Soft tissue

Question 1

1. An ultrasound scan of a patient’s left shoulder suggests subacromial impingement. Which is the single best answer?

A. Type 2 concave pattern is the most common morphology

B. Type 2 is the most common type to be associated with rotator cuff tears

C. ACJ degeneration increases the supraspinatus outlet

D. Significant subacromial subdeltoid bursitis is diagnosed with thickness > 10mm

E. Is associated with the presence of bursal fluid lateral to the Acromio clavicular joint (ACJ)

Answer 1

A. Type 2 concave pattern is the most common morphology

Type 1-flat (12%)
Type 2-concave (56%)
Type 3-hooked (29%)
Type 4-inferior convex (3%)

Type 3 more than Type 2 is associated with increased incidence of rotator cuff tears.

ACJ degeneration can narrow the supraspinatus outlet.

Significant subacromial subdeltoid (SASD) bursitis include thickness > 3mm, presence of bursal fluid medial to the ACJ and presence of fluid in the anterior aspect of the bursa.

Question 2

2. A 32-year-old keen tennis player has had shoulder pain for 6 weeks. An MRI confirms a superior labral tear from anterior to posterior (SLAP) lesion. Regarding these lesions, which of the following is the single best answer?

A. Are isolated tears of glenoid labrum with superior and inferior components

B. Tears are classically located at the biceps anchor

C. Occur with repetitive underarm activity

D. Is often diagnosed clinically alone

E. Begins in the anterior aspect of superior labrum and extends posteriorly

Answer 2

B. Tears are classically located at the biceps anchor

SLAP lesions are isolated tears of the glenoid labrum with anterior and posterior components. These lesions occur with repetitive over-arm activity, begin in the posterior aspect of the superior labrum and extend posteriorly.

Question 3

3. A 20-year-old man sustains a knee injury after playing football. Regarding imaging of the infrapatellar tendon, which is the best answer?

A. Normal infrapatellar tendon appears high signal on all sequences

B. A triangular area of high signal at the patellar enthesis when imaged on gradient echo indicates tendon rupture

C. In infrapatellar tendnopathy, the tendon may be swollen and contain focal areas of reduced echogenicity

D. The paratenon is more commonly primary site of acute inflammation in infrapatellar tendon than Achilles tendon

E. An echo-rich halo around the tendon is seen in paratenonitis on US

Answer 3

C. In infrapatellar tendnopathy, the tendon may be swollen and contain focal areas of reduced echogenicity

The normal infrapatellar tendon is homogenously low SI on all sequences.

A triangular area of high signal at the patellar enthesis when imaged on gradient echo is of no clinical significance.

The paratenon is more commonly the primary site of acute inflammation in the Achilles tendon than the infrapatellar tendon.

An echo-poor halo around the tendon is seen in paratenonitis on US.

Question 4

@# 21. Which of the following is associated with anteromedial ankle impingement syndrome?

A. Usually occurs from eversion injury only

B. Well-defined signal intensity on T1 and T2 in the deep deltoid ligament related to scarring

C. Large corticated ossicles are seen

D. Lateral displacement of the tibialis posterior tendon

E. Post-traumatic synovitis

Answer 4

E. Post-traumatic synovitis

Anteromedial ankle impingement syndrome was previously thought to be from eversion injury but recent studies are showing inversion is the causative injury.

There is associated amporphous SI in ATTL (Anterior tibiotalar ligament) with heterotopic bone formation and small corticated ossicles.

Post-traumatic synovitis and fibrosis are recognised.

The tibialis posterior tendon may be displaced medially.

Question 5

40. A 35-year-old woman with bilateral forefoot pain is investigated for Morton’s neuromas. Which is the single best answer?

A. Low on T1 and high on T2

B. Do not enhance with contrast

C. Associated proximal fluid-filled bursae are seen

D. Occur most commonly between the heads of the first and second metatarsals

E. Occur most commonly between the heads of the second and third metatarsals

Answer 5

C. Associated proximal fluid-filled bursae are seen

Most commonly between third and fourth metatarsal heads.

Question 6

22. An MRI of the ankle shows deep injury to the deltoid ligament. Which of the following belong to the deep components of the deltoid (medial collateral) ligament of the ankle?

A. Tibiocalcaneal ligament

B. Tibionavicular ligament

C. Posterior superficial tibiotalar ligament

D. Anterior tibiotalar ligament (ATTL)

E. Tibiospring ligament

Answer 6

D. Anterior tibiotalar ligament (ATTL)

The other answers all belong to the superficial components. The posterior deep tibiotalar ligament is also deep. The superficial and deep components function almost synergistically and stabilise against valgus and pronation as well as rotational force against the talus.

Question 7

45. Which of the following is a characteristic of plantar fasciitis?

A. Calibre of plantar fascia > 2mm

B. Increased reflectivity of ligament

C. Enthesal new bone formation

D. Low SI T1, high SI T2

E. Pain typically worse with progressive exercise

Answer 7

C. Enthesal new bone formation

Most common type of plantar fascia injury.

Sharp pain, worse after rest, lessening with exercise.

US shows increased caliber > 4mm, loss of reflectivity of the ligament, specifically within the central bundle.

MR shows high to intermediate T1 and high T2 SI.

Question 8

3) Plain knee radiographs performed in accident and emergency following a sports injury in a 20-year-old footballer show an effusion, a small avulsion fracture immediately proximal to the fibular head, deepening of the lateral femoral sulcus and anterior translocation of the tibia. What is the likely underlying ligamentous injury?

a. complete posterior cruciate ligament rupture

b. complete anterior cruciate ligament rupture

c. partial anterior cruciate ligament rupture

d. tibial collateral ligament rupture

e. fibular collateral ligament rupture

Answer 8

b. complete anterior cruciate ligament rupture

The avulsion fracture described is a Segond fracture, which is classically associated with anterior cruciate ligament (ACL) rupture, and represents avulsion of the meniscotibial portion of the middle third of the lateral capsular ligament.

Anterior translocation of the tibia occurs in complete ACL rupture, and manifests clinically as the anterior draw sign.

Also associated with ACL rupture is an impaction injury of the lateral femoral condyle, which can be seen on radiographs as a deepened lateral femoral condylar sulcus, although sometimes this cannot be identified on acute films.

Question 9

6) Of the lateral fibrous structures contributing to the stability of the posterolateral corner of the knee, which is most likely to be congenitally absent and not identified on MRI, being present in only approximately 2/3 of patients?

a. lateral collateral ligament

b. popliteus tendon

c. popliteofibular ligament

d. arcuate ligament

e. fabellofibular ligament

Answer 9

d. arcuate ligament

The structures of the posterolateral corner of the knee have a very important role in maintaining the rotational stability of the knee joint.

The lateral collateral ligament forms the superficial layer, with the remainder of the structures comprising the deep layer.

Injury is relatively common and results most frequently from a varus force on an extended joint.

The lateral collateral ligament and popliteus tendon are present in all joints, with the popliteofibular ligament being present in approximately 98%.

Both the arcuate ligament and fabellofibular ligaments are variable, with the former absent more frequent.

Absence of one of these structures is often compensated for by hypertrophy of the other.

Question 10

9) A 30-year-old man undergoes shoulder MRI for chronic anterior pain. There is no history of trauma. Sagittal images reveal an absent anterior labrum with a thickened middle glenohumeral ligament. What is the most likely diagnosis?

a. anterior labral tear

b. Bankart’s lesion

c. superior labrum anterior-to-posterior (SLAP) lesion

d. glenohumeral tendonitis

e. normal variant

Answer 10

e. normal variant

The findings describe the Buford complex, a normal variant present in 1.5% of the population.

It consists of an absent anterior labrum with a thickened cord-like middle glenohumoral ligament.

It can be misdiagnosed as a torn or avulsed anterior labrum, resulting in unnecessary shoulder arthroscopy.

Question 11

38) A 49-year-old woman presents to her general practitioner with a history of mild midfoot pain exacerbated by walking and wearing tight shoes. Ultrasound scan demonstrates a hypoechoic, 7 mm, rounded lesion lying in the third tarsal interspace. The lesion is poorly demonstrated on MRI, returning intermediate T1 and low T2 signal. Which of the following conditions best explains these findings?

a. tendon sheath ganglion

b. tendon sheath giant cell tumour

c. synovial cyst

d. Morton’s neuroma

e. paraganglioma

Answer 11

d. Morton’s neuroma

Morton’s or interdigital neuroma is a benign lesion consisting of perineural fibrosis that entraps a plantar digital nerve. It is frequently asymptomatic and women represent 80% of cases.

Clinical presentation is with foot pain exacerbated by walking, and symptomatic lesions are surgically excised.

They are not usually demonstrated on plain radiography and are poorly seen on MRI, returning intermediate T1 and low T2 signal (similar to surrounding tissues).

Typical ultrasound appearances are of a hypoechoic rounded lesion, larger in the axial than the sagittal plane.

Ganglia and cysts would return high signal on T2W images, and pathology arising from the tendon sheath itself can also show high signal. Giant cell tumours are usually painless.

Question 12

49) Tarsal coalition is a common cause of foot pain. Which of the following joints is most commonly affected?

a. anterior subtalar

b. middle subtalar

c. posterior subtalar

d. calcaneonavicular

e. calcaneocuboid

Answer 12

d. calcaneonavicular

MRI is valuable in the diagnosis of a number of musculoskeletal conditions of the ankle, including osteochondral lesions of the talus, bone infarcts and bruising, stress fractures, osteoid osteoma and tarsal coalition.

Forty-five per cent of tarsal coalition occurs at the calcaneonavicular joint, with a further 45% at the subtalar joint, most commonly involving the middle facet.

Radiographic findings include joint space narrowing, indistinct articular margins, elongation of the anterior calcaneus, a hypoplastic talus and reactive sclerosis of the involved bones.

It is commonly associated with pes planus.

Treatment options include physical supports, anti-inflammatory medication, local steroid injection, and surgical resection or arthrodesis.

Question 13

50) O’Donoghue’s unhappy triad consists of injuries to which three internal structures of the knee that are commonly injured together?

a. anterior cruciate and lateral collateral ligaments, medial meniscus

b. anterior cruciate and lateral collateral ligaments, lateral meniscus

c. anterior cruciate and medial collateral ligaments, medial meniscus

d. anterior cruciate and medial collateral ligaments, lateral meniscus

e. posterior cruciate ligament, medial and lateral menisci

Answer 13

c. anterior cruciate and medial collateral ligaments, medial meniscus

O’Donoghue’s unhappy triad (silent G) consists of injuries to the anterior cruciate and medial collateral ligaments and the medial meniscus, and is an injury associated with contact sports.

The mechanism is indirect trauma causing deceleration, hyperextension and twisting forces. The combination of external rotation of the tibia on the femur, knee flexion and valgus stress can produce an anterior cruciate ligament injury combined with additional medial collateral ligament injury.

The meniscus and collateral ligament medially are attached to one another, unlike their lateral counterparts, resulting in a higher frequency of concordant injury to the other medial structure when one is injured.

Question 14

71) On MRI of the foot performed for non-specific pain, which single feature is most specific for a diagnosis of sinus tarsi syndrome?

a. subtalar joint effusion

b. subtalar sclerosis

c. loss of fat signal in the sinus

d. bone marrow oedema in the talus

e. flexor tendon high signal on T2W images

Answer 14

c. loss of fat signal in the sinus

Sinus tarsi syndrome is a common complication of ankle sprains, but may also result from an inflammatory arthropathy.

It is associated with abnormalities of one or more structures in the tarsal sinus and tarsal canal that lead to pain and a feeling of instability of the hindfoot.

Most patients with this syndrome present in the third or fourth decade of life with persistent lateral foot pain, though the pathogenesis of the condition is poorly understood.

Conventional radiography generally is not valuable,

but on MRI there is alteration of the fat signal, the most common changes being diffuse low-signal-intensity infiltration on both T1W and T2W images.

Other common MR findings include synovial thickening and diffuse enhancement of the tarsal sinus following intravenous gadolinium.

Question 15

@# 85) Radiographic arthrography of the shoulder with injection of contrast into the glenohumeral joint is performed for a painful joint with a globally reduced range of movement. Which single finding is most likely to indicate a diagnosis of adhesive capsulitis?

a. pain on injection of contrast

b. small axillary recess

c. contrast tracking along the subscapularis muscle

d. contrast in the subacromial space

e. obliteration of the subcoracoid fat

Answer 15

b. small axillary recess

Adhesive capsulitis or frozen shoulder is clinically characterized by restriction of both active and passive elevation and external rotation.

Patients are commonly 40–70 years old and predominantly female. It may be idiopathic, preceded by trauma, or associated with diabetes mellitus or other conditions.

Patients have been shown to have a significantly thickened coracohumeral ligament and joint capsule, and an axillary recess significantly reduced in volume.

Obliteration of the fat triangle between the coracohumeral ligament and the coracoid process is specific when seen on MR arthrography.

Treatment options include physiotherapy, intra-articular corticosteroid injection, manipulation under anaesthetic and surgical capsulotomy.

Question 16

86) A 45-year-old, right-handed, male mechanic presents to orthopaedic clinic with intermittent ulnar-sided wrist pain that is at its worst while he uses a screwdriver. Radiographs show positive ulnar variance with a normal ulnar styloid. Subsequent MRI reveals a central perforation of the triangular fibrocartilage complex with chondromalacic changes in the lunate. What is the most likely condition?

a. ulnar impingement syndrome

b. ulnar impaction syndrome

c. ulnar styloid impaction syndrome

d. hamatolunate impaction syndrome

e. triangular fibrocartilage tear

Answer 16

b. ulnar impaction syndrome

Ulnar-sided wrist pain is often caused by one of the spectrum of conditions known as impaction syndromes.

These include ulnar impaction syndrome (most common), ulnar impingement syndrome, ulnocarpal impaction syndrome secondary to non-union of the ulnar styloid process, ulnar styloid impaction syndrome and hamatolunate impingement syndrome.

Ulnar impaction syndrome is a degenerative condition secondary to excessive loading across the wrist and characteristically shows a positive ulnar variance that is accentuated in pronation and during a firm grip.

MRI is used to identify complications such as triangular fibrocartilage complex tear or bone marrow oedema.

Question 17

97) Which of the following can cause a false-negative result in performing an ultrasound scan of the shoulder for suspected rotator cuff tear?

a. rotator interval

b. musculotendinous junction

c. limited joint mobility

d. anisotropy

e. acoustic shadowing

Answer 17

c. limited joint mobility

A false-negative result in this context is failure to identify pathology and to report incorrectly the ultrasound examination as normal. Limited shoulder mobility will not permit correct positioning of the shoulder for best interrogation of the whole of each tendon and may lead to nonvisualization of a tear. Other causes of false negatives include technical factors such as using an incorrect transducer (should be at least 7.5 MHz), poor focusing and poor transducer handling. There are alsoanatomical causes, including non-diastasis of the tendon fibres, scar tissue, bursitis, tendinosis and massive tear, with complete retraction of the tendon ends preventing their visualization. Anisotropy, poor transducer positioning or misinterpretation of the rotator interval, musculotendinous junction, supraspinatus–infraspinatus interface, acoustic shadowing and fibrocartilaginous insertion can all give rise to false-positive findings.

Question 18

98) Following wrist arthrography by a single-compartment radiocarpal injection technique, contrast seen on MR arthrographic images in the midcarpal compartment can be explained by disruption of which of the following structures?

a. triangular fibrocartilage

b. lunotriquetral ligament

c. dorsal distal radioulnar ligament

d. flexor retinaculum

e. radioscapholunate ligament

Answer 18

b. lunotriquetral ligament

The two most important intercarpal ligaments are the scapholunate and lunotriquetral ligaments. These are crescent shaped with strong anterior and posterior zones and a relatively thin middle membrane.

Disruption of either of these will result in communication of the radiocarpal compartment proximally with the midcarpal compartment distally.

Contrast material seen in the distal radioulnar joint indicates disruption to the triangular fibrocartilage complex or distal radioulnar ligaments.

Some authors advocate selective midcarpal injection as superior in delineating injury to the scapholunate and lunotriquetral ligaments, and a sequential technique of three injections has also been described.

Question 19

99) A young footballer sustains a twisting injury to the right knee in training. He is able to continue practising but complains of moderate medial knee pain. The following morning he wakes with a swollen stiff joint. Radiographs show an effusion only. Subsequent MRI confirms an effusion and reveals a truncated medial meniscus with a ‘bow-tie’ configuration seen on only a single sagittal image. Sagittal sequences reveal a ‘double’ appearance of the posterior cruciate ligament. He has not had any previous surgery. What is the most likely injury or combination of injuries?

a. torn medial meniscus

b. torn medial meniscus and anterior cruciate ligament

c. torn medial meniscus and posterior cruciate ligament

d. torn anterior cruciate ligament

e. torn posterior cruciate ligament

Answer 19

a. torn medial meniscus

Truncation of a meniscus may be due to previous injury or surgical resection, but in the absence of a relevant history it suggests meniscal tear with displacement of the body of the meniscus.

On sagittal sequences, one would normally expect to see a full ‘bow-tie’-shaped meniscus on three or more contiguous images, as the meniscal body is approximately 11 mm in thickness (this of course will depend on slice thickness). Any fewer suggests a meniscal body tear with displacement of the fragment.

The fragment often flips into the intercondylar groove of the femur to lie anterior and parallel to the posterior cruciate ligament, giving the impression of two similar structures.

This injury is known as a bucket-handle tear.

Question 20

2 A 35 year old man suffers a knee injury during a football match and presents with pain, swelling, knee locking and an inability to fully extend his knee. He undergoes an MRI examination.
What is the most common site of injury?

(a) Anterior cruciate ligament

(b) Posterior cruciate ligament

(c) Anterior horn medial meniscus

(d) Posterior horn medial meniscus

(e) Anterior horn lateral meniscus

Answer 20

(d) Posterior horn medial meniscus

The symptoms described are more consistent with those of a meniscal injury, rather than a ligamentous tear. Such tears are commonest in the posterior horn of the medial meniscus.

Question 21

27 Axial MR imaging of the ankle is performed. You are asked to review a single image at the level of the tibio-talar joint. You note a tendon which is swollen and contains unusually high signal, located immediately posterior to the tendon of tibialis posterior. What is the likely diagnosis?

(a) Tendonitis of extensor hallucis longus

(b) Tendonitis of extensor digitorum longus

(c) Tendonitis of flexor hallucis longus

(d) Tendonitis of flexor digitorum longus

(e) Tendonitis of tibialis anterior

Answer 21

(d) Tendonitis of flexor digitorum longus

The flexor tendons occur in the order (from anterior to posterior): tibialis posterior, flexor digitorum longus, flexor hallucis longus – the mnemonic ‘Tom, Dick, and Harry’ aids memory.

Question 22

11 A patient presents with a painless, slow growing mass of the finger. On clinical and radiographic grounds, this is likely to be a giant cell tumour of the tendon sheath. Regarding this condition, which of the following are incorrect?

(a) The lesion is typically non-calcified

(b) The lesion is typically hypointense to muscle on T1 W

(c) Most lesions are associated with bony erosion

(d) The lesion is not usually centred on a joint

(e) The lesion is often painless

Answer 22

(c) Most lesions are associated with bony erosion

Giant cell tumours of the tendon sheath are histologically identical to pigmented villonodular synovitis. They usually occur in the hand, where they are the second most common benign tumour (the most common are ganglia). Only 10% of lesions are associated with bony erosion.

Question 23

28 A patient has lateral ankle pain and a feeling of hindfoot instability. MR imaging reveals a torn lateral collateral ligament and obliteration of the normal fat between the talus and calcaneus; no ligaments are visualised in this s’pace. What is the most likely diagnosis?

(a) Fibrous tarsal coalition

(b) Sinus tarsi syndrome

(c) Longitudinal split tears of peroneus brevis

(d) Lateral gutter syndrome

(e) Osteomyelitis

Answer 23

(b) Sinus tarsi syndrome

The sinus tarsi is the space between the talus and calcaneum that contains several ligaments conferring some hindfoot stability. In sinus tarsi syndrome there is obliteration of the normal fat and disruption of at least one of the ligaments.

Question 24

40 A 36 year old active male patient presents with medial foot pain. AP foot x-ray shows a triangular bone fragment projected adjacent to the medial aspect of the navicular bone, which is itself irregular in outline with a sclerotic rim. Subsequent MR imaging shows bone marrow oedema within the medial navicular and the adjacent bone seen on x-ray; additionally there is high signal within the posterior tibial tendon on T2W imaging.
What is the likely underlying diagnosis?

(a) Cornuate navicular bone

(b) Avulsion fracture of the medial navicular tuberosity

(c) Stress fracture of the navicular

(d) Os tibiale externum

(e) Type 2 accessory navicular bone

Answer 24

(e) Type 2 accessory navicular bone

3 types of accessory navicular bones have been described; they have a collective incidence of 4-21 %.

Type 1 (os tibiale externum) is asmall, round sesamoid bone within the posterior tibial tendon.

Type 2 is a triangular ossification centre adjacent to the navicular tuberosity and connected by a synchondrosis (which is often irregular).

Type 3 (cornuate navicular bone) describes an enlarged medial horn of the navicular.

Types 2 and 3 are associated with PTT tears, but can independently cause pain also.

Type 2 accounts for 70% of accessory navicular bones and are the dominant type in symptomatic patients.

In types 2 or 3, the PTT inserts onto the access ossicle, leading to a more prox insertion, reducing leverage of malleolus on PTT and increasing stress on tendon.

Question 25

65 An active 48 year old woman presents with pain and paresthesia between the 3rd and 4th metatarsals, which radiates to the toes. On examination, direct pressure between the metatarsal heads replicates the pain. On axial compression of the forefoot a 'click' is heard. MR shows a well demarcated 'teardrop-shaped' mass arising between the 3rd and the 4th metatarsal heads. The lesion is isointense to muscle on T1W and hypointense to fat on T2W, and enhances on T1W following i.v. gadolinium. What is the likely diagnosis? (a) Freiberg's disease (b) Morton's neuroma (c) Rheumatoid nodule (d) Schwannoma (e) Tendon sheath ganglion

Answer 25

(b) Morton's neuroma Morton's neuroma is actually a peri-neural fibrosis entrapping a plantar digital nerve. It is most commonly found in the 3rd/ 4th intermetatarsal space. The fibrous nature of the lesion accounts for the described MR findings. The 'click' which can be heard or palpated on examination is known as 'Mulder's' sign.

Question 26

19. A 50 year old woman presents with a mass on the plantar aspect of her right foot. Ultrasound reveals a small oval-shaped lesion between the plantar portions of the metatarsal heads. MRI characteristics of the lesion are low-to-intermediate signal on T1 and low signal intensity on T2. Which of the following is the most likely diagnosis? a. Lipoma b. Morton’s neuroma c. Plantar fibromatosis d. Giant cell tumour of the tendon sheath e. Ganglion cyst

Answer 26

19. b. Morton’s neuroma The description is that of a Morton’s neuroma. This occurs most commonly in the third metatarsal space and less commonly in the second space. There is often an associated metatarsal bursitis which is a high signal on STIR imaging. Ultrasound is usually the first imaging modality; squeezing the metatarsal heads together during scanning will usually make the lesion more prominent.

Question 27

@# 39. A 72 year old woman presents to her GP with pain in her right shoulder which is worse on movement. Plain films of the right shoulder show loss of subacromial space and superior subluxation of the humeral head. She is referred for an ultrasound with a suspected supraspinatus tear. Which is the best position of the arm for visualization of the free edge of the supraspinatous tendon? a. Adduction and internal rotation b. Abduction and internal rotation c. Adduction and external rotation d. Abduction and external rotation e. Flexion and internal rotation

Answer 27

39. a. Adduction and internal rotation The best position for visualising the supraspinatous tendon is with the patient’s arm in adduction and internal rotation. Often the patient may be asked to place the back of their hand onto their back, or alternatively asking them to simulate putting the hand into the back pocket of their trousers. The most medial part of the tendon when imaged transversely is the free edge – this is where the majority of supraspinatous tears occur.

Question 28

44. A 24 year old woman presents with a painless mass on the dorsal aspect of the right index finger measuring approximately 1_1 cm. MRI shows a lobulated lesion which has low signal intensity on both T1- and T2-weighted imaging. Which of the following is the most likely diagnosis? a. Haemangioma b. Lipoma c. Ganglion cyst d. Giant cell tumour of the tendon sheath e. Neurilemmoma

Answer 28

44. d. Giant cell tumour of the tendon sheath This is a benign lesion thought to represent an extra-articular form of pigmented villonodular hyperplasia. This is low signal on both T1- and T2-weighted imaging due to haemosiderin deposition. It most commonly affects the fingers and characteristically lies along a tendon sheath.

Question 29

56. A 56 year old woman who has had chronic wrist pain since a fall several months previously is referred for an MR arthrogram of her wrist with a suspected triangular fibrocartilage complex (TFCC) tear. Which of the following would be the best sequence for visualizing a TFCC tear? a. T1 axial b. T2 coronal c. Gradient echo sagittal d. T2 sagittal e. T1 sagittal

Answer 29

56. b. T2 coronal The best sequence would be a T2 or T2* image for detecting a tear. This is also a useful plane in which to assess for ulnar variance; positive ulnar variance has an association with perforations. The central portion of the articular disc is not well vascularised and therefore a tear in this portion will heal poorly. The peripheral portion, however, has been vascularised.

Question 30

57. A 64 year old woman undergoes MRI of her left knee for investigation of chronic knee pain. Which of the following would be considered an abnormal finding on MR? a. Bowing of the posterior collateral ligament on sagittal imaging b. Low signal ACL on T1-weighted imaging c. High signal around the MCL on T2* on coronal imaging d. Low signal of the menisci on both T1- and T2-weighted imaging e. Medial patellar plica

Answer 30

57. c. High signal around the MCL on T2* on coronal imaging The only abnormal finding is the presence of high signal around the MCL on T2* imaging. This would represent oedema or haemorrhage around the MCL and may be associated with a tear. Bowing of the PCL occurs when the knee is extended. A medial patellar plica is a normal finding in approximately 50% of the population. This is an embryological remnant from when the knee was divided into three compartments.

Question 31

QUESTION 15 A 70-year-old man complains of a tense painless swelling posterior to his right knee. Ultrasound demonstrates a large cyst, which communicates with the knee joint between which two structures? A Through the interval between semimembranosus and the lateral head of gastrocnemius B Through the interval between semimembranosus and the medial head of gastrocnemius C Through the interval between semimembranosus and semitendinosus D Through the interval between semitendinosus and the lateral head of gastrocne1nius E Through the interval between semitendinosus and the medial head of Gastrocnemius

Answer 31

B Through the interval between semimembranosus and the medial head of gastrocnemius

Question 32

A 30-year-old amateur footballer twists his right knee during a march, and is brought to the Emergency Medicine department with a painful swollen knee. Radiographs reveal an avulsion fracture closely related to the posterolateral tibial plateau, prompting an urgent MRI of the right knee. What are the most likely findings? A Disruption of the extensor mechanism B Rupture of the ACL C Rupture of the PCL D Tear of the medial meniscus E Tear of the lateral collateral ligament

Answer 32

B Rupture of the ACL

Question 33

QUESTION 24 Regarding MRI examination of the shoulder, what are the signal characteristics of the normal supraspinatus tendon? A High signal intensity on all sequences B High signal on Tl w, low signal on T2w C Intermediate signal on all sequences D Low signal on all sequences E Low signal on Tl w, high signal on T2w

Answer 33

D Low signal on all sequences

Question 34

@#e QUESTION 25 A 28-year-old tennis player undergoes a MR arthrogram to investigate recurrent right shoulder instability following a previous glenohumeral dislocation. The MRI reveals a tear of the anterosuperior labrum, closely related to the insertion of the biceps tendon. How are these appearances best described? A Anterior labral tear B Bankart lesion C Hill-Sachs lesion D Reverse Hill-Sachs lesion E Superior labrum from anterior to posterior (SLAP) lesion

Answer 34

E Superior labrum from anterior to posterior (SLAP) lesion

Question 35

@#e A young man undergoes an MRI of the right knee due to clinical suspicion of an acute rupture of the ACL. The ACL is indistinct, and cannot be visualised in either the coronal or sagittal plane. Which additional features would be supportive of a diagnosis of ACL rupture? A Bunching up of the PCL B Oedema within the medial collateral ligament C Posterior translation of the femur on the tibial condyles D Straightening of the patellar ligament E Tear of the medial meniscus

Answer 35

A Bunching up of the PCL

Question 36

During an MRI examination of the shoulder, a 4-cm, well-defined structure is noted within the spinoglenoid notch, exhibiting high signal on T2w and low signal on Tlw images. Which muscles should be carefully scrutinised for evidence of swelling or atrophy? A Infraspinatus and supraspinatus B Subscapularis and trapezius C Supraspinatus and subscapularis D Teres minor and infraspinatus E Trapezius and teres minor

Answer 36

A Infraspinatus and supraspinatus

Question 37

A 30-year-old man undergoes an MRI examination of his left ankle, which shows a rounded mass within the pre-Achilles fat pad, with signal characteristics identical to adjacent muscle. Which anatomical variant could best account for these appearances? A Accessory popliteus muscle B Accessory soleus muscle C Anomalous insertion of the gastrocnemius tendon D Anomalous insertion of plantaris tendon E Presence of peroneus quartus

Answer 37

B Accessory soleus muscle

Question 38

QUESTION 44 A young footballer has an MRI of the left knee following a recent injury. There is amorphous intermediate signal in the region of the anterior cruciate ligament and a bone contusion involving the articular surface of the lateral femoral condyle. In which other location is a bone contusion most likely? A The anterolateral aspect of the tibia B The anteromedial aspect of the tibia C The central articular surface of the tibia D The posterolateral aspect of the tibia E The posteromedial aspect of the tibia

Answer 38

D The posterolateral aspect of the tibia

Question 39

QUESTION 61 A 55-year-old lady, complaining of recent flattening of the longitudinal arch of the foot, is referred for an ultrasound examination of the left ankle. Which tendon should be the subject of particular scrutiny? A Achilles tendon B Flexor hallucis longus C Peroneus longus D Tibialis anterior E Tibialis posterior

Answer 39

E Tibialis posterior

Question 40

55-year-old woman undergoes arthrography to investigate a 3-month history of pain and stiffness in her left shoulder, with particular limitation of external rotation. Only a few millilitres of contrast medium could be injected into the joint, before provoking discomfort. What other finding would be supportive of the diagnosis of adhesive capsulitis? A Contrast medium opacifies the subacromial/subdeltoid bursa B Decreased resistance to contrast injection C Distended axillary recess D Lymphatic filling E Venous fllling

Answer 40

D Lymphatic filling

Question 41

@#e QUESTION 69 A 40-year-old tennis player undergoes an MRl following a 3-month history of left ankle pain. The Achilles tendon has a convex anterior margin and exhibits a small linear area of increased signal within the tendon on T2- and T2*-weighted images. What is the most likely diagnosis? A Achilles paratendonitis B Achilles tendinosis C Achilles tendinosis with complete tear D Achilles tendinosis with cystic degeneration E Achilles tendinosis with partial tear

Answer 41

E Achilles tendinosis with partial tear

Question 42

A 50-year-old man has an MRI examination of his right shoulder. Which pattern of imaging features is compatible with a partial thickness supraspinatus tear? A A gap between the distal and proximal portions of the tendon, with retraction of the proximal tendon B Areas of increased signal on Tl and T2 images C Areas of increased signal on Tl and T2 images, extending across the full thickness of the tendon D Areas of intermediate signal on Tl- and PD-weighted images, with low signal on T2w images E Low signal on all sequences

Answer 42

B Areas of increased signal on Tl and T2 images

Question 43

QUESTION 73 A 50-year-old man has an MRl of his right shoulder for chronic shoulder pain. The distal supraspinatus tendon displays intermediate signal intensity on Tl w images and low signal intensity on T2w images. What is a possible explanation for these appearances? A Chemical shift artefact B Magic angle phenomenon C Movement artefact in the frequency-encoding direction D Movement artefact in the phase-encoding direction E Susceptibility artefact from calcification

Answer 43

B Magic angle phenomenon The magic angle phenomenon refers to the increased signal observed on sequences with a short echo time (eg TI w, proton density (PD)) within tissues containing parallel unidirectional collagen fibres, when such fibres are at an angle of 55° to the main magnetic field. It is of particular relevance in shoulder MR, where it may mimic supraspinatus tendinosis.

Question 44

10. A 24-year-old male presents to the A&E department with pain and swelling of his right thumb after landing against his ski pole while practicing at the local dry ski-slope. An avulsion fracture at the base of the proximal phalanx is noted on a radiograph of the thumb. What underlying soft tissue structure has been injured to result in this fracture? A. Ulnar collateral ligament. B. Radial collateral ligament. C. Joint capsule. D. Flexor pollicis longus tendon. E. Extensor pollicis longus tendon.

Answer 44

10. A. Ulnar collateral ligament. The history and radiographic findings are typical of gamekeeper’s thumb, which is an injury to the ulnar collateral ligament at its insertion site into the proximal phalanx of the thumb. This injury usually requires internal fixation to secure the ligament. Radial collateral ligament injuries of the thumb lead to painful deformity and articular degeneration. Rupture of flexor pollicis longus results in loss of active flexion of the thumb. The thumb remains in flexion with rupture of extensor pollicis longus. Thumb tendon injuries are typically seen in RA due to their susceptibility to synovitis.

Question 45

9. A 26-year-old woman presents with a 2-year history of an enlarging soft tissue mass in her left thumb adjacent to the interphalangeal joint. An x-ray of the left thumb shows a soft tissue swelling with a large well-defined erosion seen affecting the distal metaphysis of the proximal phalanx. There is no soft tissue calcification or evidence of arthropathy at the interphalangeal joint. A subsequent MRI scan shows a 3.5-cm well-defined soft-tissue mass, which is low signal on T1WI and enhances post administration of gadolinium. The lesion is low signal on T2WI & gradient echo (GE) imaging. What is the likely diagnosis? A. Ganglion cyst. B. Peripheral nerve sheath tumour. C. Lipoma. D. GCT of the tendon sheath. E. Soft tissue haemangioma.

Answer 45

9. D. GCT of the tendon sheath. A GCT of the tendon sheath is a nodular form of PVNS. These tumours are intimately associated with a tendon sheath and are most commonly located in the hand. They usually manifest as a small slow-growing mass, with or without pain. Radiographs may show no abnormality or non-aggressive remodelling of the adjacent bone. These lesions are typically hypo- or isointense to muscle on T1WI and T2WI, owing to abundant collagen and haemosiderin, often with enhancement. This is similar to the findings of diffuse intra-articular PVNS, when the extent of haemosiderin deposition may cause hypointense nodules on T2WI and blooming artifact on gradient echo (GE) sequences. It must be stated that the degree of haemosiderin content may not always be enough to cause marked hypointensity on T2WI in GCT of the tendon sheath. A ganglion cyst could occur in this location and be related to a tendon sheath, but on MRI it is typically hyperintense on T2WI secondary to its fluid component. There may be thin rim enhancement of the wall post administration of gadolinium. Peripheral nerve sheath tumours are typically hyperintense on T2WI with variable contrast enhancement. Lipomas are similar in signal characteristic to subcutaneous fat on MRI, i.e. hyperintense on both T1WI and T2WI. A soft-tissue haemangioma may contain phleboliths on plain radiographic imaging. On MRI, haemangiomas may be well circumscribed or have poorly defined margins, with varying amounts of increased T1WI signal owing to either reactive fat overgrowth or haemorrhage. Areas of slow flow are typically hyperintense on T2WI, while rapid flow can demonstrate a signal void on images obtained with a non-flow-sensitive sequence.

Question 46

20. An 18-year-old motorcyclist is involved in an RTA in which he was dragged by the colliding car. He is noted to have pain in his right shoulder and neck with associated paraesthesia. An MRI is requested, suspecting brachial plexus injury. What finding is most suggestive of nerve root avulsion? A. Pseudomeningocoele. B. Intradural nerve root enhancement. C. Spinal cord T2WI hyperintensity. D. T2WI hyperintensity within the paraspinal muscles. E. Thickening of the brachial plexus.

Answer 46

20. A. Pseudomeningocoele. Imaging in brachial plexus injury via CT myelography and/or MRI helps to determine whether the injury is pre- or postganglionic, which has therapeutic implications. Signal intensity changes in the spinal cord are seen in only 20% of preganglionic injuries and lack specificity. Intradural nerve root enhancement suggests functional impairment of the nerve roots, despite morphological continuity. This is not a common finding. T2WI signal intensity changes within the paraspinal muscles are observed in nerve root avulsion, but this is less accurate than enhancement on T1WI post contrast. Abnormal enhancement within the multifidus muscle is the most accurate of all paraspinal muscle findings since it is innervated by a single nerve root. Thickening of the brachial plexus, secondary to oedema and fibrosis, is seen in postganglionic injury. Traumatic pseudomeningocoele, although not pathognomonic, is the most valuable sign of a preganglionic lesion.

Question 47

21. A 54-year-old man presents with a swelling in his right popliteal fossa. A Baker’s cyst is suspected clinically and an ultrasound scan is arranged. This confirms a complex cystic structure with debris. To help confirm this is a Baker’s cyst, you look for a communication of this cyst with fluid at the posterior aspect of the knee joint between which two tendons? A. Semitendinosis and lateral head of gastrocnemius. B. Semitendinosis and medial head of gastrocnemius. C. Semitendinosis and semimembranosis. D. Medial and lateral heads of gastrocnemius. E. Lateral head of gastrocnemius and semimembranosis. F. Medial head of gastrocnemius and semimembranosis

Answer 47

21. F. Medial head of gastrocnemius and semimembranosis. Identification of anechoic cysts communicating with fluid between the semimembranosis and gastrocnemius tendons confirms the diagnosis of Baker’s cyst. It is important to perform further imaging if the mass in the posterior compartment lacks signs of communication with fluid between the semimembranosis and medial gastrocnemius tendons. If this is the case, there are other possibilities for the lesion, including meniscal cyst or even a myxoid sarcoma.

Question 48

30 A 56-year-old plumber complained of long-standing bilateral pain anterior to his knees. There was no history of trauma although he reports spending two hours a day kneeling. AP, lateral and skyline radiographs of both knees showed soft-tissue swelling anterior to the patella but no bony abnormality. What is the most appropriate further management? a 1.5T MRI b Unenhanced CT c 3.OT MRI d Arthroscopy e No further imaging - rest and occupational modification alone are adequate

Answer 48

30 Answer E: No further imaging - rest and occupational modification alone are adequate The history is highly suggestive of pre-patellar bursitis. Hence no further imaging is required. Removal of provocative factors and rest are normally adequate. Use of kneepads may also be of benefit. Complications such as secondary infection may necessitate antibiotic therapy

Question 49

38. A 39-year-old man presents with a gradually enlarging swelling in the upper lateral aspect of the right calf. He is also experiencing some numbness affecting the dorsum of his right foot. An ultrasound scan and subsequently an MRI scan demonstrate a well-defined, thinly septated cystic lesion intimately related to the proximal tibio-fibular joint and extending into the adjacent soft tissues. It measures approximately 4cm in maximum diameter. There is no enhancement of the soft tissue component post injection of gadolinium. What is the most likely diagnosis? A. Parameniscal cyst. B. Bursitis. C. Focal tenosynovitis. D. Ganglion cyst. E. Chronic seroma.

Answer 49

38. D. Ganglion cyst. What is being described is a ganglion cyst adjacent to the proximal tibiofibular joint that is causing a common peroneal nerve palsy. This is a well-recognized entity. Ganglion cysts can be uni- or multilocular. They occur predominately in peri-articular locations and may arise from tendon sheaths, joint capsules, bursae, or ligaments. Although parameniscal cysts can extend inferiorly from the lateral knee joint margin, they typically show a communication with a meniscal tear. This is not described in the radiological findings and they are not typically centred at the level of the proximal tibiofibular joint. Bursal distension can cause a multiloculated fluid collection. It can occur in typical locations around the knee joint, but not usually adjacent to the proximal tibiofibular joint. Examples include pes anserine bursitis, semi-membranosis-tibial collateral ligament bursitis, and pre-, supra-, and infrapatellar bursitis. Focal tenosynovitis and chronic seroma do not particularly fit with the clinical and radiological findings.

Question 50

41. A 15-year-old boy presents with a history of knee pain. Plain radiographs demonstrate calcification at the patellar tendon attachment to the inferior pole of the patella. MRI of the knee demonstrates oedema at the patellar attachment of the patellar tendon. What is the diagnosis? A. Osgood–Schlatter disease. B. Patellar sleeve avulsion. C. Sinding–Larsen–Johansson syndrome. D. Complete rupture of patellar tendon. E. Partial tear of quadriceps tendon.

Answer 50

41. C. Sinding–Larsen–Johansson syndrome. This is a traction tendonitis occurring at the attachment of the patellar tendon to the inferior pole of the patella. Repetitive stress/microtrauma at the tendinous attachment results in calcification or ossification of the tendon on the plain film. MRI demonstrates oedema within the tendon and at the inferior pole of the patella. Similar changes occurring at the tibial attachment of the patellar tendon is called Osgood– Schlatter disease. Patellar sleeve fracture is a unique paediatric injury in which the cartilage at the inferior pole of the patella is avulsed along with a small bone fragment. The quadriceps tendon inserts into the superior pole of the patella, therefore a partial tear produces oedema at the superior pole of the patella.

Question 51

46. A 40-year-old female presents with a small lump in her foot. An MRI of the foot demonstrates a small soft tissue mass, which has homogenous low signal on T1WI and T2WI. The mass enhances with gadolinium. What is the most likely diagnosis? A. Morton’s neuroma. B. Lipoma. C. Ganglion cyst. D. Plantar fibromatosis. E. Hemangioma.

Answer 51

46. D. Plantar fibromatosis. Fibrous masses containing mature collagen are homogenously low in signal on T1WI and T2WI sequences, and demonstrate enhancement with gadolinium. Common fibrous masses in the foot are plantar fibromatosis and fibroma of the tendon sheath. Morton’s neuroma is typically intermediate in signal on T1WI and low on T2WI with variable contrast enhancement. Lipomas follow fat signal intensity. They are high on T1WI and T2WI, and low on fat-suppressed sequences. A ganglion cyst follows fluid signal. Ganglion cysts are low on T1WI and high on T2WI with rim enhancement. Haemangiomas are of mixed signal on T1WI and T2WI due to the presence of vessels, fat, and fibrous tissue. The vascular portions of hemangiomas enhance homogenously

Question 52

45. A 56-year-old woman is referred for MR arthrography of her right shoulder for query rotator cuff tear. You are asked to explain the procedure to a group of medical students attached to the department. What is the advantage of using a fat-suppressed T1WI sequence? A. Differentiating partial from full thickness tear. B. Identify bursal fluid collections. C. Differentiating inadvertent air injection from intra-articular loose body. D. Diagnosing capsular laxity. E. Detecting incidental bone marrow lesions.

Answer 52

45. A. Differentiating partial from full thickness tear. MR arthrography is most helpful for outlining labral-ligamentous abnormalities in the shoulder and distinguishing partial thickness from full thickness tears in the rotator cuff. The technique involves injection of diluted gadolinium mixed with iodinated contrast, which allows fluoroscopic confirmation of intra-articular needle placement. Partial and full thickness tears may not be distinguishable on standard T1WI because fat and gadolinium have similar signal intensities. This is especially the case when cuff tendons show contrast solution extending to the bursal surface but not definitively through it. This problem can be overcome with use of fat suppression. MR arthrography should include a T2WI sequence to identify bursal fluid collections and tears. T2WI is also helpful in characterizing incidental bone marrow lesions. Inadvertent injection of gas may lead to a false-positive diagnosis of intra-articular loose bodies, but gas bubbles will rise to non-dependent regions, whereas loose bodies will gravitate to dependent locations. No accurate MR imaging criteria are recognized in the diagnosis of capsular laxity.

Question 53

65. A 24-year-old man undergoes acute trauma to his right knee playing football. He is unable to weight bear. An x-ray of the right knee is performed and this demonstrates a large joint effusion and a small, avulsed elliptical fragment of bone at the medial aspect of the proximal tibia at the joint margin. Which knee structure is likely to be deranged in association with this injury at a subsequent MRI? A. Anterior cruciate ligament. B. Posterior cruciate ligament. C. Lateral collateral ligament. D. Patellar tendon. E. Lateral meniscus.

Answer 53

65. B. Posterior cruciate ligament. The avulsion injury described is a reverse Segond fracture. This injury is known to be associated with both mid-substance tears of the posterior cruciate ligament and avulsions of the PCL from the posterior tibial plateau. They can also be associated with medial meniscus injuries. They are not to be confused with a Segond fracture, which is a small elliptical fragment of bone avulsed from the lateral tibial plateau at the lateral joint margin, best seen on the AP view of the knee. They have a strong association with tears of the anterior cruciate ligament and also meniscal tears.

Question 54

8 A 38-year-old man presented with a lump on the dorsal aspect of his hand that moved with the tendons on flexion and extension of his fingers. An X-ray and then MRI of this area were performed. What imaging findings might be expected? a A dense calcified mass b Low signal on T2-weighted images C High signal on T1-weighted images d No internal septations e Periosteal new bone formation

Answer 54

8 Answer E: Periosteal new bone formation A soft-tissue ganglion is a cystic tumour-like lesion usually attached to a tendon sheath. It can present with a painful or a painless lump, most commonly over the hand, wrist or foot. The T1-weighted imaging characteristics are typically low to intermediate signal. Other features include: communication with joint, high signal on T2, internal septations, periosteal new bone formation. The natural history is spontaneous resolution although steroid injections may improve symptoms. Other types of ganglion include intraosseous and periosteal.

Question 55

19 A 19-year-old woman was investigated for foot stiffness and was found to have a tarsal coalition. What type of coalition is she most likely to have? a Calcaneocuboid b Calcaneonavicular C Cubonavicular d Cuneometatarsal e Talonavicular

Answer 55

19 Answer B: Calcaneonavicular Calcaneonavicular and talocalcaneal coalitions each account for approximately 45%.

Question 56

31 A footballer was tackled from behind while playing in his local park. He felt a sudden `pop' and his knee became swollen and unstable. While waiting for an MRI scan he noticed his leg pivoted outward about his knee as he walked. What are the most likely findings on the MRI scan? a MCL rupture due to valgus stress b LCL rupture due to direct blow C MCL rupture due to varus stress d LCL rupture due to varus stress e MCL rupture due direct blow

Answer 56

31 Answer A: MCL rupture due to valgus stress Isolated medial collateral ligament (MCL) injuries usually result from a valgus stress without a rotary component. They are more commonly associated with other injuries (e.g. ACL and medial meniscal tears) but isolated MCL tears are sometimes seen.

Question 57

27 A 55-year-old lady with rheumatoid arthritis presented to the Emergency Department with sudden onset pain and swelling on the medial side of her left foot. Clinical examination revealed marked weakness of plantar flexion and inversion on the left, but normal power on the right. What tendon is most likely to have been injured? a Extensor digitorum b Peroneus tertius c Tibialis anterior d Flexor hallucis longus e Tibialis posterior

Answer 57

27 Answer E: Tibialis posterior Spontaneous tibialis posterior rupture tends to occur in those with underlying pathology, especially rheumatoid arthritis. The typical presentation is in a woman of 40-60 years and the presenting signsand symptoms are pain, difficulty walking, and swelling along the medial malleolus and the arch of the foot. Traumatic rupture is more common in a younger age group and is not normally secondary to another pathology.

Question 58

69 A 70-year-old man presented with shoulder pain and was assessed with ultrasound. He was found to have torn part of his rotator cuff. Which muscle was most likely to have been damaged? a Deltoid b Infraspinatous C Subscapularis d Supraspinatous e Teres minor

Answer 58

69 Answer D: Supraspinatus Deltoid is not part of the rotator cuff. Supraspinatus is most frequently injured at or close to its insertion into the humerus.

Question 59

19 An 18-year-old boy presented with foot pain and was diagnosed with a talocalcaneal coalition. What sort of coalition is most likely? a Bony union across anterior facet b Fibrous coalition across anterior facet c Bony union across middle facet d Fibrous coalition across middle facet e Fibrous union across posterior facet

Answer 59

19 Answer C: Bony union across middle facet Tarsal coalition is an abnormal fibrous, cartilaginous or osseous fusion of two or more tarsal bones. It affects 1-2 % of the population and is thought to be present at birth with a fibrous band, which later ossifies leading to diagnosis in late teens/ early adulthood. It is generally an incidental finding, but can be associated with hindfoot pain. MR can distinguish between cartilaginous and bony unions.

Question 60

2. A 55-year-old housewife attended her GP with a gradually growing soft tissue swelling on the dorsum of her foot for 1 year. The swelling is tender and mobile in a side-to-side direction. Ultrasound shows a 4 cm hypervascular lesion on the dorsum of the foot between the tendons of extensor hallucis and extensor digitorum. MRI shows that the lesion is bright on STIR and intermediate signal on T1. It shows homogenous enhancement with gadolinium. What is the most likely diagnosis? (a) Soft tissue ganglion (b) Peripheral nerve sheath tumour (c) Lipoma (d) Liposarcoma (e) Callus from a previous fracture.

Answer 60

2. (b) Peripheral nerve sheath tumour The location and direction of mobility along with typical MRI features clinch the diagnosis of peripheral nerve sheath tumour. Ganglion, lipoma and callous would not appear as hypervascular lesions. Liposarcoma can show increased vascularity but demonstrates heterogenous enhancement on MRI.

Question 61

16. A 35-year-old man presents with knee pain. MRI shows a 1.5 cm homogenous ovoid lesion which pushes the medial collateral ligament. It returns high signal on STIR and T2 images. There is also a horizontal cleavage tear of the posterior horn of the medial meniscus and a radial tear of the lateral meniscus. The most likely cause of the lesion is? (a) Dissecting bakers cyst (b) Ganglion (c) Pes anserinus bursa (d) Haemangioma (e) Meniscal cyst

Answer 61

16. (e) Meniscal cyst Meniscal cysts are very commonly associated with meniscal tears. MRI shows classic features of the cyst, related to the parameniscal structures. Lateral meniscal cysts tend to be smaller but are often more symptomatic than cysts in the medial counterparts.

Question 62

19. A 35-year-old woman with moderate hallux valgus deformity, complains of pain between the second and third toes of left foot. Ultrasound shows a 1 cm hypoechoic lesion in the region of the distal intermetatarsal heads of the second and third toes. This is non-compressible and shows no significant vascularity. The most likely diagnosis is? (a) Bursitis (b) Morton’s neuroma (c) Ganglion from metatarsophalangeal joint (d) Tenosynovitis from the flexor tendons (e) Synovial sarcoma

Answer 62

19. (b) Morton’s neuroma This is the typical ultrasound appearance of a Morton’s neuroma. Treatment is conservative or surgical removal. On MRI the lesion appears as intermediate signal intensity on T1 and T2. Bursitis is compressible on ultrasound probe pressure.

Question 63

29 A 48-year-old female complained of pain in the ulnar aspect of her wrist with no specific antecedent history. Examination did not elicit any positive findings and she was referred for an MRI of her wrist. The only significant finding was a linear band of high signal in a structure just distal to the ulnar styloid that was otherwise of uniformly low signal on both Ti- and T2 - weighted images. What structure is most likely to have been damaged? a Triquetral bone b Triangular fibrocartilage c Extensor carpi ulnaris tendon sheath d Luno-triquetral ligament e Proximal surface of lunate bone

Answer 63

29 Answer B: Triangular fibrocartilage Injuries to the TFC are a frequent cause of ulnar-sided wrist pain. The ulnar side of the wrist is supported by the TFC, which articulates with the Innate and triquetral distally. Tears are most commonly associated with a positive ulnar variance but may occur as a result of direct trauma; for example forced ulnar deviation on hitting a ball with a cricket bat. The extensor carpi ulnaris tendon sheath, dorsal and volar radioulnar ligaments and ulnocarpal ligaments are all part of the TFC complex. However, it is the TFC proper (articular disc) that is the most commonly injured structure in the complex.

Question 64

30. A 51-year-old man with a palpable nodule on the planter aspect of the foot. Ultrasound shows a 2 cm, vascular and hypoechoic lesion within the mid part of the plantar fascia. The most likely diagnosis is? (a) Plantar lipoma (b) Plantar fibromatosis (c) Ganglion cyst (d) Accessory muscle (e) Haemangioma

Answer 64

30. (b) Plantar fibromatosis This presents as nodular thickening in the plantar fascia. There can be single or multiple lesions. On MRI, the lesion is low signal on T1 and mild hyperintensity on T2, and the nodule enhances with gadolinium.

Question 65

36. A 20-year-old football player presents after injuring his right knee in a tackle. Plain radiographs show fracture of the tibial spine with lipohaemarthrosis. What structure is attached to the medial part of the anterior tibial spine? (a) Anterior cruciate ligament (b) Posterior cruciate ligament (c) Medial collateral ligament (d) Lateral collateral ligament (e) Medial meniscus

Answer 65

36. (a) Anterior cruciate ligament The anterior cruciate ligament is attached to the medial part of the tibial spine.

Question 66

46. A 28 year old long-distance runner is to undergo MR arthrography of the hip joint for a suspected labral tear. Which of the following statements is correct regarding MR arthrography? a. A solution of 20mmol/L gadopentetate dimeglumine is injected into the hip joint under fluoroscopic guidance b. Patients with developmental dysplasia of the hip are at increased risk of labral tears c. A communication between the joint capsule and the iliopsoas bursa is always pathological d. T2-weighted imaging is used to visualise the high signal of the gadopentetate dimeglumine solution e. The normal labrum has uniformly high signal on T1-weighted imaging

Answer 66

46. b. Patients with developmental dysplasia of the hip are at increased risk of labral tears The increased risk of labral tears in developmental dysplasia is due to the increased stress placed upon the acetabular rim and labrum. A communication between the joint capsule and iliopsoas bursa has been described as a normal finding in 10–15% of patients. A dilute solution of 0.2mmol/L gadopentetate dimeglumine solution would usually be used for arthrography. A normal labrum has uniformly low signal on T1-weighted imaging with slightly increased signal on gradient echo imaging. Appearances on T2-weighted imaging can be more variable.

Question 67

61 A 23-year-old man was investigated with an MRI scan for knee symptoms following an injury playing football four weeks before. On the sagittal images the posterior cruciate ligament was intact but followed an obviously curved course. What underlying injury is likely? a None - normal variant b Anterior cruciate ligament tear C Patella tendon tear d Lateral collateral ligament tear e Medial collateral ligament tear

Answer 67

61 Answer B: Anterior cruciate ligament tear The PCL is bowed due to posterior translation of the femur on the tibia. There is very often an associated meniscal tear.

Question 68

4. Which of the following are correct regarding popliteal (Baker’s) cysts: (T/F) (a) Are commonly associated with meniscal pathology in adults. (b) Are frequently associated with osteoarthritis and rheumatoid arthritis in adults. (c) Ultrasound can differentiate Baker’s cysts from popliteal aneurysms and ganglion cysts. (d) Typically extends posteriorly between the tendons of semimembranosus and the medial head of gastrocnemius. (e) Calcified loose bodies are a recognized complication.

Answer 68

Answer: (a) Correct (b) Correct (c) Correct (d) Correct (e) Correct Explanation: Popliteal cysts are fluid filled synovial lined bursa in the popliteal fossa communication with the knee joint. They are generally located at or below the joint line. Majority of them are incidental findings. Acute rupture of Baker’s cyst resembles DVT in clinical presentation.

Question 69

22. Which of the following are correct regarding anatomy of the knee joint (T/F) (a) The popliteus muscles tendon passes through a portion of the posterior horn of the lateral meniscus. (b) The medial and lateral collateral ligaments are best assessed on sagittal MRI imaging of the knee (c) The normal medial meniscus is seen as low signal on T1W spine echo and high signal on T2W spine echo MRI images (d) The posterior cruciate ligament is attached to the inner aspect of the medial femoral condyle. (e) The commonest site of meniscal injury is the posterior horn of the lateral meniscus.

Answer 69

Answers: (a) Correct (b) Not correct (c) Not correct (d) Correct (e) Not correct Explanation: Both collateral ligaments are best assessed on coronal images. Normal medial meniscus shows low signal on T1 and T2 images. Posterior horn of medial meniscus is most common site for meniscal injury.

Question 70

30. Which of the following are correct regarding morton neuroma: (T/F) (a) Is asymptomatic (b) On US , has appearance of an ovoid hypoechoic mass orientated to the long axis of the metatarsal bones (c) Is typically found in the 4th inter-metatarsal space (d) Is of high signal on T2W MRI (e) Has a high malignant potential

Answer 70

Answers: (a) Not correct (b) Not correct (c) Not correct (d) Not correct (e) Not correct Explanation: Morton neuroma is a benign condition representing perineural fibrosis, likely due to chronic nerve entrapment by inter-metatarsal ligaments. It is most commonly found in 3rd inter-metatarsal space presenting with burning/ electric forefoot pain. On ultrasound it appears as a round to oval hypoechoic mass and on MRI as a low signal mass lesion on T1WI and T2WI with intense post contrast enhancement.