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Explain each question and explain further respectively
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Finding Sources
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I now have enough to produce a thorough, well-organized answer for all the questions across the 9 images. Here is the complete explanation for every question:
KMTC Radiology / Orthopaedics MCQ Paper - Full Explanations
SECTION A: MULTIPLE CHOICE QUESTIONS
Q1. The main source of unnecessary irradiation to patients - Which one is NOT?
Answer: d) MRI examination
MRI uses powerful magnetic fields and radio waves - it produces NO ionizing radiation at all. The three options that DO cause unnecessary radiation exposure are: multiple chest x-rays taken over a lifetime, repeated x-rays for the same condition, and x-rays taken for fractures. Each conventional x-ray, CT, fluoroscopy, and nuclear medicine scan delivers ionizing radiation. MRI is completely free of ionizing radiation, which is why it is the correct "NOT" answer here.
Q2. The main radiological method of liver examination in children
Answer: a) Ultrasound
Ultrasound is the first-line imaging method for the liver in children because it:
- Uses no ionizing radiation (safe for pediatric patients)
- Is non-invasive and painless
- The liver is a superficial, large organ easily accessed by ultrasound
- Readily available and inexpensive
Angiography is invasive. CT/MRI deliver radiation or require sedation. Radionuclide imaging delivers significant radiation. Ultrasound is always the starting point in pediatric hepatic assessment.
Q3. Rheumatoid arthritis primarily involves
Answer: c) Synovial membrane
Rheumatoid arthritis (RA) is a systemic autoimmune disease that targets the synovial membrane (synovium) first. The synovium becomes inflamed (synovitis) and produces a destructive proliferating tissue called pannus, which then erodes the articular cartilage and underlying bone. Unlike osteoarthritis which primarily destroys articular cartilage, RA starts in the synovium. This is why x-ray findings of RA include periarticular osteoporosis, joint space narrowing (from cartilage loss), and bony erosions - all secondary to primary synovial inflammation.
Q4. The following when seen in a radiograph means R or L
Answer: c) R for Right, L for Left
On every radiograph, the letters "R" and "L" are lead markers placed on the cassette or detector before exposure to indicate the patient's right and left sides respectively. This is a universal radiographic convention. "R" = patient's Right side, "L" = patient's Left side. These markers are legally and clinically mandatory - confusing left and right could lead to wrong-side surgery.
Q5. The following does NOT use ionizing radiation
Answer: b) Ultrasound
- CT scan - uses X-rays (ionizing radiation)
- Ultrasound - uses HIGH-FREQUENCY SOUND WAVES (no ionizing radiation)
- OPG (Orthopantomogram/dental panoramic x-ray) - uses X-rays
- X-ray - uses ionizing radiation
Ultrasound is the only modality here that is completely radiation-free. MRI also uses no ionizing radiation but is not listed.
Q6. Spiral fracture is due to
(Options visible are a) Blunt trauma, b) Axial compression, c) Twist - answer continues on next page)
Answer: c) Twist (Torsion/Rotational force)
A spiral fracture results from a twisting/rotational force applied to a bone. The fracture line spirals around the bone shaft like a corkscrew. Classic examples: a rugby player whose foot is planted and the body rotates, fracturing the tibia. In adults, spiral fractures of long bones (especially humerus, tibia) are common in non-accidental injury investigations in children, as they suggest twisting of a limb. Blunt trauma causes transverse fractures; axial compression causes burst/impaction fractures.
Q7. Fracture may appear in the radiograph EXCEPT
Answer: d) Continuous trabeculae line
Fractures are visible on x-ray as DISRUPTIONS of normal bone architecture. The expected radiographic signs include:
- a) Loss of continuity of the cortex - YES, cortex breaks
- b) Dark line traversing the bone - YES, lucent fracture line
- c) Dense/sclerotic line if fracture ends overlap (impacted fracture) - YES
A "continuous trabeculae line" means the normal trabecular pattern is uninterrupted - this indicates intact bone with NO fracture. If trabeculae cross the fracture site continuously, there is no fracture. So this is the answer - it represents the ABSENCE of a fracture.
Q8. The meaning of the 10-day rule in radiation protection
Answer: c) Women of childbearing age should be taken an x-ray if possible within the first 10 days after the first day of menstruation
The 10-day rule (also called the "10-day rule for women") was a radiation protection guideline designed to protect a potentially early and unknown pregnancy. During the first 10 days following the onset of menstruation, the woman is unlikely to be pregnant (ovulation and potential fertilization has not yet occurred). Therefore, elective abdominal/pelvic x-rays should be scheduled within this 10-day window. This minimizes the risk of irradiating an early embryo. Note: this rule has largely been replaced by modern "if in doubt, ask about pregnancy" protocols, but it remains a standard exam topic.
Q9. Which is NOT a way to minimize radiation dose received by patients and staff
Answer: c) To increase the dose to get good quality x-ray images
Radiation protection follows the ALARA principle - As Low As Reasonably Achievable. All legitimate methods to minimize dose include:
- a) Reducing gonad dose to the general population - YES, use gonad shielding
- b) Protecting radiosensitive tissues - YES
- d) Ensuring staff receive low levels via distance, shielding, monitoring - YES
Option c - "increasing the dose to get better quality images" - is NOT a dose-reduction strategy. While high-quality images are important, you achieve quality through technique optimization, not by just increasing dose. Modern digital systems can produce excellent images at low dose.
Q10. What tumour has a similar radiological picture as osteomyelitis?
Answer: b) Ewing's tumour
Ewing's sarcoma is notorious for mimicking osteomyelitis radiologically AND clinically. Both show:
- Periosteal reaction ("onion-skin" periosteal layering in Ewing's)
- Bone destruction
- Soft tissue mass
- Fever, raised ESR, raised WBC (in osteomyelitis AND Ewing's)
- Permeative bone destruction pattern
This is a classic "great mimicker" trap in radiology. Ewing's sarcoma is often biopsied after initially being treated as osteomyelitis with no response. The onion-skin periosteal reaction is characteristic of Ewing's but can also be seen in osteomyelitis.
Q11. The radiological picture of bone destruction in osteomyelitis occurs
Answer: d) In the second week of the disease
This is a critical radiological principle: plain x-ray changes in acute osteomyelitis are DELAYED. X-ray appears normal for the first 7-10 days because:
- Bone destruction only becomes visible when >30-50% of bone mineral content is lost
- This takes approximately 10-14 days (second week) from onset
- Early disease (first hours, first day, first few days) shows NO x-ray changes
Early diagnosis of acute osteomyelitis uses MRI (changes visible within 24-48 hours) or bone scintigraphy. The "second week" rule is the key teaching point.
Q12. Cartilages as seen on ultrasound
Answer: a) Are visible
Unlike conventional x-rays (where cartilage is radiolucent/invisible), ultrasound can visualize cartilage directly. Hyaline articular cartilage appears as a smooth, anechoic (dark) layer overlying the bone. This is one of ultrasound's key advantages over x-ray in joint assessment. Cartilage is NOT invisible on US, NOT hidden by subdermal fat, and IS differentiated from bone (bone surface shows a bright hyperechoic line with acoustic shadowing beneath, while cartilage is dark and uniform).
Q13. The most specific radiological feature of CHRONIC osteomyelitis
Answer: b) Sequestrum
A sequestrum is a fragment of dead (necrotic) bone that has become separated from living bone. It is the PATHOGNOMONIC (most specific) feature of chronic osteomyelitis. It appears as a dense, sclerotic fragment within a radiolucent cavity (involucrum).
- Osteophytes = osteoarthritis
- Generalized sclerosis = seen in many conditions
- Linear periostitis = seen in both acute and chronic infection
The sequestrum-involucrum complex is unique to chronic suppurative osteomyelitis.
Q14. Which is NOT TRUE regarding radiological densities
Answer: b) Metal is seen as dark image
Standard radiological densities from darkest to brightest:
- Air/Gas - darkest (black)
- Fat - dark grey
- Soft tissue/Water - grey
- Bone/Calcium - white
- Metal - BRIGHTEST WHITE (most dense)
Metal (surgical implants, bullets, foreign bodies) appears as the brightest/most opaque (white) structure on x-ray, NOT dark. Option b is therefore FALSE/NOT TRUE.
Q15. Which is NOT TRUE on radiological densities
Answer: c) Osteoporotic bone lesion will show increased density on X-ray
Osteoporosis means DECREASED bone mineral density. On x-ray, osteoporotic bones appear MORE RADIOLUCENT (darker/less dense), not increased density. The bones look "washed out." This is the false statement.
- a) Calcification in tendons/vessels increases soft tissue density - TRUE
- b) Sclerotic lesions show increased density - TRUE
- d) Calcified cartilage/menisci cause dense lines in joint space - TRUE
Q16. Radiological examination of shoulder trauma - EXCEPT which view?
Answer: d) Superior view
Standard shoulder trauma views include:
- AP external rotation view - standard
- AP internal rotation view - standard
- Axillary view - essential to detect posterior dislocations
- Grashey view (true AP of glenohumeral joint) - standard
There is NO standard "superior view" used in shoulder trauma radiology. The other four are all part of the standard shoulder trauma series.
Q17. Which is NOT a characteristic of a good X-ray
Answer: c) It should be under-penetrated
Characteristics of a good (diagnostic quality) radiograph:
- a) At least two views required - TRUE (one view is never sufficient)
- b) Entire anatomical area should be included - TRUE
- d) Nature of soft tissue may speak for occult fractures - TRUE (soft tissue swelling can indicate hidden fractures)
Under-penetration (too little radiation) produces a too-light/pale image where bone details are obscured. A good x-ray should be properly penetrated - neither under- nor over-penetrated.
Q18. Which is NOT a cause of generalized increased bone density on X-ray?
Answer: c) Osteoporosis
Causes of INCREASED bone density (sclerosis/osteosclerosis) on x-ray:
- Fluorosis - causes dense bones (skeletal fluorosis)
- Myelosclerosis - bone marrow replaced by fibrous tissue, leading to dense bone
- Metastatic bone tumours - prostate, breast mets can be sclerotic
Osteoporosis = DECREASED bone density (bones appear darker/more radiolucent). It is the exact opposite - a cause of REDUCED density, not increased. So osteoporosis is the "NOT" answer.
Q19. Which is NOT true regarding X-rays as used in traumatology?
Answer: a) At least one view should be taken
The rule in traumatology is "two views at 90° to each other are MINIMUM." A single view is grossly inadequate because:
- A fracture may only be visible in one plane
- Displacement/angulation cannot be assessed in one view
- The standard is TWO views (e.g., AP + Lateral)
Options b, c, d are all correct:
- Both joints above and below the fracture must be included - TRUE
- X-ray of both limbs may be needed (especially in children, for comparison) - TRUE
- X-rays taken on two different occasions to ascertain fracture (stress fractures may not be initially visible) - TRUE
Q20. TRUE regarding callus formation in fracture healing
Answer: a) Callus formation tends to be large when there is much periosteal stripping
Periosteum is the primary source of the osteogenic cells that form callus. When the periosteum is stripped or damaged extensively (e.g., by high-energy injury or surgical dissection), the osteogenic response is vigorous and the external callus is LARGE. This seems counterintuitive but more periosteal disruption stimulates more reparative callus formation.
The other options are false:
- b) Small haematoma = small callus (FALSE - large haematoma = more callus)
- c) Marked displacement = more callus (TRUE, but the statement is already answered by a)
- d) Rigid fixation in close apposition = LESS callus (primary/direct bone healing without visible callus)
Q21. NOT TRUE regarding fracture lines as seen in X-rays
Answer: a) Comminuted fractures are fractures with one fragment
Comminuted fractures have THREE OR MORE fragments (the bone is shattered into multiple pieces). The word "comminuted" comes from the Latin for "broken into many small pieces." A fracture with only one fragment would be a simple/closed fracture. The others are correct:
- b) Fracture pattern indicates causative force - TRUE (spiral = torsion, transverse = direct blow)
- c) Greenstick = incomplete break in resilient children's bones - TRUE
- d) Impacted = fragments driven into each other with no movement - TRUE
Q22. NOT TRUE on rate of bone union as seen in X-rays
Answer: c) Age has a far smaller effect upon the rate of union in adults
In fact, age has a SIGNIFICANT effect on union. Children heal much faster than adults. The rate of healing progressively slows with age, and elderly patients take much longer to unite than young adults. So option c - saying age has a "far smaller" effect - is FALSE.
True statements:
- a) Callus visible on X-ray within 2 weeks in young children - TRUE
- b) Union is slower in older children than younger ones - TRUE
- d) Hard cortical bone takes longer to heal than cancellous bone - TRUE (cortical/diaphyseal fractures take longer than metaphyseal/cancellous fractures)
Q23. NOT a cause of pathological fractures
Answer: b) Fall on outstretched hand
A pathological fracture is one that occurs in abnormal/diseased bone - it breaks under a force that would NOT fracture normal bone. Causes include:
- Pyogenic osteomyelitis - weakens bone
- Bone tumours - primary or metastatic destroy bone
- Osteoporosis - reduced mineral density
A "fall on an outstretched hand" (FOOSH) is a TRAUMATIC mechanism that fractures NORMAL bone (typically causing Colles' fracture, scaphoid fracture). It is a mechanical injury to normal bone, NOT a pathological fracture.
Q24. To ascertain sound union - which feature is NOT present in well-united bone?
Answer: a) Mobile bone fragments
In a well-united (solid) fracture, bone fragments are FIXED and immobile. Mobile bone fragments indicate NON-UNION or inadequate healing. The features of sound union are:
- b) No pain over the fracture site - sign of union
- c) Callus visible on x-ray - sign of healing
- d) Continuity of bone trabeculae across the fracture on x-ray - definitive sign of union
Mobility at the fracture site = failure of union.
Q25. Late complications of fractures - which is NOT?
Answer: d) Haemorrhage
Haemorrhage is an EARLY/IMMEDIATE complication of fractures (occurs at the time of injury or shortly after). Late complications occurring weeks to months later include:
- Avascular necrosis (AVN) - blood supply interruption leading to bone death
- Shortening - malunion with limb length discrepancy
- Volkmann's ischaemic contracture - compartment syndrome sequela with muscle fibrosis
Haemorrhage happens acutely, not as a late complication.
Q26. Features associated with non-union - which is NOT?
Answer: c) Good apposition of fracture fragments
Non-union (failure to heal) is caused by:
- a) Interposition of soft tissues - prevents bone contact
- b) Excessive movement at fracture line - disrupts healing tissue
- d) Severed blood supply - avascular necrosis
Good apposition (fragments aligned and touching) is a FAVOURABLE condition for union, not non-union. Non-union requires poor apposition, poor blood supply, movement, or infection.
Q27. NOT true about fracture lines of the forearm
Answer: a) Monteggia fracture is distal third radial fracture with distal radio-ulna dislocation
The correct definition of a Monteggia fracture is: fracture of the PROXIMAL third of the ULNA with dislocation of the radial head at the elbow (proximal radio-ulnar joint). Option a incorrectly states it as distal third radial fracture.
Correct definitions:
- Nightstick fracture = isolated mid-shaft ulna fracture (from direct blow, like defending against a nightstick) - TRUE
- Colles' fracture = distal radius fracture with DORSAL displacement ("dinner fork deformity") - TRUE
- Smith's fracture = distal radius fracture with VOLAR/palmar displacement (reverse Colles') - TRUE (visible on next question)
Q28. Radiological features of Rickets - which is NOT?
Answer: d) Sclerosis
Rickets (vitamin D deficiency causing defective bone mineralization) shows:
- a) Broadening/widening of the metaphysis - TRUE (unmineralized osteoid accumulates)
- b) Rarefaction (reduced bone density) - TRUE
- c) Cupping of the metaphysis - TRUE (classic "cupped and frayed" metaphysis)
Sclerosis (increased bone density) is NOT a feature of rickets. Rickets causes DECREASED density due to poor mineralization. Sclerosis is seen in conditions like fluorosis, osteopetrosis, or treated rickets (healing phase with dense provisional calcification).
Q29. Radiological features of dislocated DRUJ - which is NOT?
Answer: d) Reduced DRUJ space on AP view
Dislocation of the Distal Radio-Ulnar Joint (DRUJ) features:
- a) Shortening of radius - can occur with associated fractures
- b) Fractured base of ulna styloid process - common associated injury
- c) Widened DRUJ space on AP view - TRUE (joint disruption widens the space)
Dislocation causes WIDENING of the DRUJ space, not reduction. A reduced space would suggest joint compression, which does not occur in dislocation.
Q30. Suggestive of a pathological fracture - which is NOT?
Answer: d) Dashboard injury
A dashboard injury is a specific TRAUMATIC mechanism (knee hits dashboard in car accident → posterior hip dislocation or femoral/patellar fracture). It occurs to NORMAL bone under high-energy trauma - it is NOT a pathological fracture.
Suggestive features of pathological fracture include:
- a) Bone pain and limb swelling PREDATING the fracture (pain before trauma = diseased bone)
- b) Marked post-fracture swelling disproportionate to minor trauma
- c) Cystic abnormality on x-ray (bone cyst, tumour visible before fracture)
Q31. Fracture lines on shaft humerus as indications of ORIF - which is NOT?
Answer: d) Un-displaced mid-transverse fractures
ORIF (Open Reduction Internal Fixation) of humeral shaft is indicated when conservative treatment will fail:
- a) Segmental fractures - need rigid fixation
- b) Displaced intra-articular extension - joint surface must be anatomically reduced
- c) Floating elbow (ipsilateral fractures of humerus and forearm) - needs fixation
Un-displaced mid-transverse humeral shaft fractures can be successfully managed conservatively with a hanging cast or functional brace - surgery is NOT required.
Q32. External fixation is particularly useful - which is NOT?
Answer: d) Simple transverse fractures
External fixation is used when internal fixation is contraindicated (contaminated wounds, severe swelling, soft tissue damage):
- a) Fractures with severe soft-tissue damage - YES (keeps bone aligned without implants in contaminated field)
- b) Open fractures where the wound must be left open - YES
- c) Severely comminuted, unstable fractures - YES (temporizing measure)
Simple transverse fractures are best treated with intramedullary nailing or plating (internal fixation) - clean, stable fractures do not need external fixation.
Q33. Radiological features of Brodie's abscess - which is NOT?
Answer: d) Osteophytes development on the site
Brodie's abscess is a chronic subacute osteomyelitis presenting as a walled-off bone abscess, typically in the metaphysis of long bones. Radiological features include:
- a) Central radiolucency with surrounding thick rim of reactive bone sclerosis - TRUE (classic)
- b) Pathognomonic tortuous parallel lucent channels extending toward the growth plate - TRUE
- c) Variable degree of periosteal new-bone formation - TRUE
Osteophytes are features of OSTEOARTHRITIS (bone spurs at joint margins). They have no association with Brodie's abscess.
Q34. Radiological features of osteoarthritis - which is NOT?
Answer: b) Joint space widening
Osteoarthritis (OA) causes progressive loss of articular cartilage. The cardinal radiological features are:
- a) Joint space NARROWING - cartilage is eroded (TRUE)
- c) Osteophytes - bone spurs at joint margins (TRUE)
- d) Sclerotic changes on margins (subchondral sclerosis) - (TRUE)
Joint space WIDENING does not occur in OA. Widening might be seen in early inflammatory arthritis or joint effusion, but never as a feature of osteoarthritis.
Q35. Radiological features of Rheumatoid Arthritis - which is NOT?
Answer: c) Sclerotic changes on the margins
RA radiological features include:
- a) Soft tissue swelling (periarticular, uniform) - TRUE
- b) Juxta-articular osteoporosis (periarticular bone loss around inflamed joints) - TRUE
- d) Widening of joint space early (due to effusion) - TRUE
Sclerotic changes on the margins is a feature of OSTEOARTHRITIS, not RA. In RA, the bone near joints becomes OSTEOPOROTIC (less dense), not sclerotic. RA causes erosions, not osteophytes or sclerosis.
Q36. True statement regarding growth plate injuries (Salter-Harris)
Answer: c) Salter-Harris type III injuries involve the joint surface
The Salter-Harris classification:
- Type I: Fracture through the physis (growth plate) only - LOWEST risk of growth arrest
- Type II: Fracture through physis AND metaphysis (most common) - low growth arrest risk
- Type III: Fracture through physis AND epiphysis - INVOLVES THE JOINT SURFACE (TRUE - answer c)
- Type IV: Fracture through all three: metaphysis, physis, epiphysis
- Type V: Crush injury of the physis - HIGHEST risk of growth arrest (not "always evident" on plain films - option d is FALSE)
So:
- a) Type I has HIGH incidence of growth arrest - FALSE (Type I has low risk)
- b) Type II = physis and metaphysis - TRUE (but this is already true!)
- d) Type V always evident on plain films - FALSE (Type V is often invisible initially)
- c) Type III involves joint surface - TRUE
Q37. Fracture remodelling depends on - which is NOT?
Answer: b) Length of time on cast
Fracture remodelling (the process by which residual deformity corrects itself over time in children) depends on:
- a) Age - younger children remodel better/faster
- c) Proximity to the joint - fractures near joints (close to the physis) remodel best
- d) Orientation to the joint axis - deformity in the plane of joint movement remodels; rotational and angulation perpendicular to the plane of movement does NOT remodel
The length of time spent in a cast affects fracture stability and union but does NOT determine the potential for bony remodelling. Remodelling is a biological process driven by the factors above, not by cast duration.
Questions 38-40 (Radiograph-based)
The radiograph shows a knee joint of a growing child with labelled structures A, C, and D.
In a long bone radiograph of a growing child, from the joint surface inward:
- The rounded end = Epiphysis
- Growth plate (dark line) = Physeal plate
- Flared region between growth plate and shaft = Metaphysis
- Long shaft = Diaphysis
Q38. What does letter A indicate?
Answer: d) Epiphysis
Letter A is at the rounded articular end (above the growth plate) - this is the epiphysis.
Q39. What does letter C indicate?
Answer: c) Physeal plate
Letter C is the thin radiolucent (dark) line between the epiphysis and metaphysis - this is the growth plate / physeal (physis) plate.
Q40. What does letter D indicate?
Answer: a) Diaphysis
Letter D is in the long shaft of the bone - the diaphysis, which is the cylindrical mid-portion of the long bone.
SECTION B: SHORT ANSWER QUESTIONS
1. ABC's approach to interpreting an X-ray image (5 marks)
The ABCs systematic approach ensures no finding is missed:
- A - Adequacy/Alignment: Is the film well-exposed, correctly positioned? Check patient alignment.
- B - Bone: Examine each bone for fractures, dislocations, density changes, periosteal reaction, lesions.
- C - Cartilage/Joints: Check joint spaces (narrowing, widening), articular surfaces, growth plates in children.
- S - Soft tissues: Swelling, gas, foreign bodies, calcifications in soft tissues. Soft tissue swelling can indicate an occult fracture.
Some expand to ABCDES adding: D = Density (abnormal bone density), E = Everything else.
2. Five radiation protection measures (5 marks)
- Justification: Only perform radiation procedures when clinically justified - no unnecessary x-rays.
- Distance: Increase distance from the radiation source (inverse square law - doubling distance reduces dose by 75%).
- Lead shielding: Use lead aprons, thyroid shields, gonad shields for both patients and staff.
- Collimation: Restrict the x-ray beam to the area of clinical interest only.
- Time: Minimize time of exposure (especially for fluoroscopy and staff in radiation areas).
- ALARA principle: As Low As Reasonably Achievable - always optimize technique to minimize dose.
- 10-day rule: Schedule elective pelvic/abdominal x-rays in women of childbearing age within the first 10 days post-menstruation.
3. What a good radiograph should entail (5 marks)
- Correct identification: Patient name, date, side markers (R/L) clearly visible.
- Two views at 90°: At minimum, AP and lateral views of the area.
- Adequate penetration: Neither overexposed (too dark) nor underexposed (too pale) - all structures visible.
- Entire area included: The region of interest plus the joints above and below (in limb trauma).
- No motion blur: Patient kept still - sharp, clear bone and soft tissue outlines.
- Proper positioning: Anatomically correct position so structures are not distorted.
4. Five uses of ultrasound (5 marks)
- Obstetrics: Fetal assessment, gestational age, anomaly screening, placenta location.
- Abdominal/Pelvic organs: Liver, gallbladder (gallstones), kidneys, uterus, ovaries, prostate.
- Musculoskeletal: Tendons, ligaments, muscles, joint effusions, soft tissue masses.
- Vascular: Doppler ultrasound for blood flow assessment (DVT, carotid stenosis, renal artery stenosis).
- Guided procedures: Real-time guidance for biopsies, aspiration of fluid collections, nerve blocks.
- Cardiac (Echocardiography): Heart valves, function, pericardial effusion.
5. Five indications for surgical management of humeral fractures (5 marks)
- Polytrauma/Multiple fractures: Patient has other injuries requiring early mobilization.
- Floating elbow: Ipsilateral fractures of the humerus and forearm bones.
- Pathological fracture: Fracture through tumour or diseased bone.
- Radial nerve palsy that does NOT recover: Explore and fix.
- Segmental fractures: Cannot be controlled with conservative management.
- Intra-articular extension with displacement: Joint surface must be anatomically reduced.
- Open fractures: Require debridement and stabilization.
- Vascular injury requiring repair: Need bone stabilization first.
6. Gustilo-Anderson classification of open fractures (5 marks)
- Type I: Open fracture with wound <1 cm, clean, minimal soft tissue damage. Simple fracture pattern.
- Type II: Open wound 1-10 cm, moderate soft tissue damage. No flaps, devascularization, or periosteal stripping. Adequate soft tissue coverage.
- Type III: High-energy injury. Extensive soft tissue damage. Subdivided:
- IIIA: Adequate soft tissue coverage despite extensive laceration/flaps. High-energy trauma.
- IIIB: Extensive periosteal stripping with massive contamination. Requires local/free flap for coverage.
- IIIC: Any open fracture with arterial injury requiring repair.
7. Salter-Harris classification of growth plate fractures (5 marks)
- Type I (S): Slip through physis only. X-ray often normal or shows widened growth plate. Good prognosis.
- Type II (A): Fracture through physis + metaphysis. Most common type (75%). Triangular metaphyseal fragment (Thurston-Holland sign). Good prognosis.
- Type III (L): Fracture through physis + epiphysis. Involves joint surface. Moderate risk of growth arrest.
- Type IV (T): Fracture through all three: metaphysis + physis + epiphysis. High risk of growth arrest. Requires ORIF.
- Type V (R): Crush injury of physis. Often invisible on initial x-ray. Highest risk of growth arrest.
Mnemonic: SALTR - Slip, Above, Lower, Through, Rammed (or SALTER).
8. Definitions (1 mark each)
a) Colles' fracture: A fracture of the distal radius within 2.5 cm of the wrist joint, with dorsal displacement and angulation of the distal fragment, producing the classic "dinner fork deformity." Caused by a fall on an outstretched hand (FOOSH).
b) Smith's fracture: A fracture of the distal radius with VOLAR (palmar) displacement of the distal fragment - the reverse of Colles' fracture. Also called a "reverse Colles." Caused by a fall on the back of the hand.
c) Monteggia fracture: Fracture of the proximal third of the ULNA with anterior dislocation of the RADIAL HEAD at the proximal radio-ulnar/elbow joint.
d) Galeazzi fracture: Fracture of the distal third of the RADIUS with dislocation of the DRUJ (distal radio-ulnar joint). The opposite limb pair to Monteggia.
e) Nightstick fracture: An isolated fracture of the MID-SHAFT of the ULNA without radial fracture or joint dislocation. Named because it results from raising the forearm to defend against a direct blow (as from a nightstick/baton).
SECTION C: LONG ANSWER
Complications of Fractures
i. Early Complications (10 marks)
These occur immediately or within the first few days/weeks:
- Haemorrhage: Blood loss into fracture haematoma. Femur fracture can lose 1-1.5L; pelvic fractures can be life-threatening with several litres.
- Shock: Hypovolaemic shock from blood loss (especially pelvic, femoral, multiple fractures).
- Fat embolism: Fat globules from bone marrow enter the bloodstream → lungs (ARDS), brain (confusion), skin (petechiae). Occurs 24-72 hours post-injury.
- Damage to adjacent vessels: Sharp bone fragments lacerate or occlude arteries (e.g., popliteal artery in supracondylar fracture, brachial artery in distal humerus fracture).
- Nerve injury: Radial nerve in humeral shaft fractures, axillary nerve in shoulder fractures/dislocations, common peroneal nerve in fibular neck fractures.
- Visceral injury: Pneumothorax from rib fractures; bladder/urethral injury from pelvic fractures; spinal cord injury from vertebral fractures.
- Compartment syndrome: Raised intracompartmental pressure from haematoma/swelling in closed fascial compartments → ischaemia of muscles and nerves. Presents with the 6 Ps: Pain (out of proportion), Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia. Emergency fasciotomy required.
- Infection: Especially in open fractures - contamination leads to osteomyelitis. Requires thorough debridement, antibiotics, and fracture stabilization.
ii. Late Complications (10 marks)
These occur weeks to months after the fracture:
- Delayed union: Fracture takes longer than expected to heal but is still progressing. Defined as no radiological evidence of union by the expected time (3-6 months for most long bone diaphyseal fractures).
- Non-union: Complete failure of fracture healing. Types: hypertrophic (abundant callus but no bridging - needs stability) and atrophic (no callus - needs bone graft + fixation). Features on x-ray: sclerotic fracture ends, no callus bridging.
- Malunion: Fracture heals in abnormal position (angulation, rotation, shortening) → deformity and dysfunction.
- Avascular necrosis (AVN): Blood supply disrupted → bone death. Common in femoral head (neck of femur fracture), scaphoid (waist fractures), talus. Shows as increased density (sclerosis) on x-ray.
- Joint stiffness: Prolonged immobilization and fibrous adhesions within and around joints.
- Osteoarthritis: Post-traumatic OA in joints affected by intra-articular fractures with residual step-off deformity.
- Myositis ossificans: Heterotopic bone formation in muscle/soft tissue around the fracture (especially elbow). Visible as calcification on x-ray.
- Volkmann's ischaemic contracture: Late sequela of untreated compartment syndrome → muscle fibrosis and contracture (typically flexion deformity of wrist and fingers after forearm compartment syndrome).
- Reflex sympathetic dystrophy (Complex Regional Pain Syndrome - CRPS): Persistent burning pain, vasomotor changes, bone demineralization (Sudeck's atrophy visible on x-ray).
- Shortening and growth disturbance: In children, physeal damage causes limb length discrepancy or angular deformity.
This covers all 40 MCQs with correct answers and explanations, plus all short answer and long answer questions from the full paper. Key subjects covered: radiation safety, fracture types and healing, bone tumours, osteomyelitis, osteoarthritis, rheumatoid arthritis, rickets, growth plate injuries, and forearm fracture eponyms.
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Here is a thorough visual guide to common fracture patterns in radiology, organized by fracture type with clinical X-ray images.
Common Fracture Patterns in Radiology - Clinical Image Guide
1. Fracture Healing Stages (Overview)
This diagram shows the radiological stages of fracture healing - from the initial cellular/haematoma phase through callus formation to remodelling:
2. Monteggia Fracture-Dislocation
A fracture of the proximal ulna shaft with dislocation of the radial head at the elbow. The AP and lateral views of the forearm below show the characteristic picture - the ulna fracture is obvious, and the radial head is dislocated anteriorly (Bado type I - most common):
Key points:
- Ulna fractures at the proximal third
- The radial head always dislocates - if you miss this, treatment fails
- Rule: always check the elbow when you see an ulna fracture
3. Galeazzi Fracture
A fracture of the distal third of the radius with DRUJ (distal radio-ulnar joint) dislocation. The two views below show a distal radial shaft fracture with widening/disruption of the DRUJ distally:
Key points:
- Fracture is at the distal radius (opposite end to Monteggia)
- The DRUJ at the wrist is disrupted - check the ulnar styloid and DRUJ space
- Mnemonic: "GAL" = GALeazzi = distal rAdius + wrist joint
4. Colles' Fracture (Smith's fracture for comparison)
The lateral wrist view here shows a distal radius fracture - note how the displacement pattern tells you which type it is:
- Colles' fracture: distal radius fracture with dorsal (posterior) displacement - "dinner fork deformity" on lateral view
- Smith's fracture: distal radius fracture with volar (anterior/palmar) displacement - "garden spade deformity"
- Both caused by FOOSH (fall on outstretched hand) but at different wrist positions
5. Torus (Buckle) Fracture - Paediatric
This is the most common fracture in children aged 7-12. Note the subtle cortical bulge/buckle on one side of the distal radius - no complete cortical break, just a crumple of the bone:
Key points:
- Only ONE side of the cortex buckles (compressive side)
- The other cortex and periosteum remain intact
- Stable fracture - treated with splint/cast only
- Easily missed! Look carefully at the metaphysis of the distal radius
6. Greenstick Fracture - Paediatric
A greenstick fracture has a partial cortical break on one side, with the other side bending but not breaking - like a fresh green twig. Seen here in the distal forearm radius:
Greenstick vs Torus distinction:
| Feature | Torus/Buckle | Greenstick |
|---|---|---|
| Cortex | Bulges/buckles, no break | Breaks on tension side |
| Side affected | Compression side | Tension (convex) side |
| Stability | Very stable | Less stable, may angulate |
| Age | Any paediatric | Usually younger children |
7. Spiral Fracture of the Femur
This AP femur view shows the classic long helical fracture line that wraps around the shaft - caused by a twisting/rotational force:
Key points:
- The fracture line spirals along the bone shaft
- Caused by torsion - a twisting force (e.g., planted foot + body rotation)
- In children under 3 years: raise concern for non-accidental injury
- Contrasted with transverse fracture (direct blow) and oblique fracture
8. Comminuted Fracture of the Tibia (AO Foundation)
This shows a severely comminuted (multi-fragment) tibial shaft fracture in two views - AP and lateral. The bone is shattered into multiple pieces:
Key points:
- Three or more bone fragments = comminuted
- Results from high-energy trauma
- More complex to fix - often requires intramedullary nail or external fixator
- Associated with greater soft tissue injury
Summary Table: Fracture Pattern Recognition
| Fracture Pattern | X-ray Appearance | Causative Force | Common Location |
|---|---|---|---|
| Transverse | Line perpendicular to bone axis | Direct blow | Tibia, ulna (nightstick) |
| Oblique | Line at an angle (~45°) | Angulation force | Any long bone |
| Spiral | Helical line wrapping the shaft | Torsion/rotation | Tibia, humerus, femur |
| Comminuted | 3+ fragments | High energy | Tibia, femur, radius |
| Impacted | Dense/sclerotic line, bone driven together | Axial compression | Femoral neck, vertebrae |
| Greenstick | Partial cortical break, one side intact | Bending | Paediatric forearm |
| Torus/Buckle | Cortical bulge, no break | Axial load + compression | Paediatric distal radius |
| Segmental | Two fracture lines, floating segment | High energy | Femur, tibia |
| Avulsion | Small fragment pulled from bone | Muscle/ligament pull | Ankle, pelvis, finger |
| Stress | Subtle cortical break or periosteal reaction | Repetitive loading | Metatarsal, tibia |
For interactive radiograph tutorials with labelled examples, Radiology Masterclass trauma series is an excellent free resource. Radiopaedia's fracture article provides comprehensive case-based image galleries for each pattern.
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Excellent findings from both the textbooks and clinical image databases. Here is the full, image-rich guide:
Radiological Features: Osteomyelitis vs. Ewing's Sarcoma
These two conditions are the most notorious mimics in musculoskeletal radiology. Both affect young patients, present with bone pain and fever, and can look strikingly similar on imaging - making the distinction one of the most clinically consequential in orthopaedic radiology.
PART 1 - OSTEOMYELITIS
Pathological Basis
Infection (usually Staphylococcus aureus) reaches bone via the bloodstream and lodges in the richly vascular metaphysis. Pus builds up under pressure, causing vascular thrombosis → bone necrosis → the classic triad of sequestrum, involucrum, and cloaca.
X-Ray: Chronic Osteomyelitis - Sequestrum, Involucrum, and Cloaca
This labelled radiograph of the tibia shows all three hallmarks of chronic osteomyelitis beautifully:
- Sequestrum (yellow arrow, right image): dense, sclerotic fragment of dead (avascular) bone separated from living bone. The most specific sign of chronic osteomyelitis.
- Involucrum (white arrow, left image): thick shell of periosteal new bone that forms around the sequestrum as the body attempts to contain the infection.
- Cloaca (red arrow, left image): opening/aperture in the involucrum through which pus drains - may form a sinus tract to the skin.
Radiological Features of Osteomyelitis - Stage by Stage
| Stage | Timing | X-ray Findings | Best Modality |
|---|---|---|---|
| Acute early | Days 1-7 | NORMAL plain x-ray (30-50% bone mineral loss needed before visible) | MRI (changes in 24-48h) |
| Acute late | Week 2 | Soft tissue swelling, subtle bone lysis, periosteal reaction beginning | X-ray + MRI |
| Subacute | Weeks-months | Well-defined lytic lesion ± sclerotic rim (Brodie's abscess) | X-ray + CT |
| Chronic | Months-years | Sequestrum + involucrum + cloaca, cortical thickening, sclerosis | X-ray + CT |
Acute osteomyelitis key x-ray features:
- Soft tissue swelling (earliest sign, days 3-5)
- Periosteal elevation and periosteal new bone formation
- Patchy/moth-eaten bone destruction in the metaphysis
- Lucent areas within bone (pus cavities)
Brodie's Abscess (Subacute/Chronic Osteomyelitis)
A walled-off bone abscess most common in the distal tibia metaphysis. X-ray shows:
- Well-defined central lucency (the abscess cavity)
- Surrounding thick rim of reactive sclerosis
- A characteristic tortuous lucent channel extending toward the growth plate (pathognomonic)
- Variable periosteal new bone formation
PART 2 - EWING'S SARCOMA
Pathological Basis
Ewing's sarcoma arises from the medullary cavity and invades the Haversian canal system of cortical bone. As it expands outward, it repeatedly lifts the periosteum, which responds by laying down new bone - creating the onion-skin layered periosteal reaction. It is the second most common malignant bone tumour in patients under 25, after osteosarcoma.
X-Ray: Classic "Onion-Skin" Periosteal Reaction
This close-up radiograph of the tibia shaft shows the lamellated "onion-skin" periosteal reaction - the most characteristic plain film feature of Ewing's sarcoma. Multiple parallel layers of periosteal new bone are visible alongside the cortex:
"A lamellated periosteal reaction looks like an onion skin and is commonly seen in Ewing sarcoma... A Codman triangle and spiculated (hair-on-end) periosteal reaction are signs of a rapidly evolving process." - Grainger & Allison's Diagnostic Radiology
X-Ray: Ewing's Sarcoma - Full Femur View (Permeative Pattern)
This AP radiograph of the entire femur in a child shows the permeative/moth-eaten destruction extending through most of the diaphysis, with periosteal reaction along the length of the shaft:
X-Ray: Ewing's Sarcoma - Distal Femur
This lateral view of the distal femur shows the typical Ewing's pattern at the meta-diaphyseal junction - aggressive bone destruction with associated periosteal reaction:
Ewing's Sarcoma with MRI Correlation
This three-panel case shows why MRI is essential: (A) plain X-ray showing onion-skin periosteal reaction in the proximal femur; (B) coronal MRI T2 showing the large soft tissue mass and marrow oedema; (C) coronal T1 showing tumour extent clearly:
PART 3 - DIRECT COMPARISON: The Great Mimic
This side-by-side panel from a landmark radiology study directly compares Ewing's sarcoma with osteomyelitis: (A) plain X-ray, (B) T2 MRI showing marrow signal, (C) T1 post-contrast showing enhancement pattern, (D) axial view:
MASTER COMPARISON TABLE
| Feature | Osteomyelitis | Ewing's Sarcoma |
|---|---|---|
| Age | Any (peak: <5 years, haematogenous) | 5-25 years (peak: 10-15 yrs) |
| Race | Any | Predominantly Caucasian (rare in Black patients) |
| Bone location | Metaphysis (children), diaphysis (adults) | Diaphysis (classic), also metaphysis |
| Bone affected | Tibia, femur most common | Femur, tibia, pelvis, flat bones |
| Pattern of destruction | Focal lytic → moth-eaten | Permeative, moth-eaten, wide zone of transition |
| Periosteal reaction | Solid/layered; less aggressive | Lamellated "onion-skin"; aggressive; Codman triangle |
| Soft tissue mass | Present but typically smaller | LARGE soft tissue mass (>50% of cases) - key differentiator |
| Sequestrum/Involucrum | YES (chronic) - pathognomonic | NOT present |
| Brodie's abscess | YES (subacute form) | NO |
| Zone of transition | Narrow (more organized) | Wide (more aggressive) |
| MRI soft tissue mass | Poorly defined, inflammatory | Well-defined, large, distinct from surrounding tissue |
| Marrow signal on MRI | Diffuse T2 high signal (oedema pattern) | More focal, sharper margins |
| Fever / raised ESR / WBC | YES (infection) | YES (tumour, mimics infection) |
| Treatment | Antibiotics ± surgical drainage | Chemotherapy + radiotherapy ± surgery |
| Key distinguishing sign | Sequestrum (chronic), Brodie's abscess | Large soft tissue mass + sharp transition zone on MRI |
KEY CLINICAL PEARL
The McCarville et al. AJR 2015 study - the most cited paper on this topic - found that a large, well-defined soft tissue mass with a sharp transition zone on MRI strongly favours Ewing's sarcoma over osteomyelitis. A diffuse, poorly defined soft tissue signal with a gradual transition zone favours infection. When in doubt: biopsy is mandatory before any treatment, as the consequences of treating one as the other (missed cancer vs. inadequate antibiotic coverage) are severe.
The Henninger et al. 2013 study (Skeletal Radiology) further validated that MRI sharpness of the soft tissue transition zone is the single most useful differentiating MRI feature.
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