MCQs in Rheumatology:
Osteoarthritis and related disorders
Contributors: These MCQs were written by Dr Michelle Hui, Dr Zoe Paskins, Dr
Dipti Patel, and Dr Pravin Patil; and were reviewed by Dr Ed Roddy, Prof Michael
Doherty and Prof Nigel Arden. The MCQs were edited by Dr A Abhishek who also
facilitated the review process.
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Question 1
A 57 year old man presents to his GP with a 3 month history of gradual onset right
knee pain, associated with mild swelling, and with several episodes of the knee
giving way. His knee shows mild crepitus, medial joint line tenderness and some
discomfort on patella stressing. There is no history of trauma. His inflammatory
markers are normal. His X Ray shows moderate osteoarthritis in the medial tibiofemoral and patello-femoral compartments and the presence of a posterior loose
body. His GP phones you for advice
What is the most appropriate single intervention?
1.
2.
3.
4.
5.
Arthroscopy with washout
Intra-articular corticosteroid injection
Non steroidal anti-inflammatory drugs
Physiotherapy for strengthening exercise
Patella taping
Question 2
A 55-year old builder presents with a 4-month history of increasing difficulties with
walking. He is now only able to walk about 1km before he develops tightness of the
right buttock radiating down to the foot. He is forced to rest for about 5 minutes, after
which he can resume walking for a little further. Apart from an accident at work when
he fell onto his back 9 months ago, he is a non-smoker, and has no significant past
medical history. There is no night pain, or rest pain.
On examination no neurological abnormalities were found. Lumbar spine movements
were reduced on extension. Peripheral pulses were present. There was no
tenderness of palpation of the spine.
What is the most likely diagnosis?
1.
2.
3.
4.
5.
Bony metastatic disease
Intermittent claudication
Osteoarthritis
Spinal canal stenosis
Vertebral fracture
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Question 3
A 32-year old female presents with a persistently painful, stiff and swollen right wrist
following a skiing accident in America 5 months ago. X-ray of the wrist at the time of
the accident showed fracture of the distal radius, which has subsequently healed on
follow-up radiographs. However, her symptoms persist.
On examination, there is allodynia, and hyperalgesia on the right wrist, which is
warmer, and erythematous. There is a reduced range of active movement at the right
wrist. There are no other swollen or painful joints.
What will most likely explain this presentation?
1. Complex regional pain syndrome type I
2. Complex regional pain syndrome type II
3. Inflammatory arthritis
4. Lyme disease
5. Osteomyelitis
Question 4
A 32-year old female presents with a perisistently painful, stiff and swollen right wrist
following a skiing accident in America 5 months ago. On examination there is
allodynia, the wrist is warmer and more erythematous compared to the other. There
is a reduced range of active movement of the right wrist. There are no swollen or
painful joints elsewhere.
What is the most appropriate initial management?
1.
2.
3.
4.
5.
Acupuncture
Intra-articular triamcilolone
Opiates
Physiotherapy
Surgical sympathectomy
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Question 5
A 65-year old farmer with spinal degenerative disc disease presents with a 2-month
history of reducing exercise tolerance due to pain in the right buttock on exertion. It is
associated with tightness radiating down the back of the right leg upon walking.
Coming down on inclines are particularly difficult. He has no night pain, and no
weight loss. On examination, there is no spinal tenderness. Straight-leg raise is
positive on the right with a positive Lasègue’s sign. Internal rotation of the hip is 45
degrees, external rotation 80 degrees, flexion 100 degrees. Peripheral pulses are
present.
What is the most appropriate next investigation?
1.
2.
3.
4.
5.
Arterial doppler
MRI lumbar spine
MRI right hip
Nerve conduction studies
5 X-ray lumbar spine
Question 6
A 69 year old man is referred to the rheumatology outpatients for worsening knee
pain. He has anterior right knee pain, worse on climbing stairs. He was coping with
these symptoms on co-codamol and topical ibuprofen till the last month, when his
symptoms worsened significantly. On examination, he has joint line tenderness, and
anterior patello-femoral joint crepitus. There is no effusion. You diagnose
osteoarthritis. He has TIA for which he takes aspirin.
What should be the next step in his management?
1.
2.
3.
4.
5.
Arthroscopy
Celecoxib with omeprazole
Joint replacement surgery
Intra-articular corticosteroid injection
Intra-articular hyaluronan
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Question 7
A 52 year old lady who works as a cleaner is referred by her GP to outpatients with
knee pain. The pain has come on gradually over the last 6 months and is worse on
going upstairs and rising from a sitting position. The knee feels unstable but has not
given way and there is no history of locking. She has no other past medical history
and weighs 70kg and is 1.5m tall. On examination she is tender on and below the
medial joint line and there is a suggestion of localised swelling there. She has a full
range of movement. A valgus strain of her unlocked knee also reproduces the pain.
An X-Ray has shown some minor medial tibio-femoral and patello-femoral joint
space loss.
What is the most likely origin of her symptoms?
1.
2.
3.
4.
5.
Anserine Bursitis
Knee osteoarthritis (tibiofemoral)
Knee osteoarthritis (patellofemoral)
Meniscal tear
Medial collateral ligament strain
Question 8
A 72 year old lady presents to outpatients with severe left groin pain which is
disrupting her daily activities. She is unable to walk more than 50 yards without pain
and has recently had to ask a friend to do her shopping. She frequently wakes up at
night with this pain. Her GP has tried physiotherapy, given advice about weight loss,
and tried co-codamol, and naproxen which have not helped.
She has
hypothyroidism and hypertension and her medication consists of co-codamol 30/500,
naproxen, omeprazole and levothyroxine. Left hip flexion, and internal rotation are
restricted and painful. Examination confirms that the pain is not soft tissue in origin.
Recent FBC, UEC, LFT, CRP and ESR are normal. The X-ray shows only modest
(Kellgren and Lawrence grade 2) left hip osteoarthritis with definite acetabular
osteophyte, and joint space narrowing. You have commenced her on tramadol and
paracetamol in order to control her pain.
Which of the following should be the next intervention?
1.
2.
3.
4.
5.
Acupuncture
Amitryptiline
Capsaicin cream
Refer for hip arthroplasty
All of the above
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Question 9
A 54 year old man is referred by his GP to the Rheumatology department with a 5
year history of progressive pain in knees, shoulders, elbows, and lumbar spine.
There is occasional swelling of hands and symptoms are worse on exertion. He also
complains of tingling and numbness in his 2nd and 3rd fingers of the left hand. He has
a history of hypertension, and diabetes mellitus. Hand radiographs show enlarged
terminal phalanges, widened MCPJs, and OA of 1st CMCJ bilaterally.
These features are most consistent with which of the following conditions?
1.
2.
3.
4.
5.
Acromegaly
Amylodosis
Hyperparathyroidism
Hyperthyroidism
Hypothyroidism
Question 10
A 46 year old Caucasian male presents to the Rheumatology department with a 3
year history of pain and stiffness affecting both hands particularly the 2 nd and 3rd
MCP joints, hips, ankles and knees.
He has a background history of Type 2 DM, CCF and is under the care of
gastroenterologist for abnormal liver function tests. Joint examination revealed bony
selling and tenderness of 2nd and 3rd MCP joint .X ray of the hands showed cystic
lesions on metacarpal heads and osteophytes in MCP joints.
Which one of the following conditions is the most likely diagnosis?
1.
2.
3.
4.
5.
Hepatitis C
Hereditary haemochromatosis
Osteoarthritis
Rheumatoid arthritis
Wilsons disease
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Question 11
A 45-year old female factory worker presents with a 5-year history of gradually
progressive swellings of the proximal and distal inter-phalangeal joints. The
development of swelling is associated with pain for about 3-6 months, which then
subsides. Early morning stiffness lasts for about 30 minutes, and the symptoms are
worse in the evenings. She has been using paracetamol and ibuprofen with modest
benefit. She has 2 first-degree relatives with rheumatoid arthritis. On examination,
there are several non-tender dorso-lateral bony swellings of the proximal and distal
inter-phalangeal joints bilaterally, with mild ulnar deviation of both index distal
interphalangeal joints. She also has bilateral knee crepitus.
The rheumatoid factor done by her GP is negative.
What is the most likely diagnosis?
1.
2.
3.
4.
5.
Crystal arthropathy
Haemochromatosis
Nodal generalised osteoarthritis
Psoriatic arthritis
Seronegative rheumatoid arthritis
Question 12
A 72-year old keen gardener presents with an increasing left sided deep groin pain,
over the past 4 months. He is systemically well. Apart from well controlled thyroid
disease, he has no other comorbidities. On examination, he has a BMI of 28.
Examination of the left hip reveals a reduced passive internal rotation to 10 degrees
and flexion to 50 degrees, limited by pain. External rotation is relatively spared. Xray of the pelvis shows left femoral head collapse. MRI of the left hip shows the
double line sign of the femoral head.
What is the most appropriate treatment?
1.
2.
3.
4.
5.
Bisphosphonate
Disease-modifying agent
Hip arthroplasty
Intra-articular steroid
Intravenous antibiotic
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Question 13
A 55-year old businessman with a history of excess alcohol intake presents with an
increasingly painful left deep groin pain over the past 6 months. Initially the pain was
mainly at night and unrelated to weight bearing, but subsequently it become worse
with weight-bearing and spread to involve his antero-lateral thigh. He was involved in
a car accident 9 months ago when he was hit from behind by another car whilst at a
traffic light. He sustained no immediate injuries. He is systemically well. On
examination, he has a BMI of 32 kg/m2. On examination of the left hip, the internal
rotation is limited to 150, and flexion to 700 due to pain. External rotation is spared.
X-ray of the pelvis shows flattening of the femoral head, with adjacent joint space
narrowing, juxta-articular sclerosis, and osteophyte formation. X-ray of the left hip in
the frog leg lateral view shows the crescent sign.
What is the most likely cause of the left hip arthropathy?
1.
2.
3.
4.
5.
Bone metastasis
Chronic septic arthritis
Osteoarthritis
Osteonecrosis
Paget's disease
Question 14
A general practitioner requests your opinion on a 50 year old patient with
haemochromatosis who is on two-monthly therapeutic venesection. He has a long
history of pain in both hands, wrists and knees. On examination, there is tenderness
and ‘bony’ hard swelling of the 2nd and 3rd metacarpophalangeal joints of both
hands. There is crepitus at the knee, and restricted internal rotation in flexion at the
left hip.
Which of the following radiological features is associated with the arthritis of
haemochromatosis?
1.
2.
3.
4.
5.
Hook-like osteophytes on the radial aspect of metacarpal head
Hook-like osteophytes on the ulnar aspect of metacarpal head
Juxta-articular osteopenia
Periostitis
"Punched-out" lytic bone lesion
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Answer
Q1.
4. Physiotherapy for strengthening exercise
Physiotherapy has good evidence for the treatment of knee OA, and in the context of
instability, strengthening exercises are key. Arthroscopy is only indicated in the
presence of locking, or if symptomatic meniscal tears/cruciate ligament damage is
suspected. There is no role of intra-articular corticosteroid injection, and NSAIDs in
the management of this patient.
Q2.
4 Spinal canal stenosis
Symptoms of spinal canal stenosis can certainly mimic those of intermittent
claudication. As he has no other risk factors of atherosclerosis, and given that he is a
builder (occupational risk for degenerative disc disease and had the fall (which may
have precipitated spinal canal narrowing which over time gives rise to the current
classical symptoms spinal canal stenosis is most likely to account for these
symptoms.
Q3.
1. Complex regional pain syndrome type I
Complex regional pain syndrome is characterised by sensory, vasomotor and
sudomotor changes. In later stages there may be muscle atrophy. There are 2 types
of CRPS – type I and type II (also known as causalgia. Type I results from trauma to
a limb and type II follows partial nerve damage. Both cause similar symptoms, type II
is rare.
Q4.
4. Physiotherapy
Psychotherapy and early graded physiotherapy are the two recommended mainstays
of treatment for CRPS. There are few controlled-trials assessing treatment with most
evidence for gabapentin, oral steroid and calcium-channel modulating drugs.
Anecdotal evidence for tricyclic antidepressants only. Techniques for sympathetic
nerve blockade can be used. Acupuncture has not demonstrated efficacy over
placebo. (Wilson et al Contin Educ Anaesth Crit Care Pain (2007 7 (2 51-54).
Q5.
2. MRI lumbar spine
The history is suggestive of spinal canal stenosis. An MRI may provide clues to the
cause of spinal canal stenosis. Often spinal canal stenosis results from acquired
degenerative changes. Osteophytes and calcified bulging disc structures can be
seen. These appear dark on T2-weighted imaging. Facet joint hypertrophy,
ligamentum flavum hypertrophy and posterior longitudinal ligament abnormalities
and vertebral body spurs can also be seen. It also provides detail about any spinal
cord compromise.
Q6.
4. Intra-articular corticosteroid injection
This patient needs intra-articular corticosteroid injection for relief of his symptoms.
NICE recommend not to use intra-articular hyaluronan. Celecoxib is associated with
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increased risk of ischemic events and is inappropriate to use in ischemic heart
disease or cerebrovascular disease. In OA, arthroscopy is inappropriate unless there
is a clear history of locking of the knee. Joint replacement surgery may be an option
but only if other treatment options have been tried.
Q7.
5.Medial collateral ligament strain
Half of adults over 50 with radiographic knee OA are asymptomatic. Anserine bursitis
alone would not result in joint line tenderness. The valgus strain test suggests medial
collateral ligament strain. Anserine bursitis alone would not result in joint line
tenderness. Tenderness over the joint line would be consistent with a meniscal tear
but this usually presents with mechanical symptoms such as locking. Tibiofemoral
OA is possible, but there is no limitation in range of movement or crepitus. In
patellofemoral OA the pain is usually localized to the anterior knee, which is not the
case here. The valgus strain test strongly suggests strain of the medial collateral
ligament, or enthesopathy of the inferior insertion of the ligament.
Q8.
4. Refer for hip arthroplasty
This patient needs referral for joint replacement surgery. Acupuncture is not
recommended by NICE for OA, and topical capsaicin is recommended for OA of
knees and hands only. Amitryptiline may have a role if the pain has a neuropathic
character, or if the patient has co-existent fibromyalgia, which is not the case here.
Q9.
1. Acromegaly
Arthropathy may be seen in 74% of patients with acromegaly. Large joints are most
commonly affected. Hands reveal the most characteristic radiographic changes,
including soft tissue thickening, enlarged terminal phalanges, increased joint space,
and deformation of epiphysis with squaring of phalalnges. Carpal tunnel occurs in up
to 50 % of patients with acromegaly.
Osteitis fibrosa cystica represents classic sequela of long standing
hyperparathyroidism and causes subperiosteal resorption with blurring blurring of
cortical margins and resorption of tuft of distal phalanges.Discrete lytic lesions due to
focal aggregates of osteoclastic giant cells and fibrous tissue may occur called
brown tumors.
Thyroid acropachy is rare complication of Graves disease with soft tissue swelling of
hands, digital clubbing and periostitis particularly involving the metacarpal and
phalangeal bones.
Q10.
2. Hereditary hemachromatosis
Approximately 40-60% of patients with hemochromatosis have arthropathy. With
some patients, the arthropathy is the first manifestation of the underlying disease.
Any joint may be affected, but osteoarthritis like symptoms and changes in the
second and third metacarpophalangeal (MCP) joints are most common. Due to the
incomplete penetrance of HFE mutations leading to haemochromatosis, tests of iron
overload (serum iron, total iron-binding capacity, ferritin, and percent transferrin
saturation) are better screening tests.
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Hemochromatotic arthropathy commonly manifests with cystic lesions on the
metacarpal heads. Squared-off bone ends and hook like osteophytes in the MCP
joints, particularly in the second and third MCP joints, are characteristic findings.
Chondrocalcinosis may be visualized.
HCV infection causes a rapidly progressive acute arthralgia (but rarely arthritis) in a
rheumatoid distribution, affecting the hands, wrists, shoulders, knees, and hips.
The arthropathy of Wilson disease is a degenerative process that resembles
premature osteoarthritis. Symptomatic joint disease, which occurs in 20-50% of
patients, usually arises late in the course of the disease, frequently after age 20
years. The arthropathy generally involves the spine and large appendicular joints,
such as knees, wrists, and hips. Osteochondritis dissecans, chondromalacia
patellae, and chondrocalcinosis have been described.
Q11.
3.Nodal osteoarthritis
Nodal osteoarthritis is common in middle-aged women. Her occupation is likely to a
risk factor for the distribution of involvement, rather than its development. During the
development of nodes, significant pain can be experienced, which subsides after the
nodes are fully formed. Lateral (ulnar or radial) deviation of interphalangeal joints is a
common deformity of interphalangeal osteoarthritis.
Q12.
3.Hip arthroplasty
Surgery is the preferred option with advanced osteonecrosis of the hip. Patients not
suitable for surgery can be treated with bisphosphonates.
Q13.
4. Osteonecrosis
Excess alcohol is a risk factor for osteonecrosis. The crescent sign on an x-ray
indicates a subchondral fracture. The frogleg lateral view is better than
anteroposterior (AP) view for demonstrating this sign because in the AP view, the
superior portion of the femoral head (where this sign is most often seen) is obscured
by the superimposed projection of the anterior and posterior margins of the
acetabulum.
Q14.
1. Hook-like osteophytes on the radial aspect of the metacarpal heads
The arthropathy of haemochromatosis targets MCPJs (particularly 2 nd and 3rd),
radiocarpal joints, hips, knees, ankles, and more rarely elbows and shoulders.
Chondrocalcinosis is frequent. The arthropathy of haemochromatosis superficially
resembles OA, with joint-space narrowing, sclerosis, osteophytosis, and cysts.
Erosions have been reported. Hook-like osteophytes in MCPJs occurs on the radial
aspect of the metacarpal head, and not on the ulnar aspect, and are regarded by
some as characteristic of the arthropathy of haemochromatosis. The arthropathy of
haemochromatosis is not improved by venesection.
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