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  • Question 1 - A 55-year-old man presents with a complaint of stiffness in his right shoulder...

    Correct

    • A 55-year-old man presents with a complaint of stiffness in his right shoulder for the past 8 months. Initially, he experienced severe pain, but now only stiffness persists. Upon examination, you observe that the right shoulder is stiff during both active and passive movements.

      What is the probable underlying cause of this stiffness?

      Your Answer: Adhesive capsulitis

      Explanation:

      Adhesive capsulitis is identified by a decrease in shoulder mobility, both when moving the shoulder voluntarily and when it is moved by someone else. The ability to rotate the shoulder outward is more affected than the ability to rotate it inward or lift it away from the body.

      On the other hand, a tear in the rotator cuff muscles will result in a reduction in active movement due to muscle weakness. Passive movement may also be restricted due to pain. However, we would not anticipate a rigid joint that opposes passive movement.

      Adhesive capsulitis, also known as frozen shoulder, is a common cause of shoulder pain that is more prevalent in middle-aged women. The exact cause of this condition is not fully understood. It is associated with diabetes mellitus, with up to 20% of diabetics experiencing an episode of frozen shoulder. Symptoms typically develop over a few days and affect external rotation more than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. Bilateral frozen shoulder occurs in up to 20% of patients, and the episode typically lasts between 6 months and 2 years.

      The diagnosis of frozen shoulder is usually made based on clinical presentation, although imaging may be necessary for atypical or persistent symptoms. There is no single intervention that has been proven to improve long-term outcomes. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids. It is important to note that the management of frozen shoulder should be tailored to the individual patient, and a multidisciplinary approach may be necessary for optimal outcomes.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 2 - A 25-year-old male patient visits his physician complaining of a rash that has...

    Incorrect

    • A 25-year-old male patient visits his physician complaining of a rash that has been present for two weeks. Upon examination, the doctor observes multiple oval-shaped lesions with a fine-scale on the outer aspects of the lesions. The rash has spread across the patient's trunk and back, resembling a fir tree. The patient reports feeling generally well. The doctor suspects pityriasis rosea and wonders which organism has been linked to its development.

      Your Answer: Coxsackie B virus

      Correct Answer: Herpes hominis virus 7 (HHV-7)

      Explanation:

      Herpes hominis virus 7 (HHV-7) is believed to be involved in the development of pityriasis rosea, while the other choices are not linked to this condition. Slapped cheek syndrome is associated with Parvovirus B-19, while Coxsackie B virus is an enterovirus that is associated with aseptic meningitis, Bornholm disease, pericarditis, and myocarditis.

      Understanding Pityriasis Rosea

      Pityriasis rosea is a rash that typically affects young adults and is characterized by an acute, self-limiting nature. While the exact cause is not fully understood, it is believed that herpes hominis virus 7 (HHV-7) may play a role. Most patients do not experience any warning signs, but some may report a recent viral infection. The rash begins with a herald patch on the trunk, followed by oval, scaly patches that follow a distinct pattern with the longitudinal diameters running parallel to the line of Langer, creating a fir-tree appearance.

      The condition is self-limiting and usually disappears within 6-12 weeks. There is no specific treatment for pityriasis rosea, but topical agents used for psoriasis may be helpful. UVB phototherapy may also be an option. It is important to differentiate pityriasis rosea from guttate psoriasis, which is characterized by tear-drop shaped, scaly papules on the trunk and limbs. Guttate psoriasis is often preceded by a streptococcal sore throat, while pityriasis rosea may be associated with recent respiratory tract infections. Both conditions typically resolve spontaneously within a few months.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      18.3
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  • Question 3 - During a soccer match, a young player is tackled and suffers a twisting...

    Correct

    • During a soccer match, a young player is tackled and suffers a twisting injury to their knee. They are diagnosed with a soft tissue knee injury. What is the name of the structure that originates from the medial surface of the lateral femoral condyle and inserts onto the anterior intercondylar area of the tibial plateau?

      Your Answer: Anterior cruciate ligament

      Explanation:

      To recall the attachments of the ACL, one can imagine placing their hand in their pocket and moving from the superolateral to inferomedial direction. Conversely, for the PCL, the movement would be from inferolateral to superomedial.

      The ACL originates from the medial surface of the lateral condyle, while the PCL originates from the lateral surface of the medial condyle.

      Located in the medial compartment of the knee, beneath the medial condyle of the femur, is the medial meniscus.

      The knee joint is the largest and most complex synovial joint in the body, consisting of two condylar joints between the femur and tibia and a sellar joint between the patella and femur. The degree of congruence between the tibiofemoral articular surfaces is improved by the presence of the menisci, which compensate for the incongruence of the femoral and tibial condyles. The knee joint is divided into two compartments: the tibiofemoral and patellofemoral compartments. The fibrous capsule of the knee joint is a composite structure with contributions from adjacent tendons, and it contains several bursae and ligaments that provide stability to the joint. The knee joint is supplied by the femoral, tibial, and common peroneal divisions of the sciatic nerve and by a branch from the obturator nerve, while its blood supply comes from the genicular branches of the femoral artery, popliteal, and anterior tibial arteries.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 4 - A 14-year-old-girl is brought into the emergency department after she accidentally poured boiling...

    Correct

    • A 14-year-old-girl is brought into the emergency department after she accidentally poured boiling water onto her hand. Upon examination, her hand appears to have turned white and she is not expressing any discomfort. What could be the reason for this?

      Your Answer: A full thickness burn has gone through the dermis and damaged sensory neurons

      Explanation:

      Patients with third-degree burns do not experience pain because the damage is so severe that it affects the sensory nerves in the deeper layers of skin, which are responsible for transmitting pain signals. In contrast, superficial burns are painful because the sensory nerves in the epidermis are still intact and able to transmit pain signals. The absence of pain in third-degree burns is not due to an increased pain threshold, but rather the damage to the sensory nerves.

      First Aid and Management of Burns

      Burns can be caused by heat, electricity, or chemicals. Immediate first aid involves removing the person from the source of the burn and irrigating the affected area with cool water. The extent of the burn can be assessed using Wallace’s Rule of Nines or the Lund and Browder chart. The depth of the burn can be determined by its appearance, with full-thickness burns being the most severe. Referral to secondary care is necessary for deep dermal and full-thickness burns, as well as burns involving certain areas of the body or suspicion of non-accidental injury.

      Severe burns can lead to tissue loss, fluid loss, and a catabolic response. Intravenous fluids and analgesia are necessary for resuscitation and pain relief. Smoke inhalation can result in airway edema, and early intubation may be necessary. Circumferential burns may require escharotomy to relieve compartment syndrome and improve ventilation. Conservative management is appropriate for superficial burns, while more complex burns may require excision and skin grafting. There is no evidence to support the use of antimicrobial prophylaxis or topical antibiotics in burn patients.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 5 - Which one of the following is not closely related to the capitate bone?...

    Incorrect

    • Which one of the following is not closely related to the capitate bone?

      Your Answer: Hamate bone

      Correct Answer: Ulnar nerve

      Explanation:

      The pisiform bone is in close proximity to both the ulnar nerve and artery. Additionally, the capitate bone is in articulation with the lunate, scaphoid, hamate, and trapezoid bones, indicating a close relationship between them.

      The Capitate Bone: Largest of the Carpal Bones

      The capitate bone is the largest of the carpal bones and is located centrally in the wrist. It has a rounded head that fits into the cavities of the lunate and scaphoid bones. The bone also has flatter articular surfaces for the hamate medially and the trapezoid laterally. At the distal end, the capitate bone primarily articulates with the middle metacarpal. Overall, the capitate bone plays an important role in the structure and function of the wrist joint.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 6 - A 25-year-old male has been struggling with anger issues for a while. Following...

    Correct

    • A 25-year-old male has been struggling with anger issues for a while. Following a disagreement with a relative, he vents his frustration by punching the wall, resulting in a cut on his hand. At the hospital, the medical team orders an x-ray to rule out any fractures and discovers a 'boxer's fracture.'

      What bone did this young man break?

      Your Answer: 5th metacarpal

      Explanation:

      A fracture of the 5th metacarpal, known as a ‘Boxer fracture’, is commonly caused by punching a hard surface. This type of fracture is typically minimally displaced. Fracture of the scaphoid bone in the wrist can lead to avascular necrosis. The 2nd metacarpal is not typically fractured in punching injuries, while the lunate and hamate bones in the wrist are not commonly affected by this type of injury.

      Boxer fracture is a type of fracture that occurs in the fifth metacarpal bone. It is usually caused by punching a hard surface, such as a wall. The fracture is typically minimally displaced, meaning that the bone is still in its proper position but has a small crack or break. This injury is commonly seen in boxers, hence the name, but can also occur in other individuals who engage in activities that involve punching or striking objects. The treatment for a boxer fracture may involve immobilization of the affected hand with a cast or splint, and in some cases, surgery may be necessary.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      8
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  • Question 7 - Which structure divides the cephalic vein and the brachial artery in the antecubital...

    Correct

    • Which structure divides the cephalic vein and the brachial artery in the antecubital fossa?

      Your Answer: Biceps muscle

      Explanation:

      The Antecubital Fossa: Anatomy and Clinical Significance

      The antecubital fossa is a depression located on the anterior aspect of the arm, between the arm and forearm. It is an important area for medical professionals as it is where venous blood samples are typically taken from. The borders of the antecubital fossa are the brachioradialis muscle laterally, the pronator teres medially, and a line between the medial and lateral epicondyles superiorly.

      There are both deep and superficial structures found in the antecubital fossa. Deep structures include the radial nerve, tendon of the biceps muscle, brachial artery, and medial nerve. Superficial structures consist of a network of veins, including the cephalic vein and basilic vein, which come together as the median cubital vein.

      The main clinical relevance of the antecubital fossa is its use for blood sampling and cannulation. However, it is also important to have a working knowledge of the anatomy as structures can become damaged. Excessive straining of the biceps tendon can cause it to rupture, leading to a ‘Popeye sign’. Damage to the medial nerve can also occur, resulting in muscle paralysis in the forearm and hand. Overall, understanding the anatomy and clinical significance of the antecubital fossa is crucial for medical professionals.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 8 - A 72-year-old retiree visits his doctor with a skin lesion on the back...

    Correct

    • A 72-year-old retiree visits his doctor with a skin lesion on the back of his right hand. The lesion appears as a red papulo-nodule with scaling and ulceration. After a biopsy, the diagnosis of cutaneous squamous cell carcinoma is confirmed.

      What histological findings are expected from the biopsy examination?

      Your Answer: Keratin pearls

      Explanation:

      Keratin pearls are a characteristic finding in cutaneous squamous cell carcinomas on biopsy. Atypical melanocytes are typically found in melanomas, not squamous cell carcinoma. Central invagination with a keratotic core is more commonly seen in keratoacanthomas. Basal cell carcinomas are characterized by the proliferation of basaloid cells parallel to the long axis of the epidermis. Seborrheic keratosis, a benign proliferation of immature keratinocytes, is typically identified by small keratin-filled cysts and a well-demarcated lesion with a stuck-on appearance.

      Understanding Squamous Cell Carcinoma of the Skin

      Squamous cell carcinoma is a type of skin cancer that is commonly seen in individuals who have had excessive exposure to sunlight or have undergone psoralen UVA therapy. Other risk factors include actinic keratoses and Bowen’s disease, immunosuppression, smoking, long-standing leg ulcers, and genetic conditions. While metastases are rare, they may occur in 2-5% of patients.

      This type of cancer typically appears on sun-exposed areas such as the head and neck or dorsum of the hands and arms. The nodules are painless, rapidly expanding, and may have a cauliflower-like appearance. Bleeding may also occur in some cases.

      Treatment for squamous cell carcinoma involves surgical excision with margins of 4mm for lesions less than 20 mm in diameter and 6mm for larger tumors. Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites. Prognosis is generally good for well-differentiated tumors that are less than 20 mm in diameter and less than 2mm deep. However, poorly differentiated tumors that are larger than 20 mm in diameter and deeper than 4mm, as well as those associated with immunosuppression, have a poorer prognosis.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      17.9
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  • Question 9 - A 27-year-old man presents to the Emergency Department following a car accident. He...

    Correct

    • A 27-year-old man presents to the Emergency Department following a car accident. He has no visible wounds or head trauma, but he is experiencing left lower limb pain and is unable to walk. Upon examination, he displays a high stepping gait and there is swelling and deformity below the knee. An X-ray confirms a fractured neck of the fibula.

      Which function is most likely impacted in this patient?

      Your Answer: Dorsiflexion of foot

      Explanation:

      A fibular neck fracture can result in foot drop due to common peroneal nerve injury. The nerve is often injured because it winds around the neck of the fibula. The common peroneal nerve is responsible for dorsiflexion of the foot, and an injury to this nerve can cause foot drop, which is characterized by a high stepping gait. In foot drop, the foot appears floppy, and the toes point downward, scraping the ground while walking. The patient tends to lift their foot very high to avoid dragging it on the ground. Eversion of the foot is not the correct answer, as it is controlled by the superficial peroneal nerve. Flexion of toes is also an incorrect answer, as it is controlled by the medial plantar nerve.

      Lower limb anatomy is an important topic that often appears in examinations. One aspect of this topic is the nerves that control motor and sensory functions in the lower limb. The femoral nerve controls knee extension and thigh flexion, and provides sensation to the anterior and medial aspect of the thigh and lower leg. It is commonly injured in cases of hip and pelvic fractures, as well as stab or gunshot wounds. The obturator nerve controls thigh adduction and provides sensation to the medial thigh. It can be injured in cases of anterior hip dislocation. The lateral cutaneous nerve of the thigh provides sensory function to the lateral and posterior surfaces of the thigh, and can be compressed near the ASIS, resulting in a condition called meralgia paraesthetica. The tibial nerve controls foot plantarflexion and inversion, and provides sensation to the sole of the foot. It is not commonly injured as it is deep and well protected, but can be affected by popliteal lacerations or posterior knee dislocation. The common peroneal nerve controls foot dorsiflexion and eversion, and can be injured at the neck of the fibula, resulting in foot drop. The superior gluteal nerve controls hip abduction and can be injured in cases of misplaced intramuscular injection, hip surgery, pelvic fracture, or posterior hip dislocation. Injury to this nerve can result in a positive Trendelenburg sign. The inferior gluteal nerve controls hip extension and lateral rotation, and is generally injured in association with the sciatic nerve. Injury to this nerve can result in difficulty rising from a seated position, as well as difficulty jumping or climbing stairs.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      17
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  • Question 10 - A 38-year-old man presents to his GP with limited mobility in his right...

    Correct

    • A 38-year-old man presents to his GP with limited mobility in his right hip. He has a long-standing history of mid and lower back pain due to his work in a lumberyard. During the examination, reduced flexion and external rotation of the hip are observed. The patient reports experiencing weakness and limited range of motion during single-leg squats on the affected side, but not during regular two-legged squats. What is the probable lower limb structure affected, leading to this patient's presentation?

      Your Answer: Psoas muscle

      Explanation:

      The main muscle responsible for hip flexion is the iliopsoas group, which includes the psoas muscle. These muscles are controlled by nerves originating from L1 to L4 and also contribute to lateral rotation of the hip.

      Femoroacetabular impingement is a condition characterized by hip and groin pain that worsens with prolonged sitting and is often accompanied by snapping, clicking, or locking of the hip. It is caused by an abnormality in hip anatomy that leads to contact between the femur and acetabulum rim.

      Meralgia paresthetica is a condition caused by compression of the lateral cutaneous nerve of the thigh, resulting in sensory symptoms such as numbness or tingling in the outer thigh. This nerve is not responsible for motor function and therefore would not cause weakness or paralysis.

      A meniscal tear is a common knee injury that can cause locking and giving way of the knee joint. A positive Thessaly’s test, which involves standing on one leg and twisting the body in internal or external rotation, may elicit pain in individuals with a meniscal tear.

      Trochanteric bursitis is a condition characterized by lateral groin pain and tenderness over the greater trochanter, which is a bony prominence on the femur.

      The Psoas Muscle: Origin, Insertion, Innervation, and Action

      The psoas muscle is a deep-seated muscle that originates from the transverse processes of the five lumbar vertebrae and the superficial part originates from T12 and the first four lumbar vertebrae. It inserts into the lesser trochanter of the femur and is innervated by the anterior rami of L1 to L3.

      The main action of the psoas muscle is flexion and external rotation of the hip. When both sides of the muscle contract, it can raise the trunk from the supine position. The psoas muscle is an important muscle for maintaining proper posture and movement, and it is often targeted in exercises such as lunges and leg lifts.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      28.5
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  • Question 11 - Which one of the following structures is not closely related to the adductor...

    Incorrect

    • Which one of the following structures is not closely related to the adductor longus muscle? Also, can you provide information on the relationship between the adductor longus muscle and nearby structures for a 12-year-old student?

      Your Answer: Femoral nerve

      Correct Answer: Tendon of iliacus

      Explanation:

      The femoral triangle is bordered by the Adductor longus medially, Inguinal ligament superiorly, and Sartorius muscle laterally. The Adductor longus muscle is located along the medial border of the femoral triangle and is closely associated with the long saphenous vein and the profunda branch of the femoral artery. The femoral nerve is located inferiorly to the Adductor longus muscle. However, the tendon of iliacus inserts proximally and does not come into contact with the Adductor longus muscle.

      Adductor Longus Muscle

      The adductor longus muscle originates from the anterior body of the pubis and inserts into the middle third of the linea aspera. Its main function is to adduct and flex the thigh, as well as medially rotate the hip. This muscle is innervated by the anterior division of the obturator nerve, which originates from the spinal nerves L2, L3, and L4. The adductor longus is one of the adductor muscles, which are a group of muscles located in the thigh that work together to bring the legs towards the midline of the body. The schematic image below illustrates the relationship of the adductor muscles.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      20.6
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  • Question 12 - Which one of the following structures is not closely related to the posterior...

    Incorrect

    • Which one of the following structures is not closely related to the posterior tibial artery?

      Your Answer: Tibial nerve medially

      Correct Answer: Deep peroneal nerve laterally

      Explanation:

      The deep peroneal nerve is in the front compartment and the tibial nerve is on the inner side. The tibial nerve is located beneath the flexor retinaculum at its end.

      Anatomy of the Posterior Tibial Artery

      The posterior tibial artery is a major branch of the popliteal artery that terminates by dividing into the medial and lateral plantar arteries. It is accompanied by two veins throughout its length and its position corresponds to a line drawn from the lower angle of the popliteal fossa to a point midway between the medial malleolus and the most prominent part of the heel.

      The artery is located anteriorly to the tibialis posterior and flexor digitorum longus muscles, and posteriorly to the surface of the tibia and ankle joint. The posterior tibial nerve is located 2.5 cm distal to its origin. The proximal part of the artery is covered by the gastrocnemius and soleus muscles, while the distal part is covered by skin and fascia. The artery is also covered by the fascia overlying the deep muscular layer.

      Understanding the anatomy of the posterior tibial artery is important for medical professionals, as it plays a crucial role in the blood supply to the foot and ankle. Any damage or blockage to this artery can lead to serious complications, such as peripheral artery disease or even amputation.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 13 - A 25-year-old patient was recently admitted to hospital with symptoms of diarrhoea, weight...

    Incorrect

    • A 25-year-old patient was recently admitted to hospital with symptoms of diarrhoea, weight loss and abdominal pain. Upon blood tests, a raised C-reactive protein (CRP) and anaemia were observed. A stool test for faecal calprotectin was significantly raised. A colonoscopy was performed, revealing deep ulceration and skip lesions. The patient was diagnosed with Crohn's disease without complications and was promptly started on glucocorticoids to induce remission. Subsequently, the gastroenterologist prescribed a drug called azathioprine to maintain remission of symptoms.

      What is the correct mechanism of action for azathioprine?

      Your Answer: Interferes with the metabolic pathway of folic acid

      Correct Answer: Its metabolite inhibits purine synthesis

      Explanation:

      Azathioprine is an immunosuppressant that is commonly used to maintain remission in Crohn’s disease. It is metabolized into mercaptopurine, which inhibits purine synthesis and helps to control inflammation.

      Infliximab is a monoclonal antibody that is sometimes used to induce remission in refractory or fistulating Crohn’s disease. It works by binding to and neutralizing tumor necrosis factor, a key mediator of inflammation.

      Mesalazine is a second-line drug that is used to induce remission in Crohn’s disease after glucocorticoids. It belongs to the 5-aminosalicylate class of drugs and works by inhibiting prostaglandin secretion. It is also considered for use in maintaining remission in post-surgical Crohn’s patients.

      Methotrexate is another immunosuppressant that is used as a second-line treatment for Crohn’s disease. It works by disrupting folic acid metabolism and accumulating the anti-inflammatory molecule adenosine.

      Metronidazole is an antibiotic that is used to treat isolated peri-anal Crohn’s disease. It works by forming radicals that disrupt the DNA of anaerobic bacteria.

      Azathioprine is a medication that is converted into mercaptopurine, which is an active compound that inhibits the production of purine. To determine if someone is at risk for azathioprine toxicity, a test for thiopurine methyltransferase (TPMT) may be necessary. Adverse effects of this medication include bone marrow depression, nausea and vomiting, pancreatitis, and an increased risk of non-melanoma skin cancer. If infection or bleeding occurs, a full blood count should be considered. It is important to note that there may be a significant interaction between azathioprine and allopurinol, so lower doses of azathioprine should be used. However, azathioprine is generally considered safe to use during pregnancy.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 14 - A teenage boy arrives at the hospital with a biking injury. An X-ray...

    Correct

    • A teenage boy arrives at the hospital with a biking injury. An X-ray reveals that he has fractured both his tibia and fibula. The medical team applies a cast to his leg.

      However, just an hour later, the boy is experiencing excruciating pain despite receiving regular doses of morphine. As a result, the doctors decide to remove his cast.

      What should be the next course of action?

      Your Answer: Notify the orthopaedic surgeon and theatre team

      Explanation:

      The appropriate course of action in this scenario is to notify the orthopaedic surgeon and theatre team immediately for an urgent fasciotomy. Sedation, increased pain relief, or reapplying a vacuum splint would not be helpful and could potentially worsen the situation.

      Compartment syndrome is a complication that can occur after fractures or vascular injuries. It is characterized by increased pressure within a closed anatomical space, which can lead to tissue death. Supracondylar fractures and tibial shaft injuries are the most common fractures associated with compartment syndrome. Symptoms include pain, numbness, paleness, and possible paralysis of the affected muscle group. Even if a pulse is present, compartment syndrome cannot be ruled out. Diagnosis is made by measuring intracompartmental pressure, with pressures over 20mmHg being abnormal and over 40mmHg being diagnostic. X-rays typically do not show any pathology. Treatment involves prompt and extensive fasciotomies, with careful attention to decompressing deep muscles in the lower limb. Patients may experience myoglobinuria and require aggressive IV fluids. In severe cases, debridement and amputation may be necessary, as muscle death can occur within 4-6 hours.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 15 - A 28-year-old man visits his GP with complaints of ongoing stiffness and pain...

    Incorrect

    • A 28-year-old man visits his GP with complaints of ongoing stiffness and pain in his lower back for the past 6 months. He reports no specific injury that could have caused his symptoms and mentions that he leads an active lifestyle. The pain is particularly severe in the morning but improves with physical activity. Following imaging tests, he is diagnosed with ankylosing spondylitis. What is the gene linked to this condition?

      Your Answer: Human leucocyte antigen- DR4

      Correct Answer: Human leucocyte antigen- B27

      Explanation:

      Ankylosing spondylitis is associated with the HLA-B27 serotype, with approximately 90% of patients with the condition testing positive for it. Adrenal 21-hydroxylase deficiency is thought to be linked to HLA-B47, while HLA-DQ2 is associated with coeliac disease and the development of autoimmune diseases. HLA-DR4 is primarily linked to rheumatoid arthritis, while HLA-DR2 is associated with systemic lupus erythematosus, multiple sclerosis, and leprosy, but not ankylosing spondylitis.

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more common in males aged 20-30 years old. Inflammatory markers such as ESR and CRP are often elevated, but normal levels do not rule out ankylosing spondylitis. HLA-B27 is not very useful in making the diagnosis as it is positive in 90% of patients with ankylosing spondylitis and 10% of normal patients. The most useful diagnostic tool is a plain x-ray of the sacroiliac joints, which may show subchondral erosions, sclerosis, squaring of lumbar vertebrae, bamboo spine, and syndesmophytes. If the x-ray is negative but suspicion for AS remains high, an MRI may be obtained to confirm the diagnosis. Spirometry may show a restrictive defect due to pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.

      Management of ankylosing spondylitis includes regular exercise such as swimming, NSAIDs as first-line treatment, physiotherapy, and disease-modifying drugs such as sulphasalazine if there is peripheral joint involvement. Anti-TNF therapy such as etanercept and adalimumab may be given to patients with persistently high disease activity despite conventional treatments, according to the 2010 EULAR guidelines. Research is ongoing to determine whether anti-TNF therapies should be used earlier in the course of the disease.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 16 - A 67-year-old man arrives at the Emergency Department with a swollen, red, and...

    Correct

    • A 67-year-old man arrives at the Emergency Department with a swollen, red, and hot first metatarsophalangeal joint. The diagnosis is an acute gout attack. What substance in the joint space is responsible for causing gout?

      Your Answer: Monosodium urate

      Explanation:

      When joint aspiration is performed in cases of gout, the presence of needle-shaped monosodium urate crystals that are negatively birefringent can be observed under polarised light. The acute manifestation of gout often involves the first metatarsophalangeal joint, which is commonly referred to as podagra. Gout is caused by elevated levels of uric acid, which results in the accumulation of monosodium urate crystals in and around the joints. Pseudogout, a similar condition, is caused by the deposition of calcium pyrophosphate. In rheumatoid arthritis, a collection of fibrous tissue known as a pannus may be observed within affected joints, while osteoarthritis may present with bony projections called osteophytes. A diet that is high in purines, such as red meat, liver, and beer, may increase the likelihood of developing gout.

      Understanding Gout: Symptoms and Diagnosis

      Gout is a type of arthritis that causes inflammation and pain in the joints. Patients experience episodes of intense pain that can last for several days, followed by periods of no symptoms. The acute episodes usually reach their peak within 12 hours and can affect various joints, with the first metatarsophalangeal joint being the most commonly affected. Swelling and redness are also common symptoms of gout.

      If left untreated, repeated acute episodes of gout can lead to joint damage and chronic joint problems. To diagnose gout, doctors may perform synovial fluid analysis to look for needle-shaped, negatively birefringent monosodium urate crystals under polarised light. Uric acid levels may also be checked once the acute episode has subsided, as they can be high, normal, or low during the attack.

      Radiological features of gout include joint effusion, well-defined punched-out erosions with sclerotic margins, and eccentric erosions. Unlike rheumatoid arthritis, gout does not cause periarticular osteopenia. Soft tissue tophi may also be visible.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 17 - A 16-year-old soccer player injures her ankle while playing a game. She reports...

    Correct

    • A 16-year-old soccer player injures her ankle while playing a game. She reports that her ankle turned inward, causing her foot to roll inward, and she experienced immediate pain and swelling.

      What ligament is the most probable to have been sprained in this scenario?

      Your Answer: Anterior talofibular ligament

      Explanation:

      The most frequently sprained ligament in ankle inversion injuries is the anterior talofibular ligament, which runs from the talus to the fibula and restricts inversion in plantar flexion. The calcaneonavicular ligament, located between the calcaneus and navicular bones, stabilizes the medial longitudinal arch and is not involved in resisting inversion or eversion, making it unlikely to be injured. The deltoid ligament, found on the medial side of the ankle, resists eversion and is therefore not typically affected in inversion injuries. The interosseous ligament, located between the tibia and fibula above the ankle joint, is only impacted if there is trauma to the lower leg. The Lisfranc ligament, which connects the second metatarsal to the medial cuneiform, is more commonly disrupted by direct blows or axial loads on a plantarflexed foot with rotation, whereas a simple sprain to the anterior talofibular ligament is more common in inversion injuries.

      Ankle Sprains: Types, Presentation, Investigation, and Treatment

      Ankle sprains occur when ligaments in the ankle are stretched or torn. The ankle joint is composed of the distal tibia and fibula and the superior aspect of the talus, which form a mortise secured by ligamentous structures. Low ankle sprains involve the lateral collateral ligaments, with the anterior inferior tibiofibular ligament being the most commonly injured. Inversion injury is the most common mechanism, causing pain, swelling, tenderness, and sometimes bruising. Low ankle sprains are classified into three grades based on the extent of ligament disruption, bruising and swelling, and pain on weight-bearing. Radiographs should be done to rule out associated fractures, and MRI may be useful for evaluating perineal tendons. Treatment for low ankle sprains involves rest, ice, compression, and elevation, with occasional use of a removable orthosis, cast, or crutches. Surgical intervention is rare.

      High ankle sprains involve the syndesmosis, which is rare and severe. The mechanism of injury is usually external rotation of the foot, causing the talus to push the fibula laterally. Patients experience more pain when weight-bearing than with low ankle sprains. Radiographs may show widening of the tibiofibular joint or ankle mortise, and MRI may be necessary for high suspicion of syndesmotic injury. Treatment for high ankle sprains involves non-weight-bearing orthosis or cast until pain subsides, or operative fixation if there is diastasis or failed non-operative management.

      Isolated injuries to the deltoid ligament are rare and frequently associated with a fracture, such as Maisonneuve fracture of the proximal fibula. Treatment for deltoid ligament injuries is similar to that for low ankle sprains, provided the ankle mortise is anatomically reduced. If not, reduction and fixation may be necessary.

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      • Musculoskeletal System And Skin
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  • Question 18 - Which one of the following is not a content of the posterior triangle...

    Correct

    • Which one of the following is not a content of the posterior triangle of the neck?

      Your Answer: Phrenic nerve

      Explanation:

      The contents of the posterior triangle include the phrenic nerve, while the carotid sheath and its contents are found in the anterior triangle.

      The Anterior Triangle of the Neck: Boundaries and Contents

      The anterior triangle of the neck is a region that is bounded by the anterior border of the sternocleidomastoid muscle, the lower border of the mandible, and the anterior midline. It is further divided into three sub-triangles by the digastric muscle and the omohyoid muscle. The muscular triangle contains the neck strap muscles, while the carotid triangle contains the carotid sheath, which houses the common carotid artery, the vagus nerve, and the internal jugular vein. The submandibular triangle, located below the digastric muscle, contains the submandibular gland, submandibular nodes, facial vessels, hypoglossal nerve, and other structures.

      The digastric muscle, which separates the submandibular triangle from the muscular triangle, is innervated by two different nerves. The anterior belly of the digastric muscle is supplied by the mylohyoid nerve, while the posterior belly is supplied by the facial nerve.

      Overall, the anterior triangle of the neck is an important anatomical region that contains many vital structures, including blood vessels, nerves, and glands. Understanding the boundaries and contents of this region is essential for medical professionals who work in this area.

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      • Musculoskeletal System And Skin
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  • Question 19 - A 27-year-old male arrives at the Emergency Department following a fall on the...

    Incorrect

    • A 27-year-old male arrives at the Emergency Department following a fall on the street. He reports experiencing difficulty breathing and sharp, stabbing pain upon inhalation. A chest X-ray reveals a pneumothorax located at the lung's apex. Which bone is most likely fractured, resulting in the pneumothorax?

      Your Answer: 2nd rib

      Correct Answer: Clavicle

      Explanation:

      The apex of the pleural cavity is situated behind the middle third of the clavicle, which can be susceptible to breaking if there is force applied through the shoulders. Unlike the clavicle, the 1st and 2nd ribs are not commonly broken except in severe trauma such as road traffic accidents. The acromion is also an uncommon site for fractures, typically occurring from falling on outstretched hands. Similarly, the coracoid process is rarely fractured and is usually associated with shoulder dislocation.

      Anatomy of the Clavicle

      The clavicle is a bone that runs from the sternum to the acromion and plays a crucial role in preventing the shoulder from falling forwards and downwards. Its inferior surface is marked by ligaments at each end, including the trapezoid line and conoid tubercle, which provide attachment to the coracoclavicular ligament. The costoclavicular ligament attaches to the irregular surface on the medial part of the inferior surface, while the subclavius muscle attaches to the intermediate portion’s groove.

      The superior part of the clavicle’s medial end has a raised surface that gives attachment to the clavicular head of sternocleidomastoid, while the posterior surface attaches to the sternohyoid. On the lateral end, there is an oval articular facet for the acromion, and a disk lies between the clavicle and acromion. The joint’s capsule attaches to the ridge on the margin of the facet.

      In summary, the clavicle is a vital bone that helps stabilize the shoulder joint and provides attachment points for various ligaments and muscles. Its anatomy is marked by distinct features that allow for proper function and movement.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      14.3
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  • Question 20 - A 25-year-old male is having a full anterior cruciate ligament reconstruction procedure in...

    Incorrect

    • A 25-year-old male is having a full anterior cruciate ligament reconstruction procedure in the primary orthopaedic operating room. While performing the surgery, the orthopaedic surgeon requests his assistant to locate the blood vessel that is being ligated to prevent bleeding and supplies oxygenated blood to the ACL.

      Your Answer: Inferior medial geniculate arteries

      Correct Answer: Middle genicular artery

      Explanation:

      The middle genicular artery is responsible for providing blood supply to the anterior cruciate ligament, while the lateral femoral circumflex artery supplies certain muscles located on the lateral side of the thigh.

      The knee joint is the largest and most complex synovial joint in the body, consisting of two condylar joints between the femur and tibia and a sellar joint between the patella and femur. The degree of congruence between the tibiofemoral articular surfaces is improved by the presence of the menisci, which compensate for the incongruence of the femoral and tibial condyles. The knee joint is divided into two compartments: the tibiofemoral and patellofemoral compartments. The fibrous capsule of the knee joint is a composite structure with contributions from adjacent tendons, and it contains several bursae and ligaments that provide stability to the joint. The knee joint is supplied by the femoral, tibial, and common peroneal divisions of the sciatic nerve and by a branch from the obturator nerve, while its blood supply comes from the genicular branches of the femoral artery, popliteal, and anterior tibial arteries.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      13.6
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