. It is therefore. either primary or secondary. Osteopetrosis. The radiographic hallmark is the diffuse loss of corticomedullary junction in the long tubular bones. B. C. Alternating bands of sclerosis indicate the fluctuating course of the disease. Bone marrow suppression is present in the infantile. B. These are further classified according to the stage of skeletal development. Incorrect. the medullary bone that is affected. lethal type. D. Question 91 Rationales: A. involves a defect in endochondral bone formation during the initial development of the skeleton. C. A defect in intramembranous bone formation. The radiographic hallmark is diffuse cortical thickening. Osteoblastic activity results in excessive bone production. for example. The abnormal bone of adults with osteopetrosis is more prone to fracture. without a preexisting cartilage template. that is affected by the diminished osteoclastic activity. therefore would result in cortical thickening as seen in progressive diaphyseal dysplasia (Engelmann’s disease). This results in alternating bands of sclerosis parallel to the respective growth plates.
A. there is some degree of cartilage damage. Osteophyte formation is quite variable. shedding of crystals into the joint. D. is the most sensitive technique for the detection of chondrocalcinosis because of the increased magnetic susceptibility. Chondrocalcinosis refers to the presence of calcification within hyaline and fibrocartilage. Pyrophosphate arthropathy is most common at the knee. however that are unique to CPPD arthropathy. B. Question 92 Rationales: A. Weight-bearing and non-weight-bearing joints may be involved. B. though not necessarily CPPD. Pseudogout is one of several possible clinical presentations of CPPD deposition disease. Monosodium urate crystals are needle shaped and demonstrate strong negative birefringence. C. Pyrophosphate arthropathy is most common at the knee.e. Incorrect. radiocarpal at the wrist. T2* GRE. Destructive bone changes may be severe and progressive resembling neuropathic disease. The wrist and MCP joints are commonly involved but any joint is susceptible. Polarized light microscopy demonstrates rhomboid crystals with weak positive birefringence. There are features. subchondral sclerosis. Incorrect. subchondral cyst and osteophyte formation may be present. The crystal is usually..Section IV – Musculoskeletal Radiology 92. Concerning calcium pyrophosphate dihydrate (CPPD) deposition which one is TRUE? Polarized light microscopy demonstrates needle-shaped crystals with negative birefringence. Water sensitive MR sequences are most sensitive to the detection of chondrocalcinosis. Subchondral cyst formation may be numerous and quite large. Incorrect. D. The arthropathy related to CPPD deposition is similar to osteoarthritis in that joint space narrowing. synovial deposition and inflammation when the patient is symptomatic. Correct. The unusual distribution of involvement within a given joint is notable i. The patient may be asymptomatic. Multiple hypointense punctuate foci are characteristic of such chondral calcification. A gradient echo sequence. C. similar to attacks of acute gouty arthritis. Pyrophosphate arthropathy refers to the type of structural joint damage that may eventually result in some patients. 18 American College of Radiology . Chondrocalcinosis is synonymous with pseudo-gout. patella-femoral compartment at the knee. Theoretically.
Though a benign process. giant cell tumor of tendon sheath favors the tendons of the hands and feet. which one is TRUE? A. B. Correct. it may be locally aggressive and a recurrence rate of 20-50% is typical following synovectomy. joint effusion. MR signal characteristics are related to hemosiderin deposition. Diagnostic In-Training Exam 2006 19 . The small joints of the hands and feet are typically involved. intracapsular form of pigmented villonodular synovitis. C. there is evidence which suggests a neoplastic as well as inflammatory or reactive etiology. hip. The recurrence rate following synovectomy is less than 5%. The disorder is monoarticular. D. Patients are typically young adults. intracapsular PVNS. Incorrect. elbow and ankle. Diffuse. Incorrect. Water sensitive images will reveal high signal intensity related to joint fluid. is a proliferative disorder of the synovium and therefore presents as a soft tissue mass within the joint. D. the knee being the most common site of involvement. Question 93 Rationales: A. extracapsular form. including knee. Areas of low signal intensity on all pulse sequences are typical of hemosiderin which is best detected with gradient echo sequences due to magnetic susceptibility. and lipid-laden macrophages. C. Although its pathogenesis is unclear. Concerning the diffuse. Incorrect. B.Section IV – Musculoskeletal Radiology 93. Osseous erosion with preservation of the joint space and normal bone density is typical. Polyarticular involvement is characteristic. The hip. The diffuse form favors the large joints. The focal. ankle and elbow are also common sites. MR typically demonstrates a heterogeneous intracapsular mass. Lipid-laden macrophages may result in signal changes characteristic of fat.
pubic rami. Collapse of an involved vertebral body may also narrow the spinal canal. Though stress fractures related to Paget’s disease are similar in appearance. Correct. Paget’s disease commonly affects the vertebra. D.Section IV – Musculoskeletal Radiology 94. usually the anterior and posterior elements. Concerning Paget’s disease of bone. and notably involve the convex rather than concave. C. Serum calcium and phosphate levels are normal. Osteoporosis circumscripta refers to Pagetic. 20 American College of Radiology . involving the posterior proximal ulna. Osteitis fibrosa cystica refers to the skeletal alterations secondary to hyperparathyroidism. incompletely traversing the bone. these are less generalized. lateral recess or neural foraminal stenosis. Incorrect. Serum and urinary hydroxyproline is elevated secondary to increased rate of bone resorption and osteoclastic activity. Cortical thickening and subsequent enlargement of bone may result in central. Incorrect. The degree to which these are elevated is roughly related to the stages and activity of the disease. bowed cortex. osteolytic involvement of the skull. B. A. ribs and axillary margins of the scapula. medial proximal femora. A Looser’s zone or pseudofracture refers to focal unmineralized osteoid seen in patients with osteomalacia. They are usually bilateral and symmetric. C. They are probably stress related but are not fractures. often with a sclerotic margin. B. which one is MOST characteristic? Decreased alkaline phosphatase Osteitis fibrosa cystica Looser’s zones Spinal stenosis Question 94 Rationales: A. They have a typical radiographic appearance: short linear lucency. perpendicular to the cortex. Serum alkaline phosphatase is elevated secondary to increased rate of bone formation and osteoblastic activity. Incorrect. D.
Joint space preservation and absence of osseous erosion is characteristic of RSD. There may be rapid and severe osteopenia.Section IV – Musculoskeletal Radiology 95. Diagnostic In-Training Exam 2006 21 . Correct. Incorrect. Incorrect. associated with injury to nerves with a large sympathetic component such as the sciatic or median nerve and Type II. usually periarticular in nature. Soft tissue swelling and regional osteoporosis are the most significant radiographic findings of RSD. a more recent designation for RSD. Concerning reflex sympathetic dystrophy (RSD). Incorrect. D. B. which one is characteristic? Diffuse unilateral appendicular osteopenia Articular accumulation of 99m Tc-pertechnetate Joint space narrowing and osseous erosion Injury to a nerve containing a large sympathetic component Question 95 Rationales: A. associated with no nerve injury. A. D. C. B. There is intra-articular accumulation of 99m Tc-pertechnetate in patient’s with RSD secondary to the increased vascularity of the synovial membrane. Joint space loss and osseous erosion are features of inflammatory/septic arthritis which may also demonstrate marked periarticular osteopenia. C. Complex regional pain syndrome. refers to two types: Type I. Nerve injury may or may not be a component of RSD. Reduced bone density results from synovial inflammation and hyperemia and can be bilateral in one-fourth to one-half of cases.
TR x TE x # averages TR x TI x # averages TR x # phase encode steps x # averages TE x # phase encode steps x # averages Question 96 Rationales: A. C. Acquisition time is determined by the time required to fill the requisite number of lines in k-space. Incorrect. Incorrect. Correct. B. Incorrect. (see A above) D. C. TI. inversion time. and the number of averages (or excitations) per row. is not a variable for standard spin-echo imaging. which in turn is determined by the repetition time.Section IV – Musculoskeletal Radiology 96. B. The TE occurs over a much shorter time than the TR 22 American College of Radiology . D. the number of phase encode steps determine the specific row of k-space to be filled. Which of the following BEST represents the acquisition time for a standard spin-echo pulse sequence? A.
Gigantism refers to the sequela of growth hormone hypersecretion in the skeletally immature. such as the costochondral junction are susceptible to endochondral stimulation and new bone formation. There is no increase in height. Acromegaly refers to the sequela of growth hormone hypersecretion in the skeletally mature patient. Only chondro-osseous junctions in the adult. C. Excessive height results from endochondral bone formation at the open growth plates.Section IV – Musculoskeletal Radiology 97. The widening of osseous structures in patients with acromegaly is secondary to periosteal new bone formation which is intramembranous in nature. Stimulation of endochondral ossification before growth plate closure leads to gigantism.. Correct. Incorrect. A. Gigantism refers to the sequela of growth hormone hypersecretion in the skeletally immature. Endochondral bone formation in the adult occurs at existing chondro-osseous junctions such as the costochondral junction resulting in the acromegalic rosary. Acromegaly refers to the sequela of growth hormone hypersecretion in the skeletally mature patient. Excessive height results from excessive endochondral bone formation at the open growth plates. D. D. which one of the following is TRUE? Stimulation of endochondral bone formation results in widening of osseous structures Stimulation of intramembranous bone formation results in gigantism Stimulation of endochondral bone formation results in enlargement of the costochondral junction Stimulation of endochondral bone formation results in gigantism Question 97 Rationales: A. stimulation of endochondral ossification leads to new bone formation at existing cartilagebone junctions such as the costochondral junctions. In adults. B. Incorrect. B. Incorrect. Diagnostic In-Training Exam 2006 23 . Intramembranous bone formation in the adult results in periosteal new bone formation and widening of osseous structures. Concerning acromegaly. C.
ultimately leading to ankylosis of the nearby joint. Incorrect. autosomal dominant. Many estimate the rate of malignant transformation at 20% or more. bursa formation and inflammation and malignant transformation. of varying size and shape( round. shortening and angular deformities. The exostoses may vary in size and shape and point away from the physis. Malignant transformation is most common in which one of the following disorders? Ollier’s disease Melorheostosis Multiple hereditary exostoses Maffucci’s syndrome Question 98 Rationales: A. muscle and joint contracture and tendon/ligament shortening.Section IV – Musculoskeletal Radiology 98. swollen joints with limited range of motion. than Ollier’s. Incorrect. D. These may occur in the viscera. Correct. The pathogenesis is unknown. Malignant transformation does not occur. Melorheostosis is a rare disorder characterized by its distinct radiographic findings and clinical course. probably 2-5%. Incorrect. Complications also include fracture. dysplastic condition characterized by multiple. It should be noted that several forms of enchondromatosis have recently been noted and that Ollier’s disease and Maffucci’s S. vessels and tendons. B. do not encompass all of them. C. The latter appears as radiolucent columns or channels extending from the physis to the metaphysis and diametaphyseal region. most commonly hemangiomas. C. B. The distribution of the cartilaginous and vascular lesions usually. the risk is much greater for the skeletal component. The estimated rate of malignant transformation. The bones themselves may be exhibit expansile remodeling. the radiographic hallmark. Although malignant transformation of both the cartilage and soft tissue lesions has been noted. There are numerous growth deformities including scoliosis and limb length discrepancies. benign cartilaginous foci. Complications include growth deformity and malignant transformation. 24 American College of Radiology . The radiographic appearance is that of enchondromatosis with soft tissue masses and phleboliths. Multiple hereditary exostosis or multiple cartilaginous exostosis is a common. though not always. has ranged from 5-30%. A. may involve one or more bones and the dense osseous excescences may resemble wax flowing along one side of a burning candle. dysplastic condition characterized by multiple cartilage-capped exostosis distributed throughout the skeleton in a bilateral. coincide. impingement and compression of adjacent structures usually nerves. some authors claiming up to 25%. D. Ossification and calcification may occur at the paraarticular soft tissues. Surface cortical hyperostosis. Usually one limb is affected. symmetric fashion. Ollier’s disease or enchondromatosis is a rare non-hereditary. which occurs in the adult. These bony masses may involve adjacent articulations. The patients exhibit painful. The estimated rate of such transformation has ranged from <1% up to 25%. dysplastic condition characterized by multiple widespread cartilaginous foci( enchondromatosis) and soft tissue vascular malformations. The distribution of involvement often corresponds to zones of the skeleton supplied by individual sensory nerves or sclerotomes suggesting that the disorder may be the sequela of a sensory nerve lesion. widespread. it is generally agreed that the rate of malignant transformation if greater with Maffucci’s S. Maffucci’s syndrome is a non-hereditary. angular or linear). intraosseous or sub-periosteal. Despite the varying estimates.
hyperparathyroidism. The patients are usually woman. Malignant transformation of monostotic or polyostotic fibrous dysplasia is rare. C. pheochromocytoma and diabetes have also been associated with fibrous dysplasia. Incorrect. B. The mature gonadal function implied by the term puberty is not present. Mazabraud described and emphasized the association of soft tissue myxomas with fibrous dysplasia. Correct. and ethmoid bones are typically involved. fibrosarcoma. B. malignant fibrous histiocytoma and chondrosarcoma have been described. frontal. D. <1%. C. Incorrect. Malignant bone tumors have been reported.Section IV – Musculoskeletal Radiology 99. Facial deformity Soft tissue myxomas Malignant transformation Endocrinopathy Question 99 Rationales: A. The facial deformity resulting from bilateral involvement of the mandible in patients with Familial fibrous dysplasia of the jaw has been referred to as cherubism. approximately 50% of cases. some with McCune-Albright syndrome. hyperthyroidism. The incidence is higher in patients with Mazabraud’s syndrome but the syndrome is a reference to the association of fibrous dysplasia and soft tissue myxomas. the incidence greater than that of fibrous dysplasia itself. Fibrous dysplasia in such cases is most often polyostotic. cutaneous pigmentation and sexual precocity or precocious pseudopuberty. Incorrect. Diagnostic In-Training Exam 2006 25 . The skull and facial bones are common sites for both monostotoic and polyostotic fibrous dysplasia. more common with the latter. Mazabraud’s syndrome refers to the association of fibrous dysplasia and which one of the following? A. D. The maxilla. The McCune-Albright syndrome describes polyostotic fibrous dysplasia. Osteosarcoma. Other endocrinopathies including Cushing’s disease. acromegaly. sphenoid. There are incomplete forms without cutaneous pigmentation. The myxomas range in size and the thigh has been reported as the most common site of involvement.
Patients are usually 10-20 years old. Correct. C. Paraosteal osteosarcoma is most dense at the center of the lesion where new bone formation predominates. The femur. is the most common location. Incorrect. posterior and distal. C. bone forming. 26 American College of Radiology .Section IV – Musculoskeletal Radiology 100. Although it may metastasize to the lungs. Peripheral ossification is a feature of myositis ossificans. tumor arising on the surface of the bone. Question 100 Rationales: A. The humerus is the most common site. Concerning parosteal osteosarcoma. D. accounting for 2/3 of all cases. which one is TRUE? The prognosis is good. New bone formation predominates at the periphery of the lesion. D. B. usually 25-40 years of age. Patients with parosteal osteosarcoma are typically older than those with conventional osteosarcoma. most cases are amenable to local excision without the need for chemotherapy. Parosteal osteosarcoma is a low grade. Incorrect. A. B. Incorrect.
The appearance is often that of a well defined lytic lesion with sclerotic margins. The patients are younger than those with conventional chondrosarcoma. provoking periosteal new bone formation when cortical or sub-periosteal in location. Incorrect. a rare form of chondrosarcoma. There is no relationship to giant cell tumor of bone. the hands and feet are more commonly involved. It is typically extra-articular. When intra-articular. however. Correct. C. Lesions may occur at the end of the bone but most arise at the metaphyseal or diaphyseal regions. it may provoke synovitis.Section IV – Musculoskeletal Radiology 101. B. There may be cartilaginous calcification. It appears as a lytic lesion with expansile remodeling. Osteoid osteoma. D. Clear cell chondrosarcoma. peri-articular osteoporosis and growth disturbance. Giant cell reparative granuloma. hyperemia. In the appendicular skeleton. Which one of the following characteristically occurs at the end of the bone? Osteoid osteoma Chondromyxoid fibroma Giant cell reparative granuloma Clear cell chondrosarcoma Question 101 Rationales: A. D. the femoral head being the most common location. Incorrect. They are lytic lesions with histology characterized by giant cells. C. A. B. CMF is an unusual benign cartilage forming lesion occurring at the metaphyseal region. was first described as an intraosseous lesion of the maxilla and mandible distinct from giant cell tumor. characteristically occurs at the end of the bone. Diagnostic In-Training Exam 2006 27 . considered a reactive phenomenon. a benign bone forming tumor. may occur at the end of a bone. usually 30-40 years of age. Incorrect.
Incorrect. malignant fibrous histiocytoma and metastatic disease. C. A. B. The brown tumor of hyperparathyroidism however. Incorrect. Correct. Incorrect. Giant cell tumor rarely arises in the pelvic and fascial bones. C. osteitis fibrosa cystica (brown tumor) and giant cell tumor. The lack of periosteal reaction is characteristic of GCT unless there is an associated fracture. 28 American College of Radiology . D. which one of the following is associated? Periosteal reaction Paget’s disease Matrix mineralization Hyperparathyroidism Question 102 Rationales: A. chondrosarcoma. is otherwise unrelated to GCT of bone. numerous tumors are known to arise in Pagetoid bone including osteosarcoma (most common). D.Section IV – Musculoskeletal Radiology 102. Concerning giant cell tumor of bone. The lack of matrix mineralization is characteristic of GCT. giant cell reparative granuloma. B. Although a rare complication. Many bone lesions demonstrate histology populated with giant cell tumors including nonossifying fibroma.
Incorrect.Section IV – Musculoskeletal Radiology 103. The use of large focal spot can cause some geometric blurring. Incorrect. Using the grid at the appropriate tube-grid distance is important to prevent cut-off. For radiographs using a table Bucky cassette. D. the MOST LIKELY reason why the grid lines are not visible is due to which one? Use of larger focal spot Focusing of the grid at proper tube-grid distance Motion blurring of the grid Use of image post-processing A. Question 103 Rationales: A. C. Correct. and the grid is next to the cassette and will have little magnification. Geometric blurring would also degrade the image. B. but it does not obscure the individual grid lines. D. image postprocessing is not performed in film-screen radiography. A bucky grid system moves or oscillates the grid to blur out the individual grid lines. While there are techniques for reducing periodic artifacts. Incorrect. such as grid lines. and grid lines may be eliminated by use of the Bucky without post-processing. B. C. Diagnostic In-Training Exam 2006 29 . however the amount of blurring is dependent on the geometric magnification.
with either superimposition of an acute tear on a degenerative tendon. 30 American College of Radiology . and the long head of the biceps tendon lies deep to it. Concerning rotator cuff tears. B. D. the patient may recall a specific event associated with the acute onset of pain and decreased function. C. or extension of a prior smaller degenerative tear. Correct. Incorrect. A massive rotator cuff tear refers to one that involves at least two of the four cuff tendons. Partial thickness rotator cuff tears may be inferior (articular surface). Incorrect. A “massive” rotator cuff tear usually involves the teres minor tendon. Partial thickness tears are more common at the superior bursal surface than the inferior articular surface.Section IV – Musculoskeletal Radiology 104. Involvement of the teres minor tendon is extremely unusual. Its presence is accounted for by the protrusion of the coracoid process through the tendinous cuff. interstitial. D. which one is TRUE? A. underlying degenerative changes of the tendon usually play a major role. Although an acute traumatic episode may be associated with a cuff tear. Question 104 Rationales: A. Incorrect. This is most commonly the supraspinatus and infraspinatus tendons. Degenerative and traumatic tears occur with equal frequency. or superior (bursal surface). this represents relatively minor trauma. B. The rotator interval refers to the junction between the anterior fibers of the supraspinatus muscle and the superior fibers of the subscapularis tendon. a disruption is considered to be a rotator cuff tear. The coracohumeral ligament lies superficial to the interval. Especially in the older population. A rotator cuff interval tear is a type of rotator cuff tear. Although the rotator interval is fibrous and represents an interruption of the otherwise continuous tendinous cuff. followed by the subscapularis tendon with further extension of the tear. More likely than not. Articular surface partial thickness tears out-number bursal-sided partial tears by approximately 3:1. C.
only one glenohumeral joint may be symptomatic. Incorrect. Multidirectional glenohumeral instability is the most common cause of secondary. Since multidirectional instability is a cause of secondary impingement and all forms of impingement may be associated with rotator cuff tear. C. the humeral head may also sublux superiorly. Multidirectional glenohumeral instability is often found in individuals with generalized joint laxity of varying degrees. In addition to antero-inferior laxity. Correct. B. Concerning multidirectional glenohumeral instability. multi-directional instability is associated with rotator cuff tear. This is usually due to osteoarthritis of the acromioclavicular joint with subsequent osteophytic impingement of the subacromial space or subacromial spurs. reducing the space in which the cuff must function. Incorrect. In this condition. laxity is present in many directions. Primary impingement refers to those conditions of and about the coraco-acromial arch that predispose to compression of the rotator cuff at its outlet. Another cause of secondary impingement is a prominent greater tuberosity (fracture malunion). it frequently involves both shoulders. B. D. A. Diagnostic In-Training Exam 2006 31 . or non-outlet impingement. Preceding trauma is not typical. C. Incorrect.Section IV – Musculoskeletal Radiology 105. Although the underlying condition is usually bilateral. Because multidirectional glenohumeral instability is generally found in individuals with generalized joint laxity. D. which one is associated? Trauma Unilateral involvement Rotator cuff tear Primary impingement Question 105 Rationales: A.
B. 32 American College of Radiology . This portion of the meniscus may also be contused with an acute injury. C. Correct. The meniscal blood supply comes from the geniculate arteries that enter the meniscus peripherally. In a young individual. Incorrect. Such tears may heal or be amenable to repair. A.Section IV – Musculoskeletal Radiology 106. Incorrect. which one is CORRECT? A peripheral tear must be excised. Intrasubstance signal may represent residual vascularity in the peripheral aspect of the meniscus in a younger patient. this occupies the outer one third of the meniscus. The free edge of the meniscus is avascular. and extend peripherally toward the meniscus-capsular junction. Concerning the meniscus of the knee. Intra-substance signal in an adolescent usually reflects premature mucoid degeneration. Question 106 Rationales: A. The blood supply comes from the geniculate arteries. D. Peripheral tears are in the "red" portion of the meniscus that has a neurovascular supply in younger patients. Radial tears begin at the meniscal free edge. Incorrect. D. The vascular portion of the meniscus decreases in size with age. and will not heal. and an adult pattern is usually reached before skeletal maturity. B. Radial tears may spontaneously heal in young individuals. and subsequently heal spontaneously. C.
With an inversion injury. Deltoid ligament tears result from abduction or eversion injuries. Concerning acute ankle inversion. the calcaneus and the talus. C. It is the first of the ankle ligaments to be injured. The anterior talofibular ligament originates at the anterior margin of the lateral malleolar tip and courses medial and anterior to insert at the talus.Section IV – Musculoskeletal Radiology 107. A. which ligament is FIRST to be injured? Calcaneofibular Anterior talofibular Posterior talofibular Deltoid Question 107 Rationales: A. A complete tear is often accompanied with a "pop". Deep fibers insert on the talus. the ligament will partially or completely tear. Incorrect. B. The deltoid ligament lies medial to the ankle joint. With more severe injuries. Incorrect. The posterior talofibular ligament extends horizontally between the posterior aspect of the lateral malleolus to the posterior process of the calcaneus. B. C. Correct. The calcaneofibular ligament originates at the anterior apex of the lateral malleolar tip and extends inferiorly and posteriorly to insert on the lateral calcaneus. it is usually the second of the lateral ankle ligaments to tear. Diagnostic In-Training Exam 2006 33 . Incorrect. With a relatively low-grade inversion ankle injury. D. D. Superficial fibers insert on the navicular bone. the anterior talofibular ligament will stretch. severe pain and swelling. arising on the medial malleolus. and an inability to walk. Tears of the posterior talofibular ligament are uncommon relative to tears of the other two lateral collateral ligaments.
The medial subtalar joint is typically spared. Concerning Maisonneuve fracture. and extend proximally. Correct. A. D. The sustentaculum tali may fracture as a component of a depressed. The unique feature of the Maisonneuve fracture is the extension of the force proximally through the tibiofibular syndesmosis to the proximal fibula shaft or neck where a fracture is encountered. Forces begin at the tibiotalar joint. The exact mechanism for the Maisonneuve fracture is poorly understood. 34 American College of Radiology . fracture of the posterior malleolus. The Maisonneuve fracture does not extend into the hindfoot. The posterior subtalar joint is typically involved.Section IV – Musculoskeletal Radiology 108. but it likely results from multidirectional forces. C. Incorrect. Incorrect. which one is associated? Fracture of the sustentaculum tali Subtalar dislocation Tear of the spring ligament Tear of the tibiofibular syndesmosis Question 108 Rationales: A. The hindfoot and midfoot are not involved in the Maisonneuve fracture. Associated ankle injuries include fracture of the medial malleolus or tear of the deltoid ligament. comminuted intra-articular calcaneal fracture. The spring ligament courses between the calcaneus and the navicular. B. B. C. D. and a tear of the anterior or posterior talofibular ligaments. Incorrect.
The peroneus brevis originates at the lower two thirds of the lateral fibula. The insertion is variable. C. The flexor digitorum longus originates at the posterior surface of the tibia. Incorrect. Incorrect. Concerning the ankle tendons. D. C. and can include the second through fourth metatarsals. The peroneus brevis inserts on the base of the fifth metatarsal. Correct. fibula and interosseous membrane. The flexor hallucis longus inserts on the head of the first metatarsal. The flexor hallucis longus originates at the mid-to distal fibula. which one is CORRECT? The flexor digitorum longus inserts on the distal shaft of the third through fifth metatarsal. and inserts on the fifth metatarsal base laterally. Diagnostic In-Training Exam 2006 35 . and navicular. Question 109 Rationales: A. The tibialis posterior inserts on the distal first metatarsal shaft. A. B. D. cuboid. B. and inserts on the plantar surface of the base of the distal phalanx of the great toe. The tibialis posterior originates from the tibia. cuneiforms. and inserts at the plantar surface of the bases of the distal phalanges of the second through fifth toes. Incorrect.Section IV – Musculoskeletal Radiology 109.
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