Question 1

PART A

Mr. Ahmad, a 65 year old retired police officer has presented to the Orthopaedic Outpatient Clinic with the problem
of bilateral knee pain, left more than right. The knee pain started 3 years ago. His pains have increased in the past 1
year, until the present moment when it even affects his sleep. He has been forced to stop his morning walk sessions
because of this pain.

(a) What is the most probable diagnosis?

Ans. Osteoarthritis

(b) What further history would you look for to confirm the diagnosis? Give TWO examples

Past history of trauma / heavy exercise; Past history of ininflammation ;Family history of joint pain; History of
obesity

(c) On physical examination, the orthopaedic surgeon found the muscle power of the left quadriceps to be
decreased. Name the quadriceps muscles. State their mode of insertion and nerve supply

Ans. Rectus femoris, Vastus lateralis, Vastus medialis, Vastus intermedius

Quardiceps tendon passes over the patella, forms ligamentum patellae which is inserted overthe tibial tuberosity;
Femoral nerve
Question 2

PART B

Radiograph of the left knee jointshowed loss of joint space with subchondral cyst formation. Osteophytes werealso
detected at the edge of femoral condyles. The orthopaedic surgeonconfirmed that Mr Ahmad had osteoarthritis of
the knee and prescribed NSAID ofselective COX-2 inhibitor class.

(a) What type of collagen is found inarticular cartilage? Name TWO aminoacids in the collagen

Ans:Type II; Glycine, Proline, 4-hydroxyproline and hydroxylysine (Any TWO)

(b) Name THREE sites in the jointwhere pathological changes in osteoarthritis can occur and briefly describe the
possible changes in each site.

Ans;

 Articular cartilage: loss of collagen and proteoglycans from the matrix / loss of chondrocyes / flaking,
fissuring
 Adjacent bone: denudation (ivory bone) / death of osteocytes / increased osteoclastic activity/ osteophyte
formation/spur formation

 Synovium: low grade synovitis(chronic inflammation) / villous hypertrophy

(c) What is the rationale of using selective COX-2inhibitor in this patient?

Ans. NSAIDs exert theiranti-inflammatory and analgesic effects by inhibition of theprostaglandin- generating
enzyme,cyclooxygenase. Reduction of prostaglandin levels can result in the well-recognized side-effects likegastric
ulceration particularly in elderly patients. Selective COX-2 inhibitor has less side-effectsof gastric ulceration.
Question 3

PART C

a.What is the definition of elderly in Malaysia. State 3 goals of health promotion among the elderly.

Persons > 60 years

I. To prevent unnecessary loss of functional capacity

II. Maintain quality of life by preventing distressing symptoms ncreasequality to life
III. Assist the elderly to live with theirfamilies/own homes to prevent unnecessary admission to residential
care
IV. To prevent iatrogenic disease, including distress caused by inappropriate intervention

b. Give 2 demographic reasons why the proportion of elderly in Malaysia is increasing.

Longer life expectancy at birth

Decrease in total fertility rate.

c. Spontaneous falls are common among the elderly. State 2 ways how drugs can cause falls.

Sedatives impair insight and balance

Antihypertensives can give rise to postural hypotension

Drugs can cause Cardiac dysrhytmias andHypoglycaemia

d. Ageing is characterized by increasing cognitive deficit. State four ways how this process can be prevented or
delayed.

• Reading widelyand varied subjects• Weeklyexercises in problem solving tasks• Crosswordpuzzles memory games

• Encouraging generativity –”desire to make a difference” in environment, communities etc.• Gainfullyemployed

in jobs requiring mental acumen Involving in social work/religiouswork Takingup a new language skills , musical
instruments
Question 4

1. Name the muscle labelled ‘A’. State its action.

Ans. Orbital part of Orbicularis oculi. It closes the eye.

2. Name the muscle labelled ‘B’ and 'E’

Ans. B. Zygomaticus major, E. Posterior belly of Digastric

3. Name the nerves labelled ‘C ‘ and ‘D’

Ans.C. Buccal branch of Facial nerve, D. Temporal branch of Facial nerve

4. Describe any TWO functional components of the main trunk of ‘C’

o Branchial motor or special visceral efferent (supply facial muscles)

o Visceral motor or general visceral efferent (supply lacrimal, submandibular, sublingual glands)
o Special sensory or special afferent (Taste senses of anterior 2/3rd tongue)
o General sensory or general somatic afferent (skin of external ear)

5. State TWO signs of lesion of the main trunk of ‘C’ (LMN type)

Ans. Same sided face will be affected

 Absence of transverse wrinkles of forehead

 Angle of mouth elevated to opposite side
 Evertion of lower eyelid with uncontrolled tearing
 Difficulty keeping food in mouth while chewing
Question 5
Provided Picture A X-ray of the tibia and fibula in a 25-year-old male who presented with a painful lesion of the leg
and the picture of the excised lesion.

Provided Picture B Gross picture of the excised femur in a 18-year-old college student with a rapidly growing mass.
Q1. Describe the radiological findings seen in picture A and identify the excised specimen. State the clinical
significance

(4 Marks)

Q1. Shows a localised out growth arising from the upper end of tibia and extending laterally into perisoteum.This
is osteochondroma. Cartilage covered bony excrescence (exostosis) usually in metaphysis of long bones. You
can see the Radio-lucency (black colour) on the surface of Radio-opaque (white colour) bony swelling. It
arises from a surface of a bone
This benign in nature.If multiple lesions are present, a few of them can turn malignant.

Q2. Describe the pathological lesion seen in the femur in picture B and state the diagnosis. (4 Marks)

Q2. Shows a big bulky, creamy tumour arising from the femur, in the middle and lower third of the bone.There is
extensive destruction of the bone inthe medullary cavity with infiltration into surrounding muscle and fibrous
tissue.There is elevation of the periosteum. Patchy areas of haemorrhage are seen in the tumour

Malignant tumour of the femur (Osteosarcoma)

Q3. State TWO conditions in the elderly which predispose to the condition seen in picture B. (2 Marks)
Q3. Paget's disease, Bone Infarct, Prior Irradiation
Question 6
A patient who sustained injuries in a motorcycle accident found that he was not able to abduct or laterally rotate his
arm on the injured side. The clinical symptoms can be attributed to loss of innervation which of the following sets of
muscles?

[Please think of muscle groups in the choices which can cause ABDUCTION and LATERAL ROTATION as also NERVE
SUPPLY. In paralysis due to injury, SOME PARTICULAR SPINAL ROOT/ROOTS injury will affect the nerves with those
roots and thus affect muscles supplied by those nerves]
Choose one answer.
A. Supraspinatus, deltoid and teres major

B. Deltoid, teres minor and supraspinatus

C. Deltoid, teres minor and pectoralis major
D. Deltoid, teres major and latissimus dorsi
E. Pectoralis major, infraspinatus and teres major

Question 7
In the extended position, the knee becomes rigid and stable because the medial femoral condyle rides posteriorly
and on the tibial plateau, rotating the femur medially or the tibia laterally and achieving a configuration that
effectively "locks" the knee. The process of "unlocking" the knee in preparation for flexion requires initial contraction
of the
Choose one answer.
A. Popliteus
B. Hamstring
C. Sartorius
D. Gastrocnemius
E. Quadriceps femoris
Naturally popliteus is the unlocking muscle which initiates flexion. Gastrocnemius also causes flexion of the knee
apart from plantar flexion of ankle. Hamstring muscles are also flexor of the ankle. Quadriceps on the other hand
is extensor of the knee. Sartorius is also a flexor of knee and flexor, lateral rotator of the hip.

Question 8
A 15-year-old girl presents with pain in her left lower leg. X-ray shows an expansile pedunculated growth arising
from the left tibial bone. Excision of the lesion shows bone tissue with a cartilaginous cap. What is the most likely
diagnosis in this case?
Choose one answer.
A. Osteoid osteoma
B. Enchondroma
C. Chondrosarcoma

D. Osteochrondroma
E. Osteoblastoma
Question 9
Colagen is main protein of connective tissue. Which of the following is TRUE regarding collagen?
Choose one answer.
A. It has has four polypeptide chains

B. Articular cartilage is composed of type II cartilage

C. Decreased cross-linking of polypeptide chains cause old age osteo-arthritis
D. Ageing changes in skin due to reduced synthesis of type II & IV in dermis
E. Formation of tropocollagen and cross-linking happens inside the cell

Question 10
According to the recommendations made by the Royal College of Physicians, when is the best time to instill the habit
of taking regular recreational exercise?

Choose one answer.

A. After being diagnosed with a lifestyle linked disease
B. During adulthood
C. During adolescence
D. After recovering from an operation
E. During childhood

Best time to instill habit of taking regular recreational exercises is in childhood—genetic component to
coordination, strength, speed, and response to resistance exercise. Improving social skill also

Question 11
Diagastric muscle forms the boundaries of the digastric triangle. Which of the statement is TRUE regarding the
digastric muscle?
Choose one answer.
A. two heads are inserted to the LESSER horn of the hyoid bone
B. two heads assist in closing the mouth

C. posterior belly is supplied by the facial nerve

D. two heads depress the hyoid bone in swallowing
E. Anterior belly is attached to the mastoid process of the temporal bone

Question 12
Pagets disease is characterized by periods of osteoclastic bone resorptions followed by hectic bone formation. Which
of these stages are seen first in the disease?
Choose one answer.
A. osteoblastic
B. osteogenic
C. osteosclerotic

D. osteolytic
E. Mixed
Question 13
Full thickness autogenous nerve graft is carried out while repairing an injured nerve. Which of these constitute the
MAJOR BULK of a myelinated peripheral nerve?
Choose one answer.
A. Blood and lymphatic vessels

B. Myelin sheath
C. Neurilemma sheath
D. Connective tissue wrapping
E. Axon

Question 14
Aspirin is most commonly used off-the-counter NSAID. Which of the following is contraindication of
aspirin use?
Choose one answer.
A. History of ischaemic stroke
B. Concurrent use with captopril
C. Concurrent use with digoxin
D. History of colon cancer

E. History of asthma

In aspirin-sensitive patients NSAIDs with anti cyclooxygenase activity invariably precipitate bronchoconstriction,
while NSAIDs deprived of this activity are well tolerated; There is positive correlation between the potency of
NSAIDs to inhibit COX in vitro and their potency to induce asthmatic attacks After aspirin desensitization, cross
desensitisation to other NSAIDs, that inhibit COX, also occurs.

Question 15
An elderly woman slipped at her bathroom and fractured the greater trochanter of the femur. Which of the
following muscles would continue to function normally?
Choose one answer.
A. Gluteus medius
B. Obturator internus

C. Gluteus maximus
D. Gluteus minimus
E. Piriformis

Question 16
Which of the following is not a complication of fractures of long bones?
Choose one answer.
A. Fat embolism syndrome
B. Adult respiratory distress syndrome

C. Extra dural haemorrhage

D. Compartment syndrome
E. Crush syndrome
Question 17
A 40-year-old woman was seen for burning sensation over both legs. She gave a history of type II diabetes for last 3
years. On examination HbA1C was 12.4%. Which of the following is TRUE regarding the disease?
Choose one answer.
A. motor deficit in the limbs occurring in the disease process is always proximal

B. One of the causes in pathogenesis is formation of sorbitol by polyol pathway

C. In mononeuropathy involving leg, tibial nerve is commonly affected first
D. Antidepressants are contra-indicated in treatment of diabetic polyneuropathy pain
E. Loss of vibration sense over the great toe would be due to small-fibre loss

Question 18
An obese pregnant lady developed pain along with tingling and numbness over the thumb and index finger of the
right hand. The physician felt that compression in the carpal tunnel may be the cause of the pain. Which of the
following structures is least likely to be a content of the carpal tunnel?
Choose one answer.
A. Flexor digitorum superficialis muscle
B. Flexor digitorum profundus muscle
C. Flexor pollicis longus muscle
D. Median nerve

E. Palmaris longus muscle

Question 19

Which of the following is least likely to occur when A is injured as shown in the picture?
Choose one answer.
A. Sensation in lower 1/3rd of leg (anterior, lateral aspect) is impaired
B. Extensors of the toes are paralysed

C. Plantarflexors of the ankle are paralysed

D. Foot is inverted and the patient walks on toes
 E. Dorsiflexors of the ankle are paralyzed
Question 20

The factor least likely to be involved in the pathogenesis of the clinical condition shown in this picture is:

Choose one answer.

A. Platelet aggravating factors
B. Macrophage
C. Proteolytic enzymes
D. CD4+ T-cells
E. Fibroblast

Question 21
The muscles of mastication move the temperomandibular joint. Which of the statement is TRUE regarding the
muscles of mastication?
Choose one answer.
A. They are supplied by the facial nerve
B. They are developed from the second branchial arch

C. Contraction of the temporalis muscle elevates the mandible

D. Contraction of the masseter muscle depresses the mandible
E. Both medial and lateral pterygoid muscles contract in elevation of the mandible
Question 22
Sciatic nerve, the thickest nerve of the body may be injured by intramuscular injections over the gluteal region.
Which of the followings is TRUE regarding the nerve?
Choose one answer.
A. It passes into thigh midway between ischial tuberosity and post sup iliac spine
B. It passes superficial to hamstring muscles to enter popliteal fossa

C. It emerges through the greater sciatic foramen inferior to piriformis muscle

D. Hamstring muscles are innervated by common peroneal divsion of this nerve
E. To avoid injury injections are given into upper & medial quadrant of buttock

Question 23
Which of the following statements about acute haematogenous osteomyelitis is most likely to be false
Choose one answer.
A. In children under 4 years, Streptococcus Gr A may be the offending organism
B. Usually occur in the children
C. Gram negative organism is often isolated in immuno-compromised adults

D. Haemophilus Influenzae is most common organism

E. Salmonella infection may occur in those with sickle cell anaemia

Question 24
Neuroglial cells are playing an important role in myelination of central nervous system neurons. Most numerous cells
in the central nervous system are
Choose one answer.
A. Pseudounipolar neurons
B. Multipolar neurons
C. Microcytes

D. Astrocytes
E. Oligodendrocytes

Question 25
Which of the following is NOT TRUE of open fracture management?
Choose one answer.
A. Irrigation with copious saline
B. Removal of foreign contaminants

C. Excision of ischaemic tissue

D. Excision of necrotic tissue
E. Leaving wound open for drainage

Debridement consists of removal of foreign contaminants, irrigation with copious saline and hydrogen peroxide,
excision of necrotic tissue and leaving wound open for drainage.
Ischaemic tissue can not be identified macroscopically
Question 26
A 12-year-old girl presents with a compound fracture of the right humerus, as a result of a road traffic accident.
Subsequently, she develops fever, pain at the site of fracture with swelling. There is restriction of movement.

The very initial histopathological change that can be observed in this case will be
Choose one answer.
A. sequestrum

B. suppuration
C. necrosis
D. involucrum
E. Brodie’s abscess

As it is a road traffic accident, bacterial infection will produce suppuration to start with. Features of osteomyelitis--
sequestrum, involucrum, brodies abscess may develop after a period of time, necrosis will be also after some time.

Question 27
An 18-year-old man has developed marked pain and swelling in his right hip since 4 days. A joint aspirate from the
hip reveals cloudy fluid that on microscopic examination shows numerous neutrophils but no crystals. Which of the
following conditions is most likely to have preceded development of his hip problem?
Choose one answer.
A. Erythema chronicum migrans
B. Systemic lupus erythematosus

C. Gonococcal urethritis
D. Rheumatoid arthritis
E. Sickle cell anaemia