Multiple Choice Questions

Muskuloskeletal Tumours

Test your knowledge , learn more and get ready for your orthopaedic exam

 

52. Regarding osteosarcoma, which of the following statements is correct?

A) Affects the epiphyses of long bones
B) Can result in pulmonary metastases via haematogenous spread
C) Is exclusively a disease of adolescence and early adult life
D) Is most commonly seen around the hip
E) On x ray shows a ‘sunburst’ appearance due to bony involvement

Correct Answer : B

Osteosarcomas affect the metaphyses of long bones.

They are most commonly seen around the knee and in the proximal humerus.

They often occur in young adults, but are also seen in the elderly in association with Paget's disease. They usually present as bone pain and a palpable lump.

An x ray will show periosteal elevation (Codman's triangle) and a 'sunburst' appearance due to soft tissue involvement.

Early haematogenous spread occurs, and the five year survival rate is approximately 50%.

Author :Firas Arnaout

 

51. When compared with postoperative external beam radiation therapy for the treatment of soft-tissue sarcomas. Preoperative radiation therapy is associated with which of the following?

A) Higher wound complications
B) Higher doses of radiation
C) Larger volumes of tissue irradiated
D) Worse overall survival
E) Worse functional results

Correct Answer : A

Preoperative radiation therapy requires a lower dose of radiation (5,000 cGy versus 6,600 cGy) and lower volume of tissue, with no difference in survival and a trend toward better functional outcome, compared with postoperative radiation. Preoperative radiation is associated with a significantly higher wound complication rate (35% versus 17%).

Author :Firas Arnaout

 

50. Acral bone metastases (to the hands and feet) are most likely the result of a primary solid organ tumour in which of the followings structures?

A) DLiver
B) Lung
C) Breast
D) Thyroid
E) Prostate

Correct Answer : B

Lung cancer is the most likely solid organ cancer to metastasize distal to the elbow and the knees. The most common sites for metastatic disease are the vertebral bodies, pelvis, and long bones. Genitourinary tumours may also metastasize to distal sites.

Author :Firas Arnaout

 

49. What is the primary problem in rickets osteomalacia?

A) Defect in the zone of proliferation within the physis
B) Defect in type I collagen
C) Defect in the ext-1 gene
D) Low level of calcium
E) Production of dysplastic fibrous bone

Correct Answer : D

Rickets is a disorder of bones in children that results from decreased calcium available in the blood resulting in poor mineralization of bone that can lead to fractures and deformity. 

The most common cause of rickets is from vitamin D deficiency but it can also be caused by poor nutrition or gastrointestinal disease that results in poor calcium absorption such as celiac disease or severe diarrhea from other causes. 

Rickets is not primarily a physeal disorder. 

Osteogenesis imperfecta is caused by a defect in type I collagen. A defect in the ext-1 gene is often seen in patients with multiple hereditary exostoses. 

Fibrous dysplasia also can result in bone deformity and fractures due to production of dysplastic fibrous bone but is not caused by calcium or vitamin D deficiency.

Author :Firas Arnaout

 

48. What syndrome is characterized by polyostotic fibrous dysplasia, cafe-au-lait spots with serrated borders, endocrine abnormalities, and unilaterality?

A) Jaffe-Campanacci syndrome
B) Hunter’s syndrome
C) Maffucci’s syndrome
D) Multiple hereditary exostoses
E) McCune-Albright syndrome

Correct Answer : E

This is a description for McCune-Albright syndrome. Jaffe-Campanacci syndrome is characterized by multiple nonossifying fibromas, cafe-au-lait spots, and the absence of neurofibromas. Hunter's syndrome is a mucopolysaccharidosis and lysosomal storage disease that affects all large joints with pain and decreased range of motion. Maffucci's syndrome is associated with multiple hemangiomas and enchondromas. Multiple hereditary exostosis is characterized by the presence of multiple exostoses and is not associated with skin lesions or endocrine abnormalities.

Author :Firas Arnaout

 

47. A 68-year-old woman has had progressive pain in the right thigh for the past several months. She has a history of hypertension, treated with hydrochlorothiazide and osteoporosis treated with alendronate for 10 years. At this point, she is virtually wheelchair bound. 

Radiographs are shown . Additional studies show no signs of systemic disease. 

What is the most likely etiology of her condition

A) Prolonged use of bisphosphonates
B) Use of calcium-wasting diuretics
C) Occult metastatic cancer
D) Vitamin D-resistant rickets
E) Disuse osteopenia

Correct Answer : A

The patient has been on alendronate for 10 years and has evidence of a proximal diaphyseal fatigue fracture. These have been associated with long-term use of bisphosphonates. Staging studies have failed to show systemic disease, and while metastasis with an unidentifiable primary does occur, it would be unlikely to present with this radiographic appearance, now recognized to be classic for stress fractures associated with chronic bisphosphonate usage. Hydrochlorothiazide does not cause calcium wasting. Vitamin D-resistant rickets would be a long-standing event and would present much earlier in life, often with pronounced deformities. Whereas the patient's progression to intolerance of weight bearing likely has led to some degree of disuse osteopenia, the underlying problem is the long-term bisphosphonate exposure.

Author :Firas Arnaout

 

46. An otherwise healthy 12-year-old boy has ankle pain after being kicked while playing soccer. Radiographs are shown in Figures.Examination reveals tenderness to palpation, but not with weight bearing. He had no pain preceding the incident. What is the next most appropriate step in management?

A) Observation
B) Curettage and grafting
C) Wide surgical resection
D) Whole body bone scan
E) Chemotherapy

Correct Answer : A

The lesion shown is a nonossifying fibroma. With no pain preceding the traumatic episode and painless weight bearing, the lesion does not appear at risk for fracture. Simple observation with repeat radiographs at a time interval (3 to 6 months) to document stability is sufficient. Surgical intervention is unnecessary because the risk of fracture is low and the natural history is one of spontaneous regression during adolescence. The lesion is benign; therefore, chemotherapy is not indicated. While a bone scan may provide some useful information, it is unnecessary for the diagnosis and adds little to management decisions.

Author :Firas Arnaout

 

45. A 20-year-old collegiate field hockey player has had diminished knee flexion for the past 3 years. Lately she has noted right knee pain that requires her to stop playing. Radiographs are shown in Figures. 

What is the next best step in management?

A) Radiation therapy
B) Surgical biopsy
C) Chemotherapy
D) Knee arthroscopy
E) Bisphosphonates

Correct Answer : B

The lesion has the characteristic features of a parosteal osteosarcoma, including its surface location on the posterior distal femur, decreased range of motion, and pain. Biopsy is necessary to confirm a diagnosis before recommending treatment. Chemotherapy and radical resection may be indicated in dedifferentiated disease, but should be considered only after a biopsy and appropriate staging have been completed. There is no role for knee arthroscopy or bisphosphonates

Author :Firas Arnaout

 

44-year-old woman with a history of breast cancer and a recent diagnosis of lung carcinoma with multiple painful biopsy-proven skeletal metastasis now reports progressive weight-bearing pain in her left thigh. 

Current treatment consists of chemotherapy for the lung mass and radiation therapy. 

An AP radiograph of the left femur is shown . What is the best option for treatment of her thigh pain?

A) Bisphosphonate therapy
B) Resection and megaprosthetic reconstruction
C) Prophylactic nailing
D) Radiation therapy
E) Chemotherapy

Correct Answer : C

Predicting which patients will sustain a fracture with metastatic bone disease is a difficult clinical decision. Mirel's rating system is a useful clinical tool but must be used cautiously. Lower extremity peritrochanteric, large, radiolucent, and painful lesions are at highest risk for fracture. The ultimate goal is palliative in nature and designed to limit pain, minimize time in the hospital, and improve the quality of life in these patients with limited survival time. If a high risk lesion is treated with radiation therapy first, the bone will become weaker before starting to regain structural integrity and the fracture risk increases. Timing of prophylactic fixation, radiation therapy, and chemotherapy requires a multidisciplinary team of doctors working collaboratively. Bisphosphonates should be included in the medical treatment for most patients with metastatic bone disease to lower the risk of further skeletal complications. They are not indicated for acute treatment of impending fractures. Resection of a metastatic lesion is reserved for patients in which internal fixation devices will not have adequate bone stock present to allow stabilization and immediate weight bearing or in patients with selected isolated metastases, such as those caused by renal carcinoma. Radiation therapy and chemotherapy have already failed to control progressive bone destruction and pain in this patient.

Author :Firas Arnaout

 

43. A 23-year-old woman who noted 1 day of thigh pain after jogging now reports persistent thigh swelling and can feel a mass. The radiograph, CT scan, and MRI scans are shown in Figures. 

What is the most likely diagnosis?

A) Soft-tissue sarcoma
B) Pseudoaneurysm
C) Abscess
D) Osteosarcoma
E) Myositis ossificans

Correct Answer : E

Myositis ossificans (MO) is a reparative lesion that is distinguished by the presence of metaplastic bone formation. The important entity that MO must be distinguished from is extraskeletal osteosarcoma. Extraskeletal osteosarcoma usually occurs in older patients and lacks the zonation phenomenon of MO. Myositis ossificans develops a well-defined ossified rim, maturing peripherally more than centrally, where osteosarcomas do the opposite. Histologically the two may be confusing; therefore, clinical and radiographic evaluation is a critical factor in the diagnosis. Soft-tissue sarcoma, pseudoaneurysm, and abcess do not have zonal ossification patterns.

Author :Firas Arnaout

 

42. Figures show the radiographs of an otherwise healthy 64-year-old man who has had right groin pain for the past 3 months. 

What is the next most appropriate step in management?

A) Biopsy
B) Observation
C) Radiation therapy
D) Prophylactic fixation of the femur
E) Bone scan, CT scan of the chest/abdomen/pelvis, laboratory studies

Correct Answer : E

The radiographs show a radiolucent lesion in the proximal femur. In a patient older than age 40 years, a new painful bone lesion most likely represents metastatic carcinoma or multiple myeloma even if the patient does not have a known history of cancer. The diagnosis must be firmly established and the patient should be staged prior to initiating treatment. Imaging studies should be completed prior to proceeding with a biopsy. This patient should undergo a bone scan to look for other lesions. A CT scan of the chest, abdomen, and pelvis should be performed to look for a primary tumour as well as other sites of metastases. (Lung or kidney would be the most common primary sites for a patient who presents with metastases of unknown origin.) Serum and
urine protein electrophoresis should be obtained to look for multiple myeloma.

Author :Firas Arnaout

41. Figures show the radiographs of a 30-year-old-man who had Ewing’s sarcoma at the age of 10 treated with radiation therapy for local control. 

What is the most likely diagnosis?

A) Recurrent Ewing’s sarcoma
B) Osteomyelitis
C) Radiation-induced sarcoma
D) Metastatic adenocarcinoma
E) Bone infarct

Correct Answer : C

The most likely diagnosis is radiation-induced sarcoma, which typically occur years after the radiation is received. The radiographs show a lytic lesion in the area of previously treated Ewing's sarcoma. Occasionally Ewing's sarcoma is treated with radiation therapy, typically in locations where limb salvage is not feasible. Recurrent Ewing's sarcoma would be unusual 20 years after the primary tumour, bone infarct is not purely radiolucent, adenocarcinoma is rare in patients younger than age 40, and osteomyelitis would be an unusual diagnosis in this clinical setting.

Author :Firas Arnaout

 

40. Figure  shows the AP and lateral radiographs of a 12-year-old boy with knee pain after a fall. Previous to the fall he denies any history of pain. What is the most likely diagnosis?

A) Unicameral bone cyst
B) Chondroblastoma
C) Fibrous dysplasia
D) Nonossifying fibroma
E) Osteosarcoma

Correct Answer : D

The patient has a nonossifying fibroma. Nonossifying fibroma is classically an eccentric, lytic lesion with a thin sclerotic border in the metaphysis. Unicameral bone cyst is typically central with variable surrounding sclerosis. Chondroblastoma is a lytic lesion in the epiphysis. Fibrous dysplasia is typically a central lytic lesion in the metaphysis or diaphysis with a ground glass appearance. Osteosarcoma is usually a mixed lytic/blastic lesion with bone destruction and formation, without sclerotic margins.

Author :Firas Arnaout

 

39. The diagnosis of gout can be made either by the presence of tophaceous deposits in the skin or bursae of the extremities or by the presence of which of the following?

A) Elevated urine pH
B) Elevated serum uric acid
C) Calcium pyrophosphate crystals in the synovial fluid
D) Monosodium urate crystals in the synovial fluid
E) Elevated serum phosphate

Correct Answer : D

Gout is an inflammatory arthritis caused by the presence of monosodium urate crystals in the joint. It is characterized acutely by a painful joint that remits after 1 to 2 weeks and recurs periodically. The diagnosis of gout can be made by confirming the presence of monosodium urate crystals in the joint fluid aspirated from the inflamed joint. Patients with gout may also have tophaceous deposits within the skin or bursae of the extremities. Elevated urine pH, serum uric acid, and serum phosphate can all be associated with numerous conditions and are not specific to gout. Calcium pyrophosphate crystals are associated with chondrocalcinosis (pseudogout).

Author :Firas Arnaout

 

38. Giant cell tumour of the tendon sheath is histologically most closely related to which of the following?

A) Desmoplastic fibroma
B) Dermatofibroma
C) Pigmented villonodular synovitis (PVNS)
D) Myositis ossificans
E) Epithelial inclusion cyst

Correct Answer : C

A giant cell tumour of the tendon sheath consists of multinucleated giant cells, polygonal mononuclear cells, and histiocytes (may contain abundant hemosiderin or lipid). This same cell population is seen in PVNS in addition to hemosiderin. Desmoplastic fibroma is composed of dense and irregularly arranged collagen bundles with infrequent fibroblasts. Dermatofibroma is composed of nodular cellular proliferation consisting of short intersecting fascicles of fibroblastic cells in a loose crisscross or storiform pattern. Myositis ossificans is characterized by zonal proliferation with central fibroblasts and peripheral osteoblast-rimmed bone trabeculae. Epithelial inclusion cysts are filled with keratin from desquamation of the hyperkeratotic, stratified squamous epithelial cells that line the cysts.

Author :Firas Arnaout

 

37. A 57-year-old woman has a right proximal humerus lesion that was originally discovered when a chest radiograph was obtained. The right shoulder is asymptomatic. An AP radiograph of the right shoulder is seen in Figure. 

What is the next step in management?

A) MRI
B) CT
C) Bone scan
D) Biopsy
E) Observation

Correct Answer : E

The radiograph shows a benign-appearing lesion with stippled calcification. There is no cortical erosion. Equally important is the fact that the patient is asymptomatic. These findings are typical of enchondroma. No further work-up is indicated for this patient except for observation with serial radiographs. If the patient has symptoms, further cross-sectional imaging may be necessary to assess the aggressiveness of the lesion. A bone scan will differentiate monostotic disease from polyostotic disease and the relative uptake may help assess activity.
Biopsy is usually not helpful in distinguishing between enchondromas and low-grade chondrosarcomas.

Author :Firas Arnaout

 

36. Radiographs of the right knee of a 21-year-old man are seen in Figures . 

What is the inheritance pattern of this disorder?

A) Sporadic
B) Autosomal dominant
C) Autosomal recessive
D) X-linked dominant
E) X-linked recessive

Correct Answer : B

The radiographs show multiple osteochondromas and are thus diagnostic for multiple hereditary exostoses (MHE). MHE is an autosomal-dominant disorder with greater than 95% penetrance. It is associated with mutations of the EXT1 or EXT2 genes. In addition to multiple osteochondromas, affected individuals typically exhibit short stature and angular deformities of the long bones.

Author :Firas Arnaout

 

35. A 63-year-old man has had increasing left leg pain over the last several months. History reveals that he has had recurring cyclic pain in the leg for the past several years. Radiographs show an enlarged, sclerotic tibia, with thickened coarse trabeculae and varus bowing. 

What is the most appropriate management for this patient?

A) Vitamin D
B) Calcium supplement
C) Methotrexate
D) Nonsteroidal antiinflammatory drugs (NSAIDs)
E) Bisphosphonate therapy

Correct Answer : E

Based on the signs and symptoms, Paget's disease is the most likely diagnosis. In Paget's disease, an elevated alkaline phosphatase level and high output heart failure may be seen. Hearing loss can be seen when there is involvement of the skull, and malignant degeneration is uncommon but recognized as a risk. Patients are often treated with bisphosphonate medications during the active disease process to help control osteoclastic activity and pain. Vitamin D and calcium are more appropriate for treatment of osteoporosis. Methotrexate is not indicated for the treatment of Paget's disease. NSAIDs may be helpful to treat pain associated with Paget's disease but will not alter the clinical course

Author :Firas Arnaout

 

34. Which of the following is the most common soft-tissue sarcoma of the hand?

A) Chondrosarcoma
B) Rhabdomyosarcoma
C) Epithelioid sarcoma
D) Myxoid liposarcoma
E) Hemangiopericytoma

Correct Answer : C

The hand is a rare location for soft-tissue sarcomas. The most common histologic subtypes seen there are epithelioid sarcoma, malignant fibrous histiocytoma, synovial sarcoma, and clear cell sarcoma.

Author :Firas Arnaout

 

33. A 55-year-old woman with a history of lung cancer who underwent resection 1 year ago now reports thigh pain. Radiographs are shown in Figures. A CT scan of the chest, abdomen, and pelvis and a bone scan show no other lesions. 

What is the most appropriate next step in management?

 

A) Chemotherapy
B) External fixation
C) Reamed intramedullary nail with reamings sent to pathology
D) Biopsy
E) External beam radiation followed by placement of an intramedullary nail

Correct Answer : D

The radiographs show a lytic lesion that is highly suggestive of metastatic cancer in this clinical setting. However, in this patient with no other bone lesion as demonstrated by bone scan, a primary sarcoma or myeloma cannot be excluded. Therefore, biopsy should be done prior to prophylactic stabilization to avoid inadvertently contaminating the entire femur. Sending reamings during the intramedullary nailing is not an acceptable method of performing a biopsy on an indeterminate lesion. Chemotherapy, radiation, nailing, or external fixation should not be performed prior to establishing a diagnosis.

Author :Firas Arnaout

 

32.A 15-year-old girl is referred for evaluation of a tibial lesion noted on radiographs performed after a twisting injury of the left knee. She was asymptomatic prior to the injury that occurred 3 weeks ago. The pain from the injury has now resolved. 

Radiographs of the left knee are seen in Figures. 

What is the next step in management of this patient?

A) CT
B) MRI
C) Bone scan
D) Needle biopsy
E) Observatione

Correct Answer :E

The radiographs reveal a benign-appearing lesion of the proximal tibia metaphysis with a narrow zone of transition, an eccentric position, and a thin rim of reactive bone. The imaging characteristics are most consistent with nonossifying fibroma. These lesions may occur multiply in 8% of patients. Most lesions are eccentric with a "soap bubble" appearance and may have significant cortical thinning. Pathologic fractures may occur. This lesion was discovered as an incidental finding. Because the patient is asymptomatic, no further work-up or treatment is indicated except for observation. Most lesions resolve spontaneously by adulthood.

Author :Firas Arnaout

 

31.A 13-year-old girl injured her left shoulder playing volleyball. The shoulder was previously asymptomatic. She was referred for evaluation of a left humeral lesion noted on radiographs obtained after the injury. Currently she has returned to playing volleyball and is asymptomatic again. 

AP and lateral radiographs of the shoulder are seen in Figures .

What is the next most appropriate step in management of this patient?

A) MRI
B) CT
C) Bone scan
D) Needle biopsy
E) Observation

Correct Answer : E

The radiographs reveal an osteochondroma of the left humerus; therefore, no further work-up is needed. The lesion was found as an incidental finding after an injury and since it is asymptomatic, no further treatment is needed except for observation. An MRI scan or a CT scan could be obtained to evaluate the thickness of the cartilaginous cap if a secondary chondrosarcoma is suspected in an enlarging lesion in an adult. These studies could also be obtained to define anatomic relationships if surgery is planned. A bone scan could be used to identify other lesions but would not likely provide useful information for this patient. Needle biopsy would not provide any useful information. 

Author :Firas Arnaout

 

30.What syndrome is associated with the presence of enchondromas and hemangiomas? 

A) Maffucci’s syndrome
B) Hunter’s syndrome
C) Multiple hereditary exostoses
D) Ollier’s disease
E) Trevor’s disease

Correct Answer : A

Maffucci's syndrome is characterized by the presence of enchondromas and hemangiomas. Ollier's disease is multiple enchondromatosis. Multiple hereditary exostoses is characterized by the presence of multiple exostoses not associated with skin lesions or endocrine abnormalities. Hunter's syndrome is a mucopolysaccharidosis and lysosomal storage disease that affects all large joints with pain and decreased range of motion. Trevor's disease is an epiphyseal osteochondroma.

Author :Firas Arnaout

 

29.7-year-old boy has multiple firm, fixed masses about his knees and extremities. Occasionally he has pain when he bumps his knee or around his proximal legs when he is playing soccer. 

Radiographs and CT scan are shown in Figures. 

What is the next most appropriate step in management?

A) Observation
B) Biopsy of the largest lesions
C) Whole body PET scan
D) Removal of all lesions about the knee
E) Bisphosphonate therapy

Correct Answer : A

The patient's clinical presentation and imaging studies are diagnostic of multiple hereditary exostoses (MHE). Whereas removal of symptomatic osteochondromas is indicated if symptoms are severe enough, biopsy of the lesions or removal of all of the lesions is not indicated. Currently, a PET scan does not have a defined role in the evaluation of MHE patients. Bisphosphonate therapy currently has no defined role in the treatment of MHE patients. These patients are best observed if asymptomatic, and the development of symptoms or masses that grow after skeletal maturity should be evaluated for possible malignant degeneration of these lesions.

Author :Firas Arnaout

 

28.Tumoural calcinosis is a hereditary disease that involves which of the following?

A) Calcium metabolism
B) Phosphate metabolism
C) Oxalate metabolism
D) Chloride metabolism
E) Renal tubular insufficiency

Correct Answer : B

Although not completely understood, the phosphate metabolic dysfunction seen in tumoural calcinosis is a hereditary disease. This is characterized by soft-tissue lesions that are calcified, lobulated, well-demarcated lesions usually found over the extensor surfaces of large joints. It is most commonly found around the hip, elbow, shoulder, foot, and wrist joints. Renal tubular insufficiency is associated with acidosis, glucosuria, phosphaturia, aminoaciduria, and mild proteinuria. Oxalate metabolism can contribute to calcium oxalate crystals and kidney stones. Oxalate is found in many food products. Calcium metabolism, which can

be abnormal in renal insufficiency, hypervitaminosis D, and milk-alkali syndrome, is normal in tumoural calcinosis. Metabolic alkalosis is often associated with an alteration in chloride metabolism. The Preferred

Author :Firas Arnaout

 

27. An otherwise healthy 15-year-old boy is seen in the emergency department for an injury sustained while playing dodge ball. 

A radiograph is shown in Figure .

What is the most appropriate treatment for this patient?

 

A) Aspiration and injection
B) Resection and reconstruction
C) Sling and pain medication
D) Curettage and bone grafting
E) Intramedullary nail fixation

Correct Answer : C

The patient has a pathologic fracture through a benign-appearing eccentric bone lesion with a soap-bubble geographic appearance, most suggestive of a nonossifying fibroma. The best initial treatment is to provide comfort measures and allow the fracture to heal. Aspiration and steroid injection has been advocated for a unicameral bone cyst, though it should be done after any associated fracture has been allowed to heal. Wide resection is not indicated for this benign tumour Extended curettage and grafting may be appropriate, but only after fracture healing has occurred unless open reduction and internal fixation is indicated for the fracture itself. Intramedullary nail fixation is unnecessary and generally should not be performed if the histopathologic diagnosis is not known. The Preferred

Author :Firas Arnaout

 

26.  Figures show the AP radiograph and axial CT scan of an 18-year-old woman who has proximal thigh pain. 

What is the most appropriate treatment?

 

A) Observation
B) Curettage and grafting
C) Radiofrequency ablation
D)Wide resection
E)Wide resection and chemotherapy

Correct Answer : C

The imaging studies are classic for osteoid osteoma, a benign lesion. Conventional treatment has involved burring down to find the lesion, followed by curettage. More recent experience with radiofrequency ablation under CT guidance has shown equivalent results with few complications. Curettage in this location would carry significant morbidity and risk for fracture, making radiofrequency ablation the most appropriate treatment. More aggressive resections are not indicated because the lesion has a low chance of recurrence. Observation and/or use of nonsteroidal anti-inflammatory drugs would be reasonable if the patient is willing to live with prolonged pain.

Author :Firas Arnaout

 

25. An 11 year-old boy presents to fracture clinic having sustained a fall the day before and knee pain. 

Which of the following statements describes this condition?

A) A malignant primary bone tumour ; wide excision and attempted limb salvage is the main treatment
B) Locally aggressive condition which requires curettage and adjuvant treatment to halt local progression and recurrence
C) A malignant primary bone tumour, commoner in childhood; chemotherapy is the mainstay of treatment
D)A benign condition of childhood that is treated with curettage
E) A benign condition of childhood that almost always spontaneously disappears in adulthood

Correct Answer : E

The radiological features and clinical scenario are suggestive of a Non-ossifying fibroma (NOF).

NOFs are the most common type of non-neoplastic fibrous bone lesion and are a larger version (>3 cm) of a fibrous cortical defect; both are encompassed by the term fibroxanthoma or metaphyseal fibrous defect.

NOFs are very common in children and adolescents, and the most common fibrous, bony lesion in this age group 6, with a peak incidence at 10-15 years of age. They are usually not seen beyond the age of 30, as they spontaneously heal, being gradually filled in by bone. The majority of NOFs are asymptomatic. Larger lesions may be painful and potentially weaken the bone enough to predispose to pathological fracture. NOFs are typically a multiloculated lucent lesion with a sclerotic rim. They are located eccentrically in the metaphysis, adjacent to the physis. As the patient ages, they seem to migrate away from the physis.

They have no associated periosteal reaction, cortical breach or associated soft tissue mass.

Author :Firas Arnaout

 

24. A 45-year-old woman has a painless thigh mass that is larger than 5 cm. 

What is the best next step?

A) Percutaneous biopsy
B) Positron emission tomography (PET)/CT scan
C) Excisional biopsy
D) MRI of the thigh with gadolinium
E) Simple analgesia and discharge

Correct Answer : D

Masses exceeding 5 cm in size and any deep mass should be evaluated with MRI prior to biopsy or excision to ensure the most viable tissue is sampled and to minimize morbidity and complications from an improperly placed biopsy site. 

Examinations are unreliable when attempting to determine if a mass is a simple lipoma, and any large or deep mass should be invistigated .

Author :Firas Arnaout

 

23.A 31 year-old woman has a 2 month history of dull, aching pain in her shoulder after fall.

Her radiograph is presented.

 

 Which of the following is the most appropriate treatment?

A) Wide resection with preoperative chemotherapy
B) Wide resection with perioperative radiation
C) Wide resection alone
D) Forequarter amputation
E) Marginal resection followed by joint reconstruction

Correct Answer : E

Patient age and pattern of bone destruction match with this diagnosis.


The treatment for giant cell tumor is curettage with or without methylmethacrylate augmentation for lesions in which the joint surfaces can be saved.if the joint surfaces cannot be saved marginal resection and joint reconstruction must then be performed.

Author :Prof Mohammed Q, Hutaif

 

22.The figuers anteroposterior and lateral radiographs, CT scan, and technetium
bone scan of a 12-year-old boy who has experienced 7 months of pain in his lower leg. The pain
limits his ability to participate in sports and he is having difficulty sleeping. 

He is afebrile, and laboratory study findings including an erythrocyte sedimentation rate, C-reactive protein, and
complete blood count are within normal limits.

What is the most likely diagnosis?

A) Osteomyelitis
B) Osteoid osteoma
C) Stress fracture
D) Adamantinoma                                                                                                                                                                                                                                         E) Fibrous Dysplasia

Correct Answer : B

The images and clinical history support a diagnosis of osteoid osteoma, which most commonly
occurs in adolescence. 

Although these lesions can be seen in any bone, they are usually located in the femur and tibia. 

The significant inflammatory response to this tumor is secondary to high levels of prostaglandin production. Characteristic night pain is relieved with nonsteroidal antiinflammatory drugs (NSAIDs) or by aspirin.

Radiographic images show thickened bone and a small central nidus. Thin-cut CT scan is the imaging of choice to visualize the nidus. A bone scan is associated with uptake but is not specific.

Treatment options include expectant management with NSAIDs and observation under the premise
that these lesions eventually burn out. Contemporary treatment involves RFA. Historically, these
lesions were treated with en bloc resection; however, this technique has largely fallen out of favor
because of the high efficacy and comparative low morbidity associated with RFA.

When an osteoid osteoma occurs in the spine, it is located in the posterior elements, and paraspinal pain and scoliosis often are present.

Author : Firas Arnaout

 

21. A 35 year old man was being evaluated for chronic thigh pain. Xray attached. 

What is your diagnosis?

A) Osteopetrosis
B) Osteopokilosis
C) Osteopathia striata
D) Melorrheostosis 
E) Osteoporosis

Correct Answer : D

Melorheostosis is a rare benign bone disease including dysostosis and sclerosis. 

Dripping candle wax presence is a common and typical sign of melorheostosis. This sign appears as irregular hyperostosis of the cortical bone which is likened to melted wax flowing down one side of a candle. 

It can sometimes cause pain, stiffness joint, or limitation of motion in the affected areas implicitly but mostly has no symptoms

Author :Firas Arnaout

 

20. Most common malignancy of bones is:

A) Osteosarcoma
B) Ewings saroma
C) Metastasis
D) Lymphoma
E) Chondrosarcoma

Correct Answer : B

Metastasis is most common malignancy of bone.

Author: S Kamat

 

19. Epiphyseal osteochondroma is also known as:

(A) Mafucci’s syndrome
(B) Freiberg’s fracture
(C) Larsen-Johansson disease
(D) Trevor’s disease
(E) Iselin’s disease

Correct Answer : D

Epiphyseal osteochondroma is also known as Trevor’s disease. Epiphyseal osteochondroma is localized to a specific region of the body, unlike multiple osteochondroma, which affects the entire body. 

Epiphyseal osteochondroma and multiple osteochondroma are unrelated disorders.

Author: Rajesh Bahadur Lakhey

 

18. The most common location of a chordoma is: 

A) Cervical vertebra
B) Thoracic vertebra
C) Lumbar vertebra
D) Sacrococcygeal region
E) Spheno-occipital region 

Correct Answer: D

Over 50% of the time, chordomas commonly occur in the sacrococcygeal region. 

Cervical, thoracic, and lumbar vertebral chordomas account for approximately 10% of chordomas. The remaining chordomas occur in the spheno-occipital region.

Author: Fouad Chaudhry

 

17. Which of the following tumors is considered to be a benign primary spine tumor:

A) Osteosarcoma
B) Chordoma
C) Multiple myeloma
D) Osteoblastoma
E) Lymphoma

Correct Answer: D

Osteoblastoma is a benign bone-forming neoplasm that accounts for about 1% of all primary bone tumors

It commonly arises in the posterior elements of the spine and the sacrum.

Author: Rajesh Bahadur Lakhey

 

16. Which of the following diagnostic modalities is used most often to evaluate suspected malignant astrocytomas of the spinal cord:

A) History and physical examination is often sufficient to make the diagnosis
B) Imaging characteristics of malignant astrocytomas on MRI are specific enough to make the diagnosis
C) Malignant astrocytoma of the spinal cord is a clinical diagnosis and only confirmed after post-mortem tissue evaluation
D) An open biopsy with tissue evaluation is the only way to make the diagnosis
E) Computed tomography with a myelogram

Correct Answer: D

Clinically, early symptoms of intramedullary tumors are nonspecific. Almost all intramedullary tumors show contrast
uptake. Even though there are specific MRI characteristics to each tumor, enough variability and overlap exists in their
radiologic appearance that histological examination is still required for definitive diagnosis.

Author: Rajesh Bahadur Lakhey

 

15. A 57-year-old man with known lung cancer and metastatic disease complains of increasing low back pain. How often is the lumbar spine involved when a patient has known spinal metastasis:

A) 5%
B) 15%
C) 50%
D) 85%
E) 99%

Correct Answer: D

In 85 % of patients with metastatic disease to the spine, the lumbar region vertebral body is involved. If operable, the vertebral body lesion can be managed via an anterior approach with a corpectomy, as opposed to a posterior approach with laminectomy and removal of all involved posterior elements (if they are involved).

Author: Rajesh Bahadur Lakhey

 

14. Pain is the most common complaint in patients presenting with a primary spine tumor and is present in which percentage of patients:

A) 55%
B) 65%
C) 75%
D) 85%
E) 95%

Correct Answer: D

Pain is the most common complaint in patients presenting with a primary spine tumor
A. Present in up to 85% of patients
B. Typically localized to the site of lesion but can be radicular
C. Characterized as:
     1. Progressive
     2. Gradual in onset
     3. Worse at night
     4. Non-mechanical
D. Loosely associated with trauma
Weakness can be seen in up to 42% of patients
Mass is evident in up to 16% of patients
Three percent of patients are asymptomatic
Other symptoms can include:
E. Sensory loss
F. Loss of sphincter control

Author: Rajesh Bahadur Lakhey

 

13. What percentage of osteoblastomas occur in the spine:

A) 20% to 30%
B) 30% to 40%
C) 40% to 50%
D) 50% to 60%
E) 60% to 70%

Correct Answer: C

Osteoblastomas are:
* Osteoblastic bone-forming lesions measuring more than 2 cm in size characterized by marked growth potential
* Similar in histology and presentation to osteoid osteoma with the main difference being the size of the tumor
* Most common in the 2nd and 3rd decades of life
* Twice as common in men than in women
* Common in the spine:
* Spinal osteoblastomas account for 40% to 45% of all osteoblastomas .

Over half of spinal osteoblastomas occur in the lumbar spine

Author: Rajesh Bahadur Lakhey

 

12. Which of the following methods is the standard in diagnosing vertebral metastatic disease:

A) Plain radiography demonstrating lytic lesion
B) Computed tomography with bony destruction respecting adjacent vertebral levels
C) Magnetic resonance imaging with typical destructive lesion characteristics
D) Tissue biopsy
E) There is no standard of care in diagnosing vertebral metastasis.

Correct Answer: D

The only definitive method of determining the presence and nature of metastatic tumor is vertebral biopsy. Computed
tomography-guided biopsy of the spine provides an accurate access to the lesion. Open biopsy is indicated when
image guided biopsy is not feasible or non-diagnostic. Differential diagnosis mainly involves spinal infections,
osteoporosis, disk disease, and multiple myeloma.

Author: Rajesh Bahadur Lakhey

 

11. The most effective treatment for malignant intramedullary tumors of the spinal cord is:

A) Surgical excision
B) Radiation therapy
C) Chemotherapy
D) Surgical excision followed by a combination of chemotherapy and radiation therapy.
E) Neither a single treatment modality nor a combination of treatment modalities has proven effective in significantly improving mortality

Correct Answer: E

Despite treatment, a poor prognosis is given to patients with malignant intramedullary tumors. The median survival
time for patients with cervical tumors is 3 to 6 months. Surgical excision, radiation, and chemotherapy are not found to significantly improve survival. Treatment is generally supportive

Author: Rajesh Bahadur Lakhey

 

10. This slide is a computed tomogram of the dominant shoulder of a 45-year-old male tennis player. 

The most likely diagnosis is:

A) Osteosarcoma
B) Synovial osteochondromatosis
C) Anterior glenoid fracture
D) Synovial cell sarcoma
E) Rotator cuff tear arthropathy

Correct Answer: B

Synovial osteochondromatosis is a rare condition typically affecting middle-aged men. The computed tomogram demonstrates the osteocartilaginous nodules. Early in the disease, arthroscopic removal of loose bodies and synovectomy usually results in an acceptable outcome. In cases of progressive disease resulting in secondary shoulder arthrosis, shoulder arthroplasty may be required.

Author: Rajesh Bahadur Lakhey


9. All of the disorders listed below are examples of osteochondrosis except:

A) Legg-Calvé-Perthes disease
B) Scheuermann’s disease 
C) Osgood Schlatter disorder 
D) Gorham’s disease
E) Blount disease

Correct Answer: D

The term osteochondrosis refers to symptomatic disorders involving cartilage growth. Cartilage affected by osteochondrosis may be epiphyseal, physeal, or apophyseal. Gorham’s disease is not an example of osteochondrosis. Gorham’s disease is a lymphatic disorder known as disappearing bone disease.

Author: Fouad Chaudery

 

8. Polyostotic fibrous dysplasia is caused by a mutation in which of the following genes:

A) GNAS 1
B) EXT 1 
C) Fibroblast growth factor receptor protein
D) CFBA1
E) COL1A1 

Correct Answer: A

Fibrous dysplasia is due to a postzygotic mutation in the GNAS1 gene. By contrast, EXT 1 mutations can cause multiple exostoses, and fibroblast growth factor receptor protein mutations cause achondroplasia, among other disorders. CFBA1 mutations are responsible for cleidocranial dysplasia. COL1A1 mutations are responsible for osteogenesis imperfecta.

Author: Fouad Chaudery

 

7. Which of the following is known about the genetics of multiple hereditary exostosis (MHE):

A) There is no genetic pattern for this condition.
B) MHE follows an x-linked inheritance pattern. 
C) MHE follows an autosomal recessive pattern. 
D) MHE involves a defect in biosynthesis of heparan sulfate. 
E) MHE involves a defect in fibroblast growth factor. 

Correct Answer: D

Multiple hereditary exostosis (MHE) is inherited as an autosomal dominant condition. There are three genes known to be involved: EXT 1, 2, and 3. EXT 1 and 2 encode glycosyltransferases needed for biosynthesis of heparan sulfate. Fibroblast growth factor receptor is abnormal in achondroplasia.

Author: Fouad Chaudery

 

6. Enchondral ossification is responsible for mineralization in all of the following conditions except: 

A) Callus formation during fracture healing
B) Heterotopic bone formation
C) Cartilage degeneration is osteoarthritis
D) Embryonic long bone development
E) Perichondrial bone formation

Correct Answer: E

Enchondral bone formation or ossification is bone formation on a cartilage module. Enchondral bone formation occurs in each of the following scenarios: embryonic long bone development, epiphyseal secondary center of ossification formation, callus formation during fracture healing, degenerating cartilage of osteoarthritis, calcifying cartilage tumors, and bone formed with use of demineralized bone matrix.

Author: Fouad Chaudhry

 

5. A 15-year-old boy has a destructive lesion in the distal femur with soft tissue extension. Needle biopsy shows a high-grade osteosarcoma. CT scan of the chest is normal and the technetium bone scan shows involvement of only the distal femur. 

What is the surgical stage according to the system of the Musculoskeletal Tumor Society:

A) Stage 1
B) Stage 2
C) Stage IIA
D) Stage IIB
E) Stage III

Corect answer: D

From the data provided in the question, this lesion has the following features:
• High-grade: Stage II
• Extra-compartmental: Add suffix B
• No evidence of metastases: Patient is not Stage III 

The Surgical Staging System of the Musculoskeletal Tumor Society is a useful system to both predict prognosis and plan treatment. The system for malignant lesions has three different stages:
Stage IA Low-grade intracompartmental lesions (the tumor remains confined to the medullary cavity)
Stage IB Low-grade extra compartmental (the tumor has penetrated the cortex and entered the soft tissues)
Stage IIA High-grade intracompartmental (the tumor remains confined to the medullary cavity)
Stage IIB High-grade extra compartmental (the tumor has penetrated the cortex and entered the soft tissues)
Stage III The presence of metastases in addition to the primary lesion, such as pulmonary metastases or other bone lesions

In order to use this system, one must know the grade of the tumor:
Low-Grade (Stage I) High-Grade (Stage II)
Parosteal osteosarcoma High-grade intramedullary osteosarcoma
Well differentiated intramedullary osteosarcoma Periosteal osteosarcoma
Grade I chondrosarcoma High-grade surface osteosarcoma
Grade I hemangioendothelioma Dedifferentiated chondrosarcoma
Grade I MFH Grade 2, 3, 4 MFH
Chondrosarcoma in Ollier's disease
Chondrosarcoma in Maffucci's syndrome

Author: Rajesh Lakhey

 

4. The most common location of adamantinoma of bone is the:

A) Radius
B) Ulna
C) Femur
D) Tibia
E) Fibula

Correct answer: D

Adamantinomas almost exclusively occur in the tibia alone or in the tibia and fibula. Occasionally, this rare tumor occurs in the femur, radius, or ulna (very rare).

Radiographically, this lesion is based in the diaphysis; there is usually one dominant lesion with surrounding sclerosis and other smaller lesions, again with areas of sclerosis.

Author : Rajesh Lakhey

 

 

 

3. The most common malignant tumor of the hand is?

A) Chondrosarcoma
B) Epithelioid sarcoma
C) Squamous cell carcinoma
D) Basal cell carcinoma
E) Osteosarcoma

Best answer: C

 

Regional LN should be examined, as it tends to spread through it.

Author: Ahmed Eltanboly

 

 

2. The most common soft tissue sarcoma of the hand is:

A) Epithelioid sarcoma
B) Malignant fibrous histiocytoma
C) Soft tissue osteosarcoma
D) Synovial sarcoma
E) Alveolar rhabdomyosarcoma

Best answer: A

 

Better to be treated by wide resection or amputation.

Author: Ahmed Eltanboly

 


1. A 10 year-old boy presents with worsening pain in the femur. MRI scan and biopsy shows features consistent with a high grade osteosarcoma. 

Which one of the following statements does NOT apply to his treatment?

A) A CT chest is required to look for pulmonary metastases                                                                                                                                         
B
) Chemotherapy is usually given both pre and post operatively and has radically improved survival rates.                                   
C) Limb salvage options might include rotationplasty.                                                                                                                                                      
D
) In this case wide local excision and a distal femoral lengthening endoprosthesis could be used.                                                     
E
) Limb salvage surgery is not possible in the majority of distal femur osteosarcoma cases

Answer : E

Limb salvage surgery should be attempted wherever possible in osteosarcoma, in this case rotationplasty could be considered. Bone and lung metastases are the commonest locations and initial staging should include CT chest and bone scan.

Author:Firas Arnaout

 

5. A 68-year-old woman has had progressive pain in the right thigh for the past several months. She has a history of hypertension, treated with hydrochlorothiazide and osteoporosis treated with alendronate for 10 years. At this point, she is virtually wheelchair bound. 

Radiographs are shown . Additional studies show no signs of systemic disease. 

What is the most likely etiology of her condition ?

A) Prolonged use of bisphosphonates
B) Use of calcium-wasting diuretics
C) Occult metastatic cancer
D) Vitamin D-resistant rickets
E) Disuse osteopenia

Correct Answer : A

The patient has been on alendronate for 10 years and has evidence of a proximal diaphyseal fatigue fracture. These have been associated with long-term use of bisphosphonates. Staging studies have failed to show systemic disease, and while metastasis with an unidentifiable primary does occur, it would be unlikely to present with this radiographic appearance, now recognized to be classic for stress fractures associated with chronic bisphosphonate usage. Hydrochlorothiazide does not cause calcium wasting. Vitamin D-resistant rickets would be a long-standing event and would present much earlier in life, often with pronounced deformities. Whereas the patient's progression to intolerance of weight bearing likely has led to some degree of disuse osteopenia, the underlying problem is the long-term bisphosphonate exposure.

 

4. An otherwise healthy 12-year-old boy has ankle pain after being kicked while playing soccer. Radiographs are shown in Figures.Examination reveals tenderness to palpation, but not with weight bearing. He had no pain preceding the incident. What is the next most appropriate step in management?

A) Observation
B) Curettage and grafting
C) Wide surgical resection
D) Whole body bone scan
E) Chemotherapy

Correct Answer : A

The lesion shown is a nonossifying fibroma. With no pain preceding the traumatic episode and painless weight bearing, the lesion does not appear at risk for fracture. Simple observation with repeat radiographs at a time interval (3 to 6 months) to document stability is sufficient. Surgical intervention is unnecessary because the risk of fracture is low and the natural history is one of spontaneous regression during adolescence. The lesion is benign; therefore, chemotherapy is not indicated. While a bone scan may provide some useful information, it is unnecessary for the diagnosis and adds little to management decisions.

 

3. A 20-year-old collegiate field hockey player has had diminished knee flexion for the past 3 years. Lately she has noted right knee pain that requires her to stop playing. Radiographs are shown in Figures. 

What is the next best step in management?

A) Radiation therapy
B) Surgical biopsy
C) Chemotherapy
D) Knee arthroscopy
E) Bisphosphonates

Correct Answer : B

The lesion has the characteristic features of a parosteal osteosarcoma, including its surface location on the posterior distal femur, decreased range of motion, and pain. Biopsy is necessary to confirm a diagnosis before recommending treatment. Chemotherapy and radical resection may be indicated in dedifferentiated disease, but should be considered only after a biopsy and appropriate staging have been completed. There is no role for knee arthroscopy or bisphosphonates

Author :Firas Arnaout

 

2-year-old woman with a history of breast cancer and a recent diagnosis of lung carcinoma with multiple painful biopsy-proven skeletal metastasis now reports progressive weight-bearing pain in her left thigh. 

Current treatment consists of chemotherapy for the lung mass and radiation therapy. 

An AP radiograph of the left femur is shown . What is the best option for treatment of her thigh pain?

A) Bisphosphonate therapy
B) Resection and megaprosthetic reconstruction
C) Prophylactic nailing
D) Radiation therapy
E) Chemotherapy

Correct Answer : C

Predicting which patients will sustain a fracture with metastatic bone disease is a difficult clinical decision. Mirel's rating system is a useful clinical tool but must be used cautiously. Lower extremity peritrochanteric, large, radiolucent, and painful lesions are at highest risk for fracture. The ultimate goal is palliative in nature and designed to limit pain, minimize time in the hospital, and improve the quality of life in these patients with limited survival time. If a high risk lesion is treated with radiation therapy first, the bone will become weaker before starting to regain structural integrity and the fracture risk increases. Timing of prophylactic fixation, radiation therapy, and chemotherapy requires a multidisciplinary team of doctors working collaboratively. Bisphosphonates should be included in the medical treatment for most patients with metastatic bone disease to lower the risk of further skeletal complications. They are not indicated for acute treatment of impending fractures. Resection of a metastatic lesion is reserved for patients in which internal fixation devices will not have adequate bone stock present to allow stabilization and immediate weight bearing or in patients with selected isolated metastases, such as those caused by renal carcinoma. Radiation therapy and chemotherapy have already failed to control progressive bone destruction and pain in this patient.

 

1. A 23-year-old woman who noted 1 day of thigh pain after jogging now reports persistent thigh swelling and can feel a mass. The radiograph, CT scan, and MRI scans are shown in Figures. 

What is the most likely diagnosis?

A) Soft-tissue sarcoma
B) Pseudoaneurysm
C) Abscess
D) Osteosarcoma
E) Myositis ossificans

Correct Answer : E

Myositis ossificans (MO) is a reparative lesion that is distinguished by the presence of metaplastic bone formation. The important entity that MO must be distinguished from is extraskeletal osteosarcoma. Extraskeletal osteosarcoma usually occurs in older patients and lacks the zonation phenomenon of MO. Myositis ossificans develops a well-defined ossified rim, maturing peripherally more than centrally, where osteosarcomas do the opposite. Histologically the two may be confusing; therefore, clinical and radiographic evaluation is a critical factor in the diagnosis. Soft-tissue sarcoma, pseudoaneurysm, and abcess do not have zonal ossification patterns.

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