Section IV Musculoskeletal Radiology

Figure 1
84. A. B. C. D. You are shown a single lateral radiograph (Figure 1). What is the MOST likely diagnosis? Klippel-Feil syndrome Chronic juvenile arthritis Ankylosing spondylitis Diffuse idiopathic skeletal hyperostosis (DISH)

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Section IV Musculoskeletal Radiology

Question 84 Rationales: A. Incorrect. Klippel-Feil syndrome includes any congenital fusion of the cervical vertebra which may involve one or more levels. This fusion may be partial or complete affecting the anterior and/or posterior elements. The original syndrome, consisting of short neck, low posterior hairline and limited neck mobility, is present in less than half of such cases. Approximately 20-25% of cases are associated with Sprengels deformity. The diffuse ankylosis in the test case is NOT associated with hypoplastic intervertebral discs with a constricted appearance which is typical of fusion that occurs on a congenital basis. B. Incorrect. Ankylosis of the apophyseal joints typically involves the upper cervical spine, usually C2 C3 and C3 C4. The associated vertebra and intervertebral discs do not develop normally and appear hypoplastic. C. Correct. Diffuse, uniform ankylosis is typical of advanced ankylosing spondylitis. There is extensive syndesmophyte formation and facet joint fusion. The vertebra and intervertebral discs are mature, without hypoplasia. Because the discs and facet joints are fused, trauma results in atypical fracture patterns as in the test case where pseudarthrosis is present at the C6 7 level. There is osseous fusion at the interverbral discs and facet joints. Fine, vertical syndesmophytes are evident. Subsequent fracture is also present at the lower cervical region D. Incorrect. Diffuse idiopathic skeletal hyperostosis involves ossification of numerous ligaments throughout the body, typically the anterior longitudinal ligament (Forrestiers Disease). Lateral radiographs show flowing, ribbon like ossification anterior to the vertebra with relative preservation of disc space height.

American College of Radiology

Section IV Musculoskeletal Radiology

Figure 2A
85. You are shown sagittal proton density and coronal proton density fat-suppressed MR images (Figures 2A and 2B). What is the MOST likely diagnosis? A. B. C. D. Meniscal flounce Bucket-handle tear Myxoid degeneration Discoid meniscus

American College of Radiology

Section IV Musculoskeletal Radiology

Figure 2B

Diagnostic In-Training Exam 2006

Section IV Musculoskeletal Radiology

Question 85 Rationales: A. Incorrect. Meniscal flounce refers to a physiologic change in the shape of the meniscus, presumably due to traction related to positioning, which may be observed during routine MR imaging. The undulating appearance may mimic a tear. B. Incorrect. The bucket-handle tear involves a longitudinal tear at the periphery of the meniscus, usually the medial, with displacement of the more central meniscal tissue (the bucket handle) to the intercondylar notch. C. Incorrect. Increased signal within the substance of the meniscus that does not extend to its superior or inferior articular surface may represent several phenomena including peripheral neurovascular structures, degeneration and perhaps intrasubstance tear. Such menisci are usually not torn. Prominent areas of increased signal intensity within the substance of a meniscus are more significant when the meniscus is discoid in nature, indicative of cavitation, or there is an associated meniscal cyst. D. Correct. There is excessive meniscal tissue occupying the lateral joint compartment, like a disc between two adjacent vertebrae. Normal menisci are semilunar fibrocartilage structures at the periphery of the medial and lateral joint compartments. The etiology of the discoid meniscus is unknown. The lateral meniscus is almost always involved.

American College of Radiology

Section IV Musculoskeletal Radiology

Figure 3A
86. You are shown AP and lateral radiographs (Figure 3A and 3B) of a 24-year-old man with chronic leg pain. What is the MOST likely diagnosis? A. B. C. D. Brodies abscess Osteoid osteoma Stress fracture Non-ossifying fibroma

American College of Radiology

Section IV Musculoskeletal Radiology

Figure 3B

Diagnostic In-Training Exam 2006

Section IV Musculoskeletal Radiology

Question 86 Rationales: A. Correct. A Brodies abscess may be evident during the subacute or chronic stages of osteomyelitis. They are characteristically 1-4 cm lucent subcortical lesions surrounded by spongy bone eburnation and periosteal reaction. The lucency itself usually demonstrates an elongated appearance with the suggestion of loculations and tracts or channels. There is an elongated, channel-like, multilculated lytic lesion at the proximal tibia adjacent to the anterior cortex, with surrounding sclerosis and chronic periosteal reaction. B. Incorrect. The nidus of osteoid osteoma is generally smaller than 1.5 cm. Most are cortically based and surrounded by exuberant reactive uniform sclerosis. C. Incorrect. The lucency of a stress fracture is linear and intracortical in location. D. Incorrect. A Nonossifying fibroma is a benign geographic lesion that occurs most frequently in a metadiaphyseal location. It is cortically based and is usually surrounded by a thin, well-defined, lobulated sclerotic margin. Periosteal reaction without fracture is rare.

American College of Radiology

Section IV Musculoskeletal Radiology

Figure 4A
87. You are shown an AP radiograph and coronal fast spin-echo proton density image of a 13-yearold boy with knee pain (Figures 4A and 4B). What is the MOST likely diagnosis? A. B. C. D. 9 Enchondroma Chondromyxoid fibroma Clear cell chondrosarcoma Chondroblastoma American College of Radiology

Section IV Musculoskeletal Radiology

Figure 4B

Diagnostic In-Training Exam 2006

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Section IV Musculoskeletal Radiology

Question 87 Rationales: A. Incorrect. Enchondroma is a common lesion characterized by the formation of mature hyaline cartilage. It is seen throughout life, usually in young adults. In long tubular bones, enchondromas are most often metaphyseal. Conventional radiographs show a lytic lesion, with or without cartilaginous calcification, well-defined, with a lobulated border. Endosteal scalloping may be present with larger lesions. They are most common at the metacarpals and phalanges. Most are asymptomatic until pathologic fracture. B. Incorrect. CMF is a rare metaphyseal lesion, most common about the knee. It is the least common benign cartilage neoplasm. Patients are adolescents and young adults. Conventional radiographs show an eccentric lesion with a sclerotic inner margin and some degree of expansile remodeling. C. Incorrect. Clear cell chondrosarcoma, like chondroblastoma and giant cell tumor, is an end-of-thebone lesion occurring in middle age and young adults. A rare, low grade malignancy, it is most common at the proximal femur and humerus. Conventional radiographs show a lytic lesion with well-defined sclerotic borders, similar in appearance to chondroblastoma, though usually larger. Lesions may also have poorly defined margins. About one third of cases show calcification within the lesion. D. Correct. Chondroblastoma is a benign cartilaginous tumor of childhood that occurs in the epiphysis or apophysis, most commonly about the knee. Most patients are between 10 and 20 years of age. Patients may present after reaching skeletal maturity. These lesions are usually small and well defined, usually with a sclerotic border. Conventional radiographs demonstrate cartilaginous calcification and periosteal reaction in less than half the cases. Associated bone marrow edema may be noted with MR imaging. There is a small, well defined lesion at the proximal tibial epiphysis.

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Section IV Musculoskeletal Radiology

Figure 5
88. You are shown an AP radiograph (Figure 5) of a 20-year-old woman. Which one of the following is associated with this disorder? A. Malignant transformation B. Sexual precocity C. Multiple fractures D. Renal disease

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Section IV Musculoskeletal Radiology

Question 88 Rationales: A. Correct. Malignant transformation to chondrosarcoma is a well known complication of multiple hereditary exostoses. The literature describes an incidence ranging from 1-25%, 2-5% more likely. B. Incorrect. Sexual precocity or precocious pseudopuberty is associated with fibrous dysplasia, the McCune-Albright syndrome. Multiple sessile osteochondromata about the hips characterize this case of multiple hereditary exostoses. C. Incorrect. Bone that is more prone to fracture is seen with many congenital/developmental and metabolic disorders including osteogenesis imperfecta, osteopetrosis, and renal osteodystrophy. Patients with multiple hereditary exostoses are not more prone to fracture. D. Incorrect. Renal osteodystrophy is characterized by osteomalacia and secondary hyperparathyroidism. Radiographic findings include subperiosteal resorption, brown tumors, insufficiency fractures, osteopenia and osteosclerosis.

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Section IV Musculoskeletal Radiology

Figure 6A

Figure 6B
89. You are shown coronal inversion recovery and axial fat-suppressed T2-weighted images (Figures 6A and 6B) of a 43-year-old woman with hip pain. What tendon is avulsed? A. B. C. D. Sartorius Rectus femoris Tensor fasciae latae Iliopsoas

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Section IV Musculoskeletal Radiology

Question 89 Rationales: A. Incorrect. The sartorius, the longest muscle in the body, originates at the anterior superior iliac spine, crosses the hip and knee and inserts as a component of the pes anserinus (sartorius, gracilis, semitendinosus) at the proximal medial tibia. B. Correct. The rectus femoris originates at the anterior inferior iliac spine where the abnormality is present in the test case. It crosses the hip and inserts as a component of the quadriceps tendon (rectus femoris, vastus medialis, vastas lateralis, vastis intermedialis) at the patella which continues distally as the patella tendon. C. Incorrect. The tensor fasciae latae originates at the posterolateral margin of the iliac crest and crosses the hip and knee and inserts as the iliotibial band at Gerdys tubercle at the proximal lateral tibia. D. Incorrect. The iliopsoas originates as the iliacus and psoas musculature at the anterior iliac wing and paravertebral lumbar spine respectively, crosses the hip and inserts at the lesser trochanter.

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Section IV Musculoskeletal Radiology

90. A. B. C. D. Concerning Type I Neurofibromatosis, which one of the following is associated? S-shaped scoliosis Posteromedial bowing of the tibia Multiple exostoses Atlanto-axial subluxation

Question 90 Rationales: A. Correct. Scoliosis and /or kyphosis are one of the most common problems of patients with Type I NFBT. Although a dysplastic, sharply angulated, short segment curve is virtually diagnostic, a typical S-shaped, idiopathic like, scoliosis is common. B. Incorrect. Anterolateral bowing of the infant tibia and fibula is characteristic of Type I NFBT. Eventual fracture is difficult to treat with repeated episodes of non-union hence the term congenital pseudarthrosis of the tibia and fibula. Posteromedial bowing of the tibia and fibula is rare and more benign. The bow spontaneously straightens over time and any limb length discrepancy is easier to treat. C. Incorrect. Numerous bony lesions/deformities are typical of Type I NFBT. Bony defects, scalloping, overgrowth, multiple non-ossifying fibromas have all been described. Multiple exostoses are not a manifestation of the mesodermal dysplasia. D. Incorrect. Numerous congenital disorders are associated with ligament laxity and scoliosis, including Downs, Marfans, and Ehlos-Danlos Syndrome. Ligament laxity is not a feature of NFBT. Joints may be deformed but are stable. Atlanto-axial subluxation is not a complication.

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Section IV Musculoskeletal Radiology

91. A. B. C. D. Concerning osteopetrosis, which one is TRUE? In the adult, bone is more resistant to fracture and undergoes bone marrow suppression. Alternating bands of sclerosis indicate the fluctuating course of the disease. The radiographic hallmark is diffuse cortical thickening. Osteoblastic activity results in excessive bone production.

Question 91 Rationales: A. Incorrect. The abnormal bone of adults with osteopetrosis is more prone to fracture. This is the most common complication. Bone marrow suppression is present in the infantile, lethal type. B. Correct. The degree of abnormal diminished osteoclastic activity varies during skeletal growth and development. This results in alternating bands of sclerosis parallel to the respective growth plates. C. Incorrect. The radiographic hallmark is the diffuse loss of corticomedullary junction in the long tubular bones. Skeletal dysplasias may be classified according to the type of bone formation, endochondral , intramembranous or both, that is affected by the diminished osteoclastic activity. These are further classified according to the stage of skeletal development, either primary or secondary. Osteopetrosis, for example, involves a defect in endochondral bone formation during the initial development of the skeleton. It is therefore, the medullary bone that is affected. Cortical or periosteal bone formation is intramembranous, without a preexisting cartilage template. A defect in intramembranous bone formation, therefore would result in cortical thickening as seen in progressive diaphyseal dysplasia (Engelmanns disease). D. Incorrect. Defective osteoclastic activity and subsequent diminished bone resorption is felt to be the primary abnormality of the sclerosing dysplasias, infantile osteopetrosis being the most studied entity in this regard.

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Section IV Musculoskeletal Radiology

92. A. B. C. D. Concerning calcium pyrophosphate dihydrate (CPPD) deposition which one is TRUE? Polarized light microscopy demonstrates needle-shaped crystals with negative birefringence. Water sensitive MR sequences are most sensitive to the detection of chondrocalcinosis. Chondrocalcinosis is synonymous with pseudo-gout. Pyrophosphate arthropathy is most common at the knee.

Question 92 Rationales: A. Incorrect. Polarized light microscopy demonstrates rhomboid crystals with weak positive birefringence. Monosodium urate crystals are needle shaped and demonstrate strong negative birefringence. B. Incorrect. A gradient echo sequence, T2* GRE, is the most sensitive technique for the detection of chondrocalcinosis because of the increased magnetic susceptibility. Multiple hypointense punctuate foci are characteristic of such chondral calcification. C. Incorrect. Chondrocalcinosis refers to the presence of calcification within hyaline and fibrocartilage. The crystal is usually, though not necessarily CPPD. The patient may be asymptomatic. Pseudogout is one of several possible clinical presentations of CPPD deposition disease, similar to attacks of acute gouty arthritis. Theoretically, there is some degree of cartilage damage, shedding of crystals into the joint, synovial deposition and inflammation when the patient is symptomatic. Pyrophosphate arthropathy refers to the type of structural joint damage that may eventually result in some patients. D. Correct. The arthropathy related to CPPD deposition is similar to osteoarthritis in that joint space narrowing, subchondral sclerosis, subchondral cyst and osteophyte formation may be present. There are features, however that are unique to CPPD arthropathy. Weight-bearing and non-weight-bearing joints may be involved. The unusual distribution of involvement within a given joint is notable i.e., patella-femoral compartment at the knee, radiocarpal at the wrist. Subchondral cyst formation may be numerous and quite large. Osteophyte formation is quite variable. Destructive bone changes may be severe and progressive resembling neuropathic disease. Pyrophosphate arthropathy is most common at the knee. The wrist and MCP joints are commonly involved but any joint is susceptible.

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Section IV Musculoskeletal Radiology

93. Concerning the diffuse, intracapsular form of pigmented villonodular synovitis, which one is TRUE? A. B. C. D. The small joints of the hands and feet are typically involved. MR typically demonstrates a heterogeneous intracapsular mass. The recurrence rate following synovectomy is less than 5%. Polyarticular involvement is characteristic.

Question 93 Rationales: A. Incorrect. The diffuse form favors the large joints, including knee, hip, elbow and ankle. The focal, extracapsular form, giant cell tumor of tendon sheath favors the tendons of the hands and feet. B. Correct. Diffuse, intracapsular PVNS, is a proliferative disorder of the synovium and therefore presents as a soft tissue mass within the joint. MR signal characteristics are related to hemosiderin deposition, joint effusion, and lipid-laden macrophages. Areas of low signal intensity on all pulse sequences are typical of hemosiderin which is best detected with gradient echo sequences due to magnetic susceptibility. Water sensitive images will reveal high signal intensity related to joint fluid. Lipid-laden macrophages may result in signal changes characteristic of fat. C. Incorrect. Though a benign process, it may be locally aggressive and a recurrence rate of 20-50% is typical following synovectomy. Although its pathogenesis is unclear, there is evidence which suggests a neoplastic as well as inflammatory or reactive etiology. D. Incorrect. Osseous erosion with preservation of the joint space and normal bone density is typical. The disorder is monoarticular, the knee being the most common site of involvement. The hip, ankle and elbow are also common sites. Patients are typically young adults.

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Section IV Musculoskeletal Radiology

94. A. B. C. D. Concerning Pagets disease of bone, which one is MOST characteristic? Decreased alkaline phosphatase Osteitis fibrosa cystica Loosers zones Spinal stenosis

Question 94 Rationales: A. Incorrect. Serum alkaline phosphatase is elevated secondary to increased rate of bone formation and osteoblastic activity. Serum and urinary hydroxyproline is elevated secondary to increased rate of bone resorption and osteoclastic activity. The degree to which these are elevated is roughly related to the stages and activity of the disease. Serum calcium and phosphate levels are normal. B. Incorrect. Osteitis fibrosa cystica refers to the skeletal alterations secondary to hyperparathyroidism. Osteoporosis circumscripta refers to Pagetic, osteolytic involvement of the skull. C. Incorrect. A Loosers zone or pseudofracture refers to focal unmineralized osteoid seen in patients with osteomalacia. They are probably stress related but are not fractures. They have a typical radiographic appearance: short linear lucency, perpendicular to the cortex, incompletely traversing the bone, often with a sclerotic margin. They are usually bilateral and symmetric, involving the posterior proximal ulna, pubic rami, medial proximal femora, ribs and axillary margins of the scapula. Though stress fractures related to Pagets disease are similar in appearance, these are less generalized, and notably involve the convex rather than concave, bowed cortex. D. Correct. Pagets disease commonly affects the vertebra, usually the anterior and posterior elements. Cortical thickening and subsequent enlargement of bone may result in central, lateral recess or neural foraminal stenosis. Collapse of an involved vertebral body may also narrow the spinal canal.

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Section IV Musculoskeletal Radiology

95. A. B. C. D. Concerning reflex sympathetic dystrophy (RSD), which one is characteristic? Diffuse unilateral appendicular osteopenia Articular accumulation of 99m Tc-pertechnetate Joint space narrowing and osseous erosion Injury to a nerve containing a large sympathetic component

Question 95 Rationales: A. Incorrect. Soft tissue swelling and regional osteoporosis are the most significant radiographic findings of RSD. There may be rapid and severe osteopenia, usually periarticular in nature. Reduced bone density results from synovial inflammation and hyperemia and can be bilateral in one-fourth to one-half of cases. B. Correct. There is intra-articular accumulation of 99m Tc-pertechnetate in patients with RSD secondary to the increased vascularity of the synovial membrane. C. Incorrect. Joint space preservation and absence of osseous erosion is characteristic of RSD. Joint space loss and osseous erosion are features of inflammatory/septic arthritis which may also demonstrate marked periarticular osteopenia. D. Incorrect. Nerve injury may or may not be a component of RSD. Complex regional pain syndrome, a more recent designation for RSD, refers to two types: Type I, associated with injury to nerves with a large sympathetic component such as the sciatic or median nerve and Type II, associated with no nerve injury.

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Section IV Musculoskeletal Radiology

96. Which of the following BEST represents the acquisition time for a standard spin-echo pulse sequence? A. B. C. D. TR x TE x # averages TR x TI x # averages TR x # phase encode steps x # averages TE x # phase encode steps x # averages

Question 96 Rationales: A. Incorrect. Acquisition time is determined by the time required to fill the requisite number of lines in k-space, which in turn is determined by the repetition time, the number of phase encode steps determine the specific row of k-space to be filled, and the number of averages (or excitations) per row. B. Incorrect. TI, inversion time, is not a variable for standard spin-echo imaging. C. Correct. (see A above) D. Incorrect. The TE occurs over a much shorter time than the TR

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97. A. B. C. D. Concerning acromegaly, which one of the following is TRUE? Stimulation of endochondral bone formation results in widening of osseous structures Stimulation of intramembranous bone formation results in gigantism Stimulation of endochondral bone formation results in enlargement of the costochondral junction Stimulation of endochondral bone formation results in gigantism

Question 97 Rationales: A. Incorrect. Stimulation of endochondral ossification before growth plate closure leads to gigantism. In adults, stimulation of endochondral ossification leads to new bone formation at existing cartilagebone junctions such as the costochondral junctions. The widening of osseous structures in patients with acromegaly is secondary to periosteal new bone formation which is intramembranous in nature. B. Incorrect. Gigantism refers to the sequela of growth hormone hypersecretion in the skeletally immature. Excessive height results from endochondral bone formation at the open growth plates. Acromegaly refers to the sequela of growth hormone hypersecretion in the skeletally mature patient. Intramembranous bone formation in the adult results in periosteal new bone formation and widening of osseous structures.. C. Correct. Endochondral bone formation in the adult occurs at existing chondro-osseous junctions such as the costochondral junction resulting in the acromegalic rosary. D. Incorrect. Gigantism refers to the sequela of growth hormone hypersecretion in the skeletally immature. Excessive height results from excessive endochondral bone formation at the open growth plates. Acromegaly refers to the sequela of growth hormone hypersecretion in the skeletally mature patient. There is no increase in height. Only chondro-osseous junctions in the adult, such as the costochondral junction are susceptible to endochondral stimulation and new bone formation.

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98. A. B. C. D. Malignant transformation is most common in which one of the following disorders? Olliers disease Melorheostosis Multiple hereditary exostoses Maffuccis syndrome

Question 98 Rationales: A. Incorrect. Olliers disease or enchondromatosis is a rare non-hereditary, dysplastic condition characterized by multiple, widespread, benign cartilaginous foci, intraosseous or sub-periosteal, of varying size and shape( round, angular or linear). The latter appears as radiolucent columns or channels extending from the physis to the metaphysis and diametaphyseal region. Complications include growth deformity and malignant transformation. The estimated rate of malignant transformation, which occurs in the adult, has ranged from 5-30%, some authors claiming up to 25%. B. Incorrect. Melorheostosis is a rare disorder characterized by its distinct radiographic findings and clinical course. The patients exhibit painful, swollen joints with limited range of motion, muscle and joint contracture and tendon/ligament shortening. There are numerous growth deformities including scoliosis and limb length discrepancies. Usually one limb is affected. Surface cortical hyperostosis, the radiographic hallmark, may involve one or more bones and the dense osseous excescences may resemble wax flowing along one side of a burning candle. These bony masses may involve adjacent articulations. Ossification and calcification may occur at the paraarticular soft tissues, ultimately leading to ankylosis of the nearby joint. The pathogenesis is unknown. The distribution of involvement often corresponds to zones of the skeleton supplied by individual sensory nerves or sclerotomes suggesting that the disorder may be the sequela of a sensory nerve lesion. Malignant transformation does not occur. C. Incorrect. Multiple hereditary exostosis or multiple cartilaginous exostosis is a common, autosomal dominant, dysplastic condition characterized by multiple cartilage-capped exostosis distributed throughout the skeleton in a bilateral, symmetric fashion. The exostoses may vary in size and shape and point away from the physis. The bones themselves may be exhibit expansile remodeling, shortening and angular deformities. Complications also include fracture, impingement and compression of adjacent structures usually nerves, vessels and tendons, bursa formation and inflammation and malignant transformation. The estimated rate of such transformation has ranged from <1% up to 25%, probably 2-5%. D. Correct. Maffuccis syndrome is a non-hereditary, dysplastic condition characterized by multiple widespread cartilaginous foci( enchondromatosis) and soft tissue vascular malformations, most commonly hemangiomas. These may occur in the viscera. The distribution of the cartilaginous and vascular lesions usually, though not always, coincide. The radiographic appearance is that of enchondromatosis with soft tissue masses and phleboliths. Although malignant transformation of both the cartilage and soft tissue lesions has been noted, the risk is much greater for the skeletal component. Many estimate the rate of malignant transformation at 20% or more. Despite the varying estimates, it is generally agreed that the rate of malignant transformation if greater with Maffuccis S. than Olliers. It should be noted that several forms of enchondromatosis have recently been noted and that Olliers disease and Maffuccis S. do not encompass all of them. 24 American College of Radiology

Section IV Musculoskeletal Radiology

99. Mazabrauds syndrome refers to the association of fibrous dysplasia and which one of the following? A. B. C. D. Facial deformity Soft tissue myxomas Malignant transformation Endocrinopathy

Question 99 Rationales: A. Incorrect. The skull and facial bones are common sites for both monostotoic and polyostotic fibrous dysplasia, more common with the latter, approximately 50% of cases. The maxilla, frontal, sphenoid, and ethmoid bones are typically involved. The facial deformity resulting from bilateral involvement of the mandible in patients with Familial fibrous dysplasia of the jaw has been referred to as cherubism. B. Correct. Mazabraud described and emphasized the association of soft tissue myxomas with fibrous dysplasia. Fibrous dysplasia in such cases is most often polyostotic. The patients are usually woman, some with McCune-Albright syndrome. The myxomas range in size and the thigh has been reported as the most common site of involvement. Malignant bone tumors have been reported, the incidence greater than that of fibrous dysplasia itself. C. Incorrect. Malignant transformation of monostotic or polyostotic fibrous dysplasia is rare, <1%. Osteosarcoma, fibrosarcoma, malignant fibrous histiocytoma and chondrosarcoma have been described. The incidence is higher in patients with Mazabrauds syndrome but the syndrome is a reference to the association of fibrous dysplasia and soft tissue myxomas. D. Incorrect. The McCune-Albright syndrome describes polyostotic fibrous dysplasia, cutaneous pigmentation and sexual precocity or precocious pseudopuberty. The mature gonadal function implied by the term puberty is not present. There are incomplete forms without cutaneous pigmentation. Other endocrinopathies including Cushings disease, acromegaly, hyperthyroidism, hyperparathyroidism, pheochromocytoma and diabetes have also been associated with fibrous dysplasia.

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100. A. B. C. D. Concerning parosteal osteosarcoma, which one is TRUE? The prognosis is good. Patients are usually 10-20 years old. New bone formation predominates at the periphery of the lesion. The humerus is the most common site.

Question 100 Rationales: A. Correct. Parosteal osteosarcoma is a low grade, bone forming, tumor arising on the surface of the bone. Although it may metastasize to the lungs, most cases are amenable to local excision without the need for chemotherapy. B. Incorrect. Patients with parosteal osteosarcoma are typically older than those with conventional osteosarcoma, usually 25-40 years of age. C. Incorrect. Peripheral ossification is a feature of myositis ossificans. Paraosteal osteosarcoma is most dense at the center of the lesion where new bone formation predominates. D. Incorrect. The femur, posterior and distal, is the most common location, accounting for 2/3 of all cases.

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101. A. B. C. D. Which one of the following characteristically occurs at the end of the bone? Osteoid osteoma Chondromyxoid fibroma Giant cell reparative granuloma Clear cell chondrosarcoma

Question 101 Rationales: A. Incorrect. Osteoid osteoma, a benign bone forming tumor, may occur at the end of a bone. When intra-articular, it may provoke synovitis, hyperemia, peri-articular osteoporosis and growth disturbance. It is typically extra-articular, however, provoking periosteal new bone formation when cortical or sub-periosteal in location. B. Incorrect. CMF is an unusual benign cartilage forming lesion occurring at the metaphyseal region. It appears as a lytic lesion with expansile remodeling. C. Incorrect. Giant cell reparative granuloma, considered a reactive phenomenon, was first described as an intraosseous lesion of the maxilla and mandible distinct from giant cell tumor. In the appendicular skeleton, the hands and feet are more commonly involved. Lesions may occur at the end of the bone but most arise at the metaphyseal or diaphyseal regions. They are lytic lesions with histology characterized by giant cells. There is no relationship to giant cell tumor of bone. D. Correct. Clear cell chondrosarcoma, a rare form of chondrosarcoma, characteristically occurs at the end of the bone, the femoral head being the most common location. The patients are younger than those with conventional chondrosarcoma, usually 30-40 years of age. The appearance is often that of a well defined lytic lesion with sclerotic margins. There may be cartilaginous calcification.

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102. A. B. C. D. Concerning giant cell tumor of bone, which one of the following is associated? Periosteal reaction Pagets disease Matrix mineralization Hyperparathyroidism

Question 102 Rationales: A. Incorrect. The lack of periosteal reaction is characteristic of GCT unless there is an associated fracture. B. Correct. Although a rare complication, numerous tumors are known to arise in Pagetoid bone including osteosarcoma (most common), chondrosarcoma, malignant fibrous histiocytoma and metastatic disease. Giant cell tumor rarely arises in the pelvic and fascial bones. C. Incorrect. The lack of matrix mineralization is characteristic of GCT. D. Incorrect. Many bone lesions demonstrate histology populated with giant cell tumors including nonossifying fibroma, giant cell reparative granuloma, osteitis fibrosa cystica (brown tumor) and giant cell tumor. The brown tumor of hyperparathyroidism however, is otherwise unrelated to GCT of bone.

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103. For radiographs using a table Bucky cassette, the MOST LIKELY reason why the grid lines are not visible is due to which one? Use of larger focal spot Focusing of the grid at proper tube-grid distance Motion blurring of the grid Use of image post-processing

A. B. C. D.

Question 103 Rationales: A. Incorrect. The use of large focal spot can cause some geometric blurring, however the amount of blurring is dependent on the geometric magnification, and the grid is next to the cassette and will have little magnification. Geometric blurring would also degrade the image. B. Incorrect. Using the grid at the appropriate tube-grid distance is important to prevent cut-off, but it does not obscure the individual grid lines. C. Correct. A bucky grid system moves or oscillates the grid to blur out the individual grid lines. D. Incorrect. While there are techniques for reducing periodic artifacts, such as grid lines, image postprocessing is not performed in film-screen radiography, and grid lines may be eliminated by use of the Bucky without post-processing.

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104. Concerning rotator cuff tears, which one is TRUE?

A. Partial thickness tears are more common at the superior bursal surface than the inferior articular surface. B. Degenerative and traumatic tears occur with equal frequency. C. A massive rotator cuff tear usually involves the teres minor tendon. D. A rotator cuff interval tear is a type of rotator cuff tear. Question 104 Rationales: A. Incorrect. Partial thickness rotator cuff tears may be inferior (articular surface), interstitial, or superior (bursal surface). Articular surface partial thickness tears out-number bursal-sided partial tears by approximately 3:1. B. Incorrect. Although an acute traumatic episode may be associated with a cuff tear, underlying degenerative changes of the tendon usually play a major role. Especially in the older population, the patient may recall a specific event associated with the acute onset of pain and decreased function. More likely than not, this represents relatively minor trauma, with either superimposition of an acute tear on a degenerative tendon, or extension of a prior smaller degenerative tear. C. Incorrect. A massive rotator cuff tear refers to one that involves at least two of the four cuff tendons. This is most commonly the supraspinatus and infraspinatus tendons, followed by the subscapularis tendon with further extension of the tear. Involvement of the teres minor tendon is extremely unusual. D. Correct. The rotator interval refers to the junction between the anterior fibers of the supraspinatus muscle and the superior fibers of the subscapularis tendon. Its presence is accounted for by the protrusion of the coracoid process through the tendinous cuff. The coracohumeral ligament lies superficial to the interval, and the long head of the biceps tendon lies deep to it. Although the rotator interval is fibrous and represents an interruption of the otherwise continuous tendinous cuff, a disruption is considered to be a rotator cuff tear.

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105. A. B. C. D. Concerning multidirectional glenohumeral instability, which one is associated? Trauma Unilateral involvement Rotator cuff tear Primary impingement

Question 105 Rationales: A. Incorrect. Multidirectional glenohumeral instability is often found in individuals with generalized joint laxity of varying degrees. Preceding trauma is not typical. B. Incorrect. Because multidirectional glenohumeral instability is generally found in individuals with generalized joint laxity, it frequently involves both shoulders. Although the underlying condition is usually bilateral, only one glenohumeral joint may be symptomatic. C. Correct. Since multidirectional instability is a cause of secondary impingement and all forms of impingement may be associated with rotator cuff tear, multi-directional instability is associated with rotator cuff tear. D. Incorrect. Primary impingement refers to those conditions of and about the coraco-acromial arch that predispose to compression of the rotator cuff at its outlet. This is usually due to osteoarthritis of the acromioclavicular joint with subsequent osteophytic impingement of the subacromial space or subacromial spurs. Multidirectional glenohumeral instability is the most common cause of secondary, or non-outlet impingement. In this condition, laxity is present in many directions. In addition to antero-inferior laxity, the humeral head may also sublux superiorly, reducing the space in which the cuff must function. Another cause of secondary impingement is a prominent greater tuberosity (fracture malunion).

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Section IV Musculoskeletal Radiology

106. A. B. C. D. Concerning the meniscus of the knee, which one is CORRECT? A peripheral tear must be excised. Radial tears may spontaneously heal in young individuals. Intra-substance signal in an adolescent usually reflects premature mucoid degeneration. The blood supply comes from the geniculate arteries.

Question 106 Rationales: A. Incorrect. Peripheral tears are in the "red" portion of the meniscus that has a neurovascular supply in younger patients. Such tears may heal or be amenable to repair. B. Incorrect. Radial tears begin at the meniscal free edge, and extend peripherally toward the meniscus-capsular junction. The free edge of the meniscus is avascular, and will not heal. C. Incorrect. Intrasubstance signal may represent residual vascularity in the peripheral aspect of the meniscus in a younger patient. This portion of the meniscus may also be contused with an acute injury, and subsequently heal spontaneously. D. Correct. The meniscal blood supply comes from the geniculate arteries that enter the meniscus peripherally. In a young individual, this occupies the outer one third of the meniscus. The vascular portion of the meniscus decreases in size with age, and an adult pattern is usually reached before skeletal maturity.

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American College of Radiology

Section IV Musculoskeletal Radiology

107. A. B. C. D. Concerning acute ankle inversion, which ligament is FIRST to be injured? Calcaneofibular Anterior talofibular Posterior talofibular Deltoid

Question 107 Rationales: A. Incorrect. The calcaneofibular ligament originates at the anterior apex of the lateral malleolar tip and extends inferiorly and posteriorly to insert on the lateral calcaneus. With an inversion injury, it is usually the second of the lateral ankle ligaments to tear. B. Correct. The anterior talofibular ligament originates at the anterior margin of the lateral malleolar tip and courses medial and anterior to insert at the talus. With a relatively low-grade inversion ankle injury, the anterior talofibular ligament will stretch. With more severe injuries, the ligament will partially or completely tear. A complete tear is often accompanied with a "pop", severe pain and swelling, and an inability to walk. It is the first of the ankle ligaments to be injured. C. Incorrect. The posterior talofibular ligament extends horizontally between the posterior aspect of the lateral malleolus to the posterior process of the calcaneus. Tears of the posterior talofibular ligament are uncommon relative to tears of the other two lateral collateral ligaments. D. Incorrect. The deltoid ligament lies medial to the ankle joint, arising on the medial malleolus. Superficial fibers insert on the navicular bone, the calcaneus and the talus. Deep fibers insert on the talus. Deltoid ligament tears result from abduction or eversion injuries.

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Section IV Musculoskeletal Radiology

108. A. B. C. D. Concerning Maisonneuve fracture, which one is associated? Fracture of the sustentaculum tali Subtalar dislocation Tear of the spring ligament Tear of the tibiofibular syndesmosis

Question 108 Rationales: A. Incorrect. The exact mechanism for the Maisonneuve fracture is poorly understood, but it likely results from multidirectional forces. Associated ankle injuries include fracture of the medial malleolus or tear of the deltoid ligament, fracture of the posterior malleolus, and a tear of the anterior or posterior talofibular ligaments. The sustentaculum tali may fracture as a component of a depressed, comminuted intra-articular calcaneal fracture. The posterior subtalar joint is typically involved. The medial subtalar joint is typically spared. B. Incorrect. The Maisonneuve fracture does not extend into the hindfoot. Forces begin at the tibiotalar joint, and extend proximally. C. Incorrect. The spring ligament courses between the calcaneus and the navicular. The hindfoot and midfoot are not involved in the Maisonneuve fracture. D. Correct. The unique feature of the Maisonneuve fracture is the extension of the force proximally through the tibiofibular syndesmosis to the proximal fibula shaft or neck where a fracture is encountered.

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American College of Radiology

Section IV Musculoskeletal Radiology

109. A. B. C. D. Concerning the ankle tendons, which one is CORRECT? The flexor digitorum longus inserts on the distal shaft of the third through fifth metatarsal. The peroneus brevis inserts on the base of the fifth metatarsal. The tibialis posterior inserts on the distal first metatarsal shaft. The flexor hallucis longus inserts on the head of the first metatarsal.

Question 109 Rationales: A. Incorrect. The flexor digitorum longus originates at the posterior surface of the tibia, and inserts at the plantar surface of the bases of the distal phalanges of the second through fifth toes. B. Correct. The peroneus brevis originates at the lower two thirds of the lateral fibula, and inserts on the fifth metatarsal base laterally. C. Incorrect. The tibialis posterior originates from the tibia, fibula and interosseous membrane. The insertion is variable, and can include the second through fourth metatarsals, cuneiforms, cuboid, and navicular. D. Incorrect. The flexor hallucis longus originates at the mid-to distal fibula, and inserts on the plantar surface of the base of the distal phalanx of the great toe.

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