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B. Femoral nerve lesions does not produce Pseudoclaudication. C. Cauda equina compression produces Pseudoclaudication. D. Popliteal artery lesions produce vascular claudication. Comments Non-vascular causes of lower extremity pain are radicular pain caused by nerve root irritation from spinal stenosis (pseudoclaudication) or intervertebral disc herniation. These patients will often describe pain induced by simply standing as well as on walking, and this history will help distinguish these patients from claudicants. Patients with pseudoclaudication often need to sit or lie down in order to relieve the pain as opposed to simply stopping walking. A careful history may reveal the sciatic distribution of the pain, suggesting its true aetiology. Tips Few pseudoterminologies (The list is incomplete)A bigger list can be seen at www.targetpg.com and www.rxpgonline. com and www.rxpg.com. Pseudocyesis Abdominal distension mimicking pregnancy Pseudopapillitis Hypermetropia Pseudohypopyon Tuberculous corneal ulcer Pseudobubo Granuloma inguinale Pseudofractures Osteomalacia (Loosers Zones) Pseudomembranous Pneumococcal conjunctivitis Pseudotuberculids Bilharziasis of bladder Pseudocoxalgia Perthes disease Pseudoparalysis Scurvy, osteomyelitis, congenital syphilis, acute rheumatic fever, trichinosis, Pseudohemophilia von Willebrands disease Pseudoachromasia is Tinea versicolor, seen in Pityriasis Seborrhic dermatitis Pseudohaemoptysis Pigmentation caused by Serratia Pseudomyopia Excess accommodation 177. A vascular necrosis can be possible sequelae of fracture of all the following bones, except: A. Femur neck B. Scaphoid. C. Talus. D. Calcaneum. Answer: D (Calcaneum) Ref: System of Orthopaedics and Fractures Apley 8th edn, 92; Essential Orthopaedics by Maheswari 3rd edn, 41; Textbook of Orthopaedics 2nd edn, 34 Quality: Spotter Status: Repeat QTDF: All books Discussion Avascular necrosis is common in: Head of femur Head of humerus S0񄋋D_-kD'|x%A\Pb '\P-kDlGáD*w-kDLD*w-kH!0Pp0PP hT ^ '\P-kDlGáD*w-kDLD*w-k '\P-kDlGáD*w-kDLD*w-kH!0߸pP0PP iU0񄋋D_-kD'|x%A\Pb0񄋋D_-kD'|x%A\Pb0Pp0PP jVZ[! 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Which one of the following tests will you adopt while examining a knee joint where you suspect an old tear of anterior cruciate ligament? A. Posterior drawer test. B. Mc Murry test. C. Lachman's test. D. Pivot shift test. Answer: D (Pivot shift test) Ref: Sureshwar Pandey 2nd edn, 307; System of Orthopaedics and Fractures Apley 8th; Essential Orthopaedics by Maheswari 3rd; Textbook of Orthopaedics 2nd edn, 135 Quality: Thinker Status: Repeat QTDF: All books Discussion Acute ACL injuries are diagnosed by Lachmans test and old tears by anterior drawer test and pivot shift test. The quesition specifically asks old tear. Explanation A. Posterior drawer test is for posterior cruciate ligament injurires. B. McMurry test is for testing medial meniscus. C. Lachman's test is mainly for acute anterior cruciate ligament injuries. D. Pivot shift test is for old anterior cruciate ligament injuries. Comments Though there are controversies, (since Lachman's test can also be used for testing ACL), pivot shift stands out as it can be used for old ACL tears. Anyhow, the topic is open for discussion. Refer Ortho books for details about the tests. In short, If the examiner wanted to test whether the candidate knows that Lachman's is for Acute ACL tear, the answer is pivot shift. If the examiner wanted to test whether the candidate knows that pivot shift produces only a small subluxation, the answer is Lachman's. God only knows Tips Be careful about the words old, newborn, boy, with features of. There might well be a trap. Capitulum Scaphoid Talus Explanation A. Femur neck fracture leads to avascular necrosis of head of femur. B. Scaphoid fracture leads to avascular necrosis of the proximal fragment. C. Talus fracture leads to avascular necrosis of proximal fragment. D. Calcaneum fracture is not commonly associated with avascular necrosis. Comments A simple question Tips Know the features and complications of common fractures and dislocations (See the subsequent questions). 178. A 30-year-old male was brought to the casualty following a road traffic accident. His physical examination revealed that his right lower limb was short, internally rotated, and flexed and adducted at the hip. The most likely diagnosis is: A. Fracture neck of femur. B. Trochanteric fracture. C. Central fracture dislocation of hip. D. Posterior dislocation of hip. Answer: D (Posterior dislocation of hip) Ref: System of Orthopaedics and Fractures Apley 8th edn, 681; Essential Orthopaedics by Maheswari 3rd edn, 110; Textbook of Orthopaedics 2nd edn, 118 Quality: Spotter Status: Repeat QTDF: All books Discussion This is a classical posture of posterior dislocation of hip. The attitudes of common conditions are: Fracture neck of femur Flexion Adduction External rotation Shortening Intertrochanteric fracture Flexion Adduction External rotation Shortening Anterior dislocation Flexion Abduction External rotation Shortening Posterior dislocation Flexion Adduction Internal rotation Shortening Explanation Self-Explanatory Comments Dislocation of the hip typically ranks second to loosening as the most troubling complication related to total hip arthroplasty. Reasons for dislocation include trauma, infection, inappropriate leg positioning, particularly in the early postoperative period, abductor muscle laxity, and or paralysis, and malposition of components. Tips Typical postures in upper limb (Policeman receiving tips, benediction attitude, etc) are also important. 179. Sciatic nerve palsy may occur in the following injury: A. Posterior dislocation of hip joint. B. Fracture neck of femur. C. Trochanteric fracture. D. Anterior dislocation of hip. Answer: A (Posterior dislocation of hip joint) Ref: System of Orthopaedics and Fractures Apley 8th edn, 682; Essential Orthopaedics by Maheswari 3rd edn, 111; Textbook of Orthopaedics 2nd Edition Ebnezar, 119 Quality: Spotter Status: Repeat QTDF: All books Discussion Complications of posterior dislocations of hip are: Early Nerve-Sciatic nerve palsy Vascular-Superior gluteal artery Fracture shaft of femur Late: Avascular necrosis Myositis ossificans Osteoarthritis Explanation A. Posterior dislocation of hip joint is commonly complicated by sciatic nerve palsy. B. Fracture neck of femur does not commonly lead to sciatic nerve palsy. C. Trochanteric fracture does not commonly lead to sciatic nerve palsy. D. Anterior dislocation of hip does not commonly lead to sciatic nerve palsy. Comments The following table gives complication of few fractures (#s) Bone Injury Vascular Injury Associated Finding # of first and second ribs Transection of thoracic aorta Widened mediastinum # of clavicle and first rib Laceration and contusion of Diminished pulse or blood subclavian artery or vein; pressure in involved arm false aneurysm Dislocation shoulder Thrombosis of axillary artery Diminished or absent distal pulse # of humeral shaft Laceration of brachial artery Diminished or absent distal pulse Supracondylar # of Obstruction of brachial artery Compartment hypertension of humerus forearm (Volkmanns phenomenon) Dislocation of elbow Disruption of brachial artery Absent radial pulse # of ribs Laceration of intercostal artery Haemothorax # of pelvis Laceration of superior Massive pelvic haematoma gluteal artery Anterior dislocation Femoral artery contusion Diminished or absent distal of hip pulse # of hip Deep femoral artery injury Excessive bleeding with no during operative repair pulse deficit # of femoral shaft Occlusion and laceration Loss of distal pulsations; cold (mid or lower third) of femoral artery foot with loss of pulsation; cold foot with bleeding Supracondylar # of Laceration of popliteal Bleeding with diminished foot femur artery or vein pulses Dislocation of knee Disruption and thrombosis Diminished pulses with cold of popliteal artery or vein foot # of proximal tibia Disruption or thrombosis Diminished pulses with cold of popliteal artery or vein foot # of tibial shaft Transection of anterior or Diminished pulses with cold posterior tibial artery foot; compartmental hypertension Dislocation of ankle Transection and thrombosis Diminished pulses of tibial arteries Tips Yet another theme couple this one is from posterior dislocation. 180. Which one of the following tests will you adopt while examining a knee joint where you suspect an old tear of anterior cruciate ligament? A. Posterior drawer test. B. Mc Murry test. C. Lachman's test. D. Pivot shift test. Answer: D (Pivot shift test) Ref: Sureshwar Pandey 2nd edn, 307; System of Orthopaedics and Fractures Apley 8th; Essential Orthopaedics by Maheswari 3rd; Textbook of Orthopaedics 2nd edn, 135 Quality: Thinker Status: Repeat QTDF: All books Discussion Acute ACL injuries are diagnosed by Lachmans test and old tears by anterior drawer test and pivot shift test. The quesition specifically asks old tear. Explanation A. Posterior drawer test is for posterior cruciate ligament injurires. B. Mc Murry test is for testing medial meniscus. C. Lachman's test is mainly for acute anterior cruciate ligament injuries. D. Pivot shift test is for old anterior cruciate ligament injuries. Comments Though there are controversies, (since Lachman's test can also be used for testing ACL), pivot shift stands out as it can be used for old ACL tears. Anyhow, the topic is open for discussion. Refer Ortho books for details about the tests. In short, If the examiner wanted to test whether the candidate knows that Lachman's is for Acute ACL tear, the answer is pivot shift. If the examiner wanted to test whether the candidate knows that pivot shift produces only a small subluxation, the answer is Lachman's. God only knows Tips Be careful about the words old, newborn, boy, with features of. 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True about calcium is/are a. Entry is regulated by calmodulin uptake b. Extracellular concentration of calcium is 10,000 times more than intracellular c. Symport uptake d. Entry into cell is passive c. Released by sarcoplasmic reticulum Ref:: ganong 35, Quality::::spotter thinker reader BATA Discussion Explanation Correct choices: b, e . C. Which of the following are organophosphates: A. dieldrin B. parathion C. malathion D. Kepone 5. Propoxur Ref::Trip 5th Page 81 Park 550 table Quality::::reader Discussion Explanation: anticholinesterases Reversible Carbamates Acridine Physostigmine (Eserine) Neostigmine Pyridostigmine Edrophonium Rivastigmine Donepezil tacrine Irreversible Organophosphates Carbamates Dyflos DFP Echothiophate Parathion Malathion Diazinon TIK 20 Tabun Sarin Soman Carbaryl (Sevin) Propoxur(Baygon) Explanation A. dieldrin-organochlorine pesticide. incorrect choice. B. parathionirreversible OPC. correct choice. C. malathion irreversible OPC. correct choice D. Kepone/chlordecone- organochlorine pesticide. incorrect choice pesticide 5. Propoxurirreversible carbamates. incorrect choice Correct choices: b c 203. Which of the following are features of spinal shock a. Spasticity b. Urinary retention c. Areflexia d. Sensory level e. Increased DTRs Ref::clinical acumen Quality::::spotter thinker reader BATA Discussion Spinal shock(neuronal) is the initial state just after an acute insult causing an UMN lesion caused by the temporary depressant effect on the anterior horn cells. Characterized by paralysis,areflexia,flaccidity,the chracteristic hypertonia and increased relexes of cotticospinal lesion appear after few hrs-days. Explanation Correct choices B C d 217. Which of the following predispose a patient to prehepatic encepalopathy a. Constipation b. Bacterial peritonitis c. Hemorrhage d. Hyperkalemia e. Dehydration Ref: HPIM 1715 Quality::::spotter thinker reader BATA Discussion Common precipitants of hepatic failure Increased nitrogen load GIT bleeding Excess dietary protein Azotemia Constipation Electrolyte & metabolic imbalance Hypokalemia Alkalosis Hypoxia Hyponatremia Drugs Narcotics and Tranqulizers Sedatives Diuretics Miscellaneous Infection surgery Superimposed acute liver disease Progressive liver disease Explanation: A. Constipation B. Bacterial peritonitis being an infection. correct choice. C. Hemorrhage D. Hyperkalemia: Hypokalemia not Hyperkalemia is known to worsen hepatic Encephalopathy. 5. Dehydration can cause hypovolemia & electrolyte disturbances that can ppt. hepatic Encephalopathy Correct choices: a b c e 8. the drugs useful in the treatment of ectopic pregnancy is A. Methotrexate B. Actinomycin D C. Cyclophosphamide D. Potassium fluoride 5. Adriamycin Ref:: Dutta 202 Quality:::: spotter Explanation A. Methotrexate: used in medical therapy. correct choice. B. Actinomycin D. correct choice. C. Cyclophosphamide. Incorrect choice. D. Potassium fluoride: potassium chloride is used in ectopic pregnancy. Incorrect choice. 5. Adriamycin is not used in ectopic pregnancy. Correct choices A b 210. Adventitial bursitis due to tuberculosis is found in which of the following sites commonly a. Prepatellar b. Greater trochanter of femur c. Sub acromial d. Metatarsal e. Sub olecranon 209. Snow ball opacities in vitreous is seen in which of the following a. Parsplanitis b. Rheumatoid arthritis c. Anterior unietis d. Retinitis pigmentosa e. Endothelial dystrophy Ref: http://www. indmedica. com/cos/journal/vasculitis. html Quality::::spotter thinker reader BATA Explanation A. Parsplanitis is characterized by snowball opacities. B. Rheumatoid arthritis is one of the causes of pars planitis hence may show snow ball opacities C. Anterior uveitis D. Retinitis pigmentosa 5. Endothelial dystrophy Correct choices: A b 77. The left border of the heart is formed by a. Pulmonary Artery b. Pulmonary vein c. Right ventricle d. Ascending aorta e. Arch of aorta Ref:: BDC 226,Grays 38th 1476 Quality:::: spotter thinker reader BATA Discussion Anatomically Right border is formed by RA. Left border of heart is formed by LA and LV. Upper border formed by LA, asc aota & pul trunk infron of it. Inferior border of the heart is formed by RV and contribution of LV at the apex. Correct choices NONE OF THE CHOICES ARE CORRECT Or 77. left border of the heart in chest XR is formed by a. pul artery b. pul vein c. abdominal aorta d. arch of aorta e. right ventricle Quality:::: :reader Ref:: Discussion: Borders of cardiac silhouette on PA view Right border from above downwards Superior vena cava Outer border of R atrium Sometimes asc, arch of aorta & inferior vena cava Left border from above downwards Aortic knuckle Pul. Trunk or L pul artery L atrial appendage outer border of L ventricle correct choice: a d 9. the resting membrane potential depends on which of the following ions A. Magnesium B. Calcium C. Potassium D. Sodium 5. Chloride Ref:: Ganong 50 Quality:::: spotter Discussion The ionic basis of RMP: Explanation A. Magnesium has no role in RMP. B. Calcium has role in action potential in muscle cells not RMP C. Potassium. The major ion whose movements produce RMP. Correct choice. D. Sodium. incorrect choice. 5. Chloride. No role. Correct choices C 79. In acute inflammation the migration of neutrophils and its attachment to endothelium is mediated by which of the follwing. a. Integrins b. Selection s c. Adhesins d. Perforins e. Opsonins Ref:: Robbins 29, 273 Quality::::spotter thinker reader BATA Explanation a. Integrins are transmembrane glycoproteins that function as cell receptors for extra cellular matrix. correct choice. b. Selectins=the loose and transient adhesions involved in rolling of leucocytes over endothelial cells are accounted for by the selectin family of molecules. E-selectin are present on on endothelial cells, P-selectin on platelets and endothelial cells and L-Selectins on leucocytes. c. Adhesins-are molecules that bind bacteria to cells e. g. lipoteichoic acid and protein F. d. Two classes of cytotoxins include perforins and granzymes. . The perforins form pores in the targets cell membranes. incorrect choice. e. Opsonins are protiens or peptides that label targets for phagocytosis by PMNs and/or macrophages. incorrect choice, Correct choices b 102. Susruta samhita was translated by a. Celsius b. harnel c. Bhargabhatta d. heslar e. Bernard Ref: http://www. ayurveda. com/online%20resource/ancient_writings. htm Quality:::: BATA Discussion: http://www. ayurveda. com/online%20resource/ancient_writings. htm Sushruta Samhita The Sushruta Samhita deals with the practice and theory of surgery, is an important source of Ayurvedic aphorisms. This work is the first to enumerate and discuss the pitta sub-doshas and the marmas. With its emphasis on pitta, surgery, and blood, this work best represents the transformational value of life. It is dais that this work was first redacted by Nagarjuna. This work, originally written in Sanskrit, is now available in English with Devanagari. Bhishagratnas translation is English and Sanskrit. P. V. Sharma has recently written a translation with both the Sanskrit/Devanagari and English that includes Dallanas commentary. Dallana has been regarded as the most influential commentator on Sushrutas work. Explanation Correct choices B d 21. Prozone phenomenon in precipitation reaction indicates a. False positive reaction b. False negative reaction c. due to excess antibodies d. Due to excess antigens e. Broken antibodies Ref: : AN 91 Quality:::: spotter 203. Which of the following are features of spinal shock f. Spasticity g. Urinary retention h. Areflexia i. Sensory level j. Increased DTRs Ref::clinical acumen Quality::::spotter thinker reader BATA Discussion Spinal shock(neuronal) is the initial state just after an acute insult causing an UMN lesion caused by the temporary depressant effect on the anterior horn cells. Characterized by paralysis,areflexia,flaccidity,the chracteristic hypertonia and increased relexes of cotticospinal lesion appear after few hrs-days. Explanation 6. Spasticity appears hrs day after spinal shock has passed in an UMN lesion. 7. Urinary retention is a feature of spinal cord disease. appears first in case of disease originating from the canal and spreading outwards and last in mass lesions compressing spinal cord from the outside. Its a feature of spinal shock. 8. Areflexia is a feature of spinal shock. 9. Sensory level is seen in case of corticospinal lesion. 10. Increased DTRs will be seen after the spinal shock has passed. Correct choices B C d 202. Diseases inherited with triple repeat sequences include a. Huntingtons chorea b. Alzheimers disease c. Spinocerebellar ataxia d. Amyotrophic lateral sclerosis e. Ataxia telangiectasia Ref:: Robbins 197,739,741,157 Quality::::spotter thinker reader BATA Discussion Harrison 2294 table gives explicit information about genetic defects in neurological disease. Robbins has enumerated three diseases having triple repeat sequences: Fragile X syndrome Huntington;s ds, Myotonic dystrophy Explanation A. Huntingtons chorea:AD : CAG triple repeats in gene encoding proein huntingtin B. Alzheimers disease:AD mutations presenilin,apolipoprotein E4,APP genen C. Spinocerebellar ataxia:expansion of trinucleotide repeats in ataxin gene D. Amyotrophic lateral sclerosis:AD mutation in Cu-Zn superoxide Dismutase SOD. 5. Ataxia telangiectasia AR mutation in ATM gene which causes triple repeat sequences and abnormal production of protein. Correct choices A c e 59. Tumor markers of hepatocellular carcinoma include a. CEA b. Des gamma carboxyprothrombin c. CA 19-9 d. Fucosylated alpha protein e. Alpha fetoprotien elevated in greater than 70% Ref:: HPIM 579, CMDT 689 http://www. intouchlive. com/consults/ccn9903b. htm Quality::::spotter thinker reader BATA Discussion Alpha fetoprotein levels raised in Cirrhosis Massive liver necrosis Chronic hepatitis hepatocellular carcinoma Normal pregnancy Fetal distress or death Fetal neural tube defects-enencephaly & spina bifida Gonadal germ cell tumours teratoblastoma, Levels above 1000 ng/ml HCC CEA (Carcino Embryonic Antigen) elevated in: malignancies of the gastrointestinal tract (pancreas, colon, rectum), lung, breast, prostatic and ovary. inflammation and heavy smoking. CA-125 normally found in adult female fallopian tube, endometrium and endocervix. CA-15 elevated breast and lung cancer. . CA-199 elevated in intra-abdominal carcinomas, adenocarcinomas of the lung, gastric, biliary and colonic neoplasms. Explanation a. serum CEA levels alone are not specific for hepatocellular carcinoma but are nonetheless raised. correct choice. b. Des gamma carboxyprothrombin, an abnormal typre of [rothrombin which correlates with h levels of AFP. c. CA 19-9 levels are elevated in HCC. D most of the patients with hepatocellular carcinoma have an elevated serum concentration of fucosylated alpha-fetoprotein. correct choice. e. Alpha-fetoprotein elevated in greater than 70% . true. Correct choices A bcde 67. Which of the following are causes of posterior mediastinal mass: A. Neuroenteric cyst B. Neurogenic cyst C. Anterior thoraxic meningocele D. Lymphoma E. Bronchogenic cyst Anterior mediastinum: Middle Mediastinum: Posterior mediastinum: Germ cell neoplasm Lymphoma: Morgagni hernia Pericardial cyst Thymic lesions: Thyroid (Retrosternal goiter) Foregut duplication cysts Castlemans disease Lymphangioma Lymphoma Bronchogenic cyst Bochdalek Hernia Extramedullary Hematopoiesis Ganglioneuroma Ganglioneuroblastoma Neuroblastoma Lateral thoracic meningocele Malignant tumor of nerve sheath origin Neurofibroma Paraganglioma Pheochromocytoma Schwannoma Explanation A. Neuroenteric cyst is present in the posterior mediastinum or paravertebral area. B. Neurogenic cyst is present in the posterior mediastinum C. Anterior thoracic meningocele is present in the posterior mediastinum D. Lymphoma is a tumour of the middle or anterior mediastinum E. Bronchogenic cyst is a tumour of the middle mediastinum. Correct choices Abc 213. Peripheral neuropathy is seen in all of the following except a. Tuberculosis b. Polyarteritis nodasa c. Diabetes mellitus d. SLE 89. Diabetes mellitus is associated with all of the following except: a. Neuropathy b. Encephalopathy c. Myopathy d. Myelitis e. Myelopathy Ref: CMDT 1191,HPIM 2481 Quality::::spotter thinker reader BATA Discussion Diabetic neuromuscular involvement may manifest as: A. Distal symmetric polyneuropathy B. Isolated peripheral neuropathy-mononeuropathy C. Mononeuritis multiplex D. Painful neuropathy 5. Autonomic neuropathy 6. Cranial neuropathypainful opthalmoplegia 7. Diabetic amyotrophy/proximal neuropathy/lumbosacral plexopathy 8. Ischemic myopathy of thigh muscles D e 127. In carbon monoxide toxicity a. There is left shift of oxygen dissociation curve b. Saturation of oxygen at 50% PaO2 is decreased c. Oxygen content of arterial blood is decreased d. Induces a state of metabolic acidosis e. Oxygen is used in treatment Ref: Ganong 17th 633 Quality::::spotter thinker reader BATA Discussion Explanation a. There is left shift of oxygen dissociation curve. COHb shifts the curve of the remaining HbO2 to left decreasing the amount of O2 released by the normal saturated Hb. b. Saturation of oxygen at 50% PaO2 is decreased. I think this choice should be saturation of Hb at given PO2 is decreased which is untrue because the curve shifts to the left. This increases the saturation of Hb at givenPO2 and even makes the available HbO2 useless for oxygenation because it wont release the O2. c. Carboxu Hb reduces oxygen transportation by Hb thus Oxygen content of arterial blood is decreased. correct. d. Induces a state of metabolic acidosis because of the hypoxia e. Ventilation with O2 is preferable to ventilation with fresh air since O2 hastens the dissociation of COHb. Hyperbaric O2 is useful. 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A most common cause for neuralgic pain in foot is: A. Compression of communication between medial and lateral plantar nerves. B. Exaggeration of longitudinal arches. C. Injury to deltoid ligament. D. Shortening of plantar aponeurosis. Answer: A (Compression of communication between medial and lateral plantar nerves) Ref: Schwartz, 1914; Essential Orthopaedics by Maheswari 3rd edn, 276; Human Anatomy 3rd BD Chaurasia Vol 2, 142 Quality: Thinker Status: New QTDF: ??` Discussion Most common pain of footMetatarsalgia Flat foot is due to loss of the arches of foot and elongation of the bow strings Flat foot leads to compression of nerves and arteries Explanation A. Compression of communication between medial and lateral plantar nerves occurs in flat foot and flat foot is a common entity. B. Exaggeration of longitudinal arches will lead to Pes cavus (high arched foot)the opposite of flat foot. C. Injury to deltoid ligament is not so common and hardly produces neurological pain. D. Shortening of plantar aponeurosis leads to Pes cavus. Comments Though we are not sure that compression of communication between medial and lateral plantar nerves is the most common cause of neuralgic pain in the foot, Of all the 4 choices given, it is the most common It is a common cause Tips Read the applied anatomy questions from Snell. 172. Osteomalacia is associated with: A. Decrease in osteoid volume. B. Derease in osteoid surface. C. Increase in osteoid maturation time D. Increase in mineral apposition rate. Answer: C (Increase in osteoid maturation time) Ref: Harrison 15th , 340; System of Orthopaedics and Fractures Apley 8th edn, 119; Essential Orthopaedics by Maheswari 3rd edn,; Textbook of Orthopaedics 2nd edn, 289 Quality: Reader Status: Repeat QTDF: All books Discussion Failure of mature bone to mineralise is called osteomalacia. In rickets, defective growth of bone results from retardation or suppression of normal growth of epiphyseal cartilage and of normal calcification. Cartilage cells fail to complete their normal cycle of proliferation and degeneration, and subsequent failure of capillary penetration occurs in a patchy manner. The result is a frayed, irregular epiphyseal line at the end of the shaft. Failure of osseous and cartilaginous matrix to mineralise in the zone of preparatory calcification, followed by deposition of newly formed uncalcified osteoid, results in a wide, irregular, frayed zone of nonrigid tissue (the rachitic metaphysis). A characteristic feature of these disorders is, therefore, an increase in osteoid volume and thickness (the latter being normally <12 to 14 um) and a decrease in calcification of the mineralisation front. This can be detected in unmineralised sections by the fluorescence of previously ingested tetracyclines or by special stains. Explanation A. Osteomalacia is associated with increase in osteoid volume. B. Osteomalacia is associated with increase in osteoid surface. C. Osteomalacia is associated with increase in osteoid maturation time D. Osteomalacia is associated with decrease in mineral apposition rate. Comments Mineralisation is also lacking in subperiosteal bone; pre-existing cortical bone is resorbed in a normal manner but is replaced by osteoid tissues over the entire shaft, which fails to mineralise. If this process continues, the shaft loses its rigidity, and the resultant softened and rarefied cortical bone is readily distorted by stress; deformities and fractures result. Tips See the choices. Choice C stands out. Obviously, the rate of maturation is delayed and that means the time is increased. 173. A classical expansive lytic lesion in the transverse process of a vertebra is seen in: A. Osteosarcoma. B. Aneurysmal bone cyst (ABC). C. Osteoblastoma. D. Metastasis. Answer: B (Aneurysmal bone cyst) Ref: Chapman 520; Schwartz , 2009; System of Orthopaedics and Fractures Apley 8th; Essential Orthopaedics by Maheswari 3rd; Textbook of Orthopaedics 2nd edn, 370 Quality: Reader Status: Repeat QTDF: All books Discussion Osteoblastoma: Spinal lesion is: Well defined Lytic Partly or extensively calcified or ossified Radiology noncontributory to pinpoint the diagnosis Aneurysmal bone cyst: Spinal lesion is: Osteolytic Expansile Involves posterior osseous elements Can be diagnosed by radiology Explanation A. 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His plain X-ray of the dorsolumbar spine reveals a solitary collapsed dorsal vertebra with preserved disc spaces. There was no associated soft tissue shadow. The most likely diagnosis is: A. Ewings sarcoma. B. Tuberculosis. C. Histiocytosis. D. Metastasis. Answer: C (Histiocytosis) Ref: Nelson, 660; OP Ghai 5th edn, 473; System of Orthopaedics and Fractures Apley 8th edn, 92; Essential Orthopaedics by Maheswari 3rd edn, 41 Quality: Spotter Reader Status: Repeat QTDF: All books Discussion The name Langerhans cell histiocytosis (LCH) has been applied to the class I histiocytoses. Histiocytosis X, constitutes class I and includes: 3 Eosinophilic granuloma, 3 Hand-Schller-Christian disease, and 3 Letterer-Siwe disease. Birbeck granule, a tennis racket-shaped bilamellar granule, which when seen in the cytoplasm of lesional cells in LCH is diagnostic of the disease. Alternatively, the definitive diagnosis of LCH can be made by demonstrating CD1-positivity of lesional cells. Clinical Manifestations: LCH has an extremely variable presentation. The skeleton is involved in 80% of patients and may be the only affected site in the child older than 5 yr of age. Bone lesions may be single or multiple and are seen most commonly in the skull. They may be asymptomatic or associated with pain and local swelling. Involvement of the spine may result in collapse of the vertebral body, which can be seen roentgenographically, and may cause secondary compression of the spinal cord. In flat and long bones, osteolytic lesions with sharp borders occur, and no evidence exists of reactive new bone formation. Lesions that involve weight-bearing long bones may result in pathologic fractures. Chronically draining, infected ears are commonly associated with destruction in the mastoid area. Bony destruction of the mandible and maxilla may result in teeth that, on roentgenograms, appear to be free floating. With response to therapy, there may be complete healing. Explanation A. Ewings sarcoma has onion peel appearence. B. Tuberculosis involves adjacent vertebra, disc is affected and often has soft tissue shadow. C. Histiocytosis is the correct answer. D. Metastasis is a possibility, but rarely is solitary. Comments Class I Class II Class III Diseases Langerhans cell Familial erythrophagocytic Malignant histiocytosis lymphohistiocytosis (FEL) histiocytosis Eosinophilic Infectionassociated Acute monocytic  granuloma, haemophagocytic leukaemia Hand-Sch syndrome (IAHS)  ller-Christian  disease, and Letterer-Siwe  disease. HPE Langerhans cells Morphologically normal Neoplastic with Birbeck reactive macrophages proliferation of cells granules with prominent with characteristics of erythrophagocytosis monocytes/ macrophages or their precursors Treatment Isolated lesions: Chemotherapy Antineoplastic Local therapy Allogeneic bone marrow chemotherapy, Disseminated transplantation including disease : (experimental) anthracyclines chemotherapy Tips Histiocytosis is a fancy topic. 175. Kinebocks disease is due to avascular necrosis of: A. Femoral neck. B. Medial cuneiform bone. C. Lunate bone. D. Scaphoid bone. Answer: C (Lunate bone) Ref: Apley 8th edn, 101; Stedmans, 516; Schwartz, 1931 Quality: Spotter (for MS Ortho) Status: Repeatedly asked so that every serious contender knows and the question has become nondecider QTDF: Most books including SARP give this. Discussion Osteochondritis is defined as derangement of growth or ossification occurring in an epiphysis. Bone Disease Eponym Epiphysis Scaphoid Preisser Primary Lunate Kienbock Primary Crushing Patella Kohler Primary Talus Mouchet Primary Tarsal navicular Kohler Primary Crushing Vertebra-ring epiphysis Schewermann Secondary Crushing Vertebra - Central Calve Crushing body nucleus Head of hemrus Hass Secondary Capitellum Panner Secondary Crushing Head of radius Brailsford Secondary Pubic symphysis VanNeck Secondary Ischiopubic junction Oldsberg Secondary Head of femur Legg-Calv-Perthes Secondary Crushing Patella lower pole Sinding Larsen Johnson Secondary Traction Tibial tuberosity Osgood Schlatter Secondary Traction Calcaneum Sever Secondary Traction Metatarsal head Freiberg Secondary Crushing Femoral condyle Osteochondritis Dessican Splitting Explanation A. Osteochondritis of femoral neck is Legg-Calv-Perthes disease. B. Osteochondritis of medial cuneiform bone disease. C. Osteochondritis of lunate bone Kienbocks disease. D. Osteochondritis of scaphoid bone Preissers disease. Comments This question can be easily answered if you know the points. And to guess in questions like this without having read the topic at least once is a big mistake. Tips Also, be prepared with the various epiphysis and when they appear and when they fuse with the main bone (Questions may be asked from Anatomy as well as from Forensic Medicine). 176. Pseudoclaudication is due to the compression of: A. Femoral artery. B. Femoral nerve. C. Cauda equina. D. Popliteal artery. Answer: C (Cauda equina) Ref: Stedmans, 360 Quality: Spotter Status: Repeat QTDF: All books Discussion Neurogenic claudication is due to lumbar canal stenosis. Explanation A. Femoral artery lesions produce vascular claudiDAdobe Compatibility CMSAdobe Compatibility CMSPageMaker 5.0 RGBDAdobe Compatibility CMS Adobe Compatibility CMSPageMaker 5.0 CMYK(xKdd (xKdd! 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