Neck of femur fracture — MCQs

$Neck of femur fracture — MCQs$

10 questions

A 29-year-old man presents with acute onset severe lower back pain and bilateral leg weakness after heavy lifting. He has saddle anesthesia and urinary retention. MRI shows central disc herniation at L4-L5. What is the expected outcome with prompt treatment?

A 45-year-old man presents with acute severe lower back pain and leg weakness. MRI shows large central disc herniation with cauda equina compression. What is the surgical urgency?

A 24-year-old man presents with acute onset severe lower back pain and bilateral leg weakness. He has urinary retention and saddle anesthesia. What is the time frame for surgical intervention?

A 72-year-old man presents with confusion and agitation 3 days after hip surgery. He sees people who aren't there and is disoriented to time and place. What is the most likely diagnosis?

A 25-year-old man presents with acute onset severe lower back pain radiating down his left leg to the foot. He has difficulty walking and reports numbness in his left foot. Straight leg raise test is positive at 30 degrees. What is the most likely diagnosis?

A 33-year-old man presents with acute onset severe lower back pain radiating down both legs. He has bilateral leg weakness and urinary retention. MRI shows large central disc herniation at L4-L5. What is the most appropriate management?

A 31-year-old man presents with acute severe lower back pain and bilateral leg weakness developing over 6 hours. He has urinary retention and saddle anesthesia. What is the most appropriate immediate management?

A 23-year-old man presents with acute onset severe lower back pain after lifting heavy weights. He has bilateral leg weakness, saddle anesthesia, and urinary retention. What is the most appropriate immediate management?

A 49-year-old woman presents with an 18-month history of lower back pain and bilateral buttock pain. She reports morning stiffness lasting 75 minutes that improves with activity. She has a history of psoriasis and inflammatory bowel disease. HLA-B27 is positive. MRI sacroiliac joints shows bilateral bone marrow oedema and erosions. She has tried NSAIDs with partial relief. What is the most appropriate next step in management according to NICE guidelines?

Q10

A 74-year-old woman undergoes hemiarthroplasty for a displaced intracapsular neck of femur fracture. She has a history of atrial fibrillation, ischaemic heart disease, and type 2 diabetes mellitus. Post-operatively she develops confusion, pyrexia of 38.2°C, and a wound with purulent discharge on day 4. Blood cultures grow Staphylococcus aureus sensitive to flucloxacillin. What is the most appropriate definitive management?

Neck of femur fracture UK Medical PG Practice Questions and MCQs

Question 1: A 29-year-old man presents with acute onset severe lower back pain and bilateral leg weakness after heavy lifting. He has saddle anesthesia and urinary retention. MRI shows central disc herniation at L4-L5. What is the expected outcome with prompt treatment?

A. Complete recovery in all cases
B. Good functional recovery in most cases
C. Variable outcome depending on delay (Correct Answer)
D. Poor prognosis regardless of treatment
E. Recovery limited to bladder function

Explanation: ***Variable outcome depending on delay***- Cauda Equina Syndrome (CES) is a neurological emergency where prognosis, especially for **bladder** and **bowel function**, is highly dependent on the **time to surgical decompression**.- Delays in treatment, typically beyond 24-48 hours, significantly increase the risk of **permanent neurological deficits**, making the outcome highly unpredictable and variable.*Complete recovery in all cases*- Even with prompt surgical intervention, severe or prolonged compression often leads to some **residual neurological deficit**, particularly affecting **bladder, bowel, and sexual function**.- While early treatment improves outcomes, **complete recovery** in all aspects is not guaranteed due to the vulnerability of the cauda equina nerve roots to ischemic damage.*Good functional recovery in most cases*- The likelihood of **good functional recovery**, especially regarding **sphincter control**, is critically dependent on the timing of intervention and the severity of pre-operative deficits.- Many patients, particularly if surgery is delayed, experience long-term defects, making "good functional recovery in most cases" an overly optimistic assessment.*Poor prognosis regardless of treatment*- Prompt surgical decompression is crucial and significantly improves motor and sensory outcomes, offering the best chance for recovery of **sphincter function** and overall neurological improvement.- The prognosis for CES is highly dependent on the timeliness of treatment, meaning a poor prognosis is not inevitable if intervention is swift.*Recovery limited to bladder function*- Cauda Equina Syndrome (CES) affects multiple neurological functions, including **motor function** (leg weakness), **sensory function** (saddle anesthesia), and **autonomic function** (bladder and bowel control).- When recovery occurs, it typically involves improvements across motor, sensory, and autonomic domains, not exclusively bladder function, although bladder and bowel function are often the slowest and most challenging to recover fully.

Question 2: A 45-year-old man presents with acute severe lower back pain and leg weakness. MRI shows large central disc herniation with cauda equina compression. What is the surgical urgency?

A. Elective (weeks)
B. Urgent (days)
C. Emergency (hours) (Correct Answer)
D. No surgery needed
E. Depends on symptoms

Explanation: ***Emergency (hours)***- **Cauda Equina Syndrome (CES)** caused by acute central disc herniation requires immediate surgical decompression, ideally within **6 to 24 hours**, to maximize the chances of recovering full **neurological function**.- Delaying intervention significantly increases the risk of permanent disabling deficits, particularly **bladder and bowel incontinence** and **irreversible muscle weakness**.*Elective (weeks)*- Elective scheduling is appropriate only for stable conditions or those where chronic pain management is the primary goal, not for acute **nerve root compression syndromes**.- Delaying care by weeks in a confirmed CES case guarantees a poor prognosis regarding **sphincter and motor function**.*Urgent (days)*- While CES is highly urgent, characterizing it over *days* risks missing the critical window for decompression; the condition deteriorates rapidly.- Intervention for CES must be initiated immediately upon diagnosis (within **hours**), differentiating it from conditions that can safely wait 24–72 hours.*No surgery needed*- A mass lesion (large central disc herniation) causing acute **cauda equina compression** will not resolve adequately through conservative management alone.- Surgery is necessary to mechanically relieve the pressure on the nerve roots and prevent **permanent paralysis and sensory loss**.*Depends on symptoms*- The provided clinical presentation (acute severe low back pain and **leg weakness**) already suggests significant neurological compromise.- The combination of symptoms and the confirmed **cauda equina compression** on MRI elevates this to a non-negotiable surgical emergency, regardless of the precise degree of **sphincter dysfunction** at presentation.

Question 3: A 24-year-old man presents with acute onset severe lower back pain and bilateral leg weakness. He has urinary retention and saddle anesthesia. What is the time frame for surgical intervention?

A. Within 6 hours
B. Within 24-48 hours (Correct Answer)
C. Within 1 week
D. Within 1 month
E. No time limit

Explanation: ***Within 24–48 hours*** - This clinical presentation (severe low back pain, bilateral weakness, urinary retention, and **saddle anesthesia**) defines **Cauda Equina Syndrome (CES)**, a true neurosurgical emergency. - Urgent **surgical decompression** performed within the **24–48 hour** window is critical to maximize the likelihood of recovery, especially of fragile **bladder and bowel function**. *Within 6 hours* - While immediate intervention is ideal and preferred, **6 hours** is often an unfeasible or highly strict cutoff given the variability in symptom presentation and necessary preparatory steps (MRI, planning). - The key critical window recognized for achieving maximal recovery after diagnosis of **CES** spans up to 48 hours. *Within 1 week* - Delaying surgical decompression past the 48-hour mark dramatically increases the risk of **irreversible neurological injury**, particularly to the **sacral roots** controlling continence. - This timeframe is too slow for an acute compressive syndrome that leads to potential permanent **paralysis** and disability. *Within 1 month* - A delay of one month ensures **permanent neurological deficits**, including irreversible loss of motor function and **bladder/bowel control**. - This time frame is irrelevant to the management of an acute, progressive **cauda equina compression**. *No time limit* - **Cauda Equina Syndrome** is an urgent condition where prolonged compression results in direct **ischemic injury** and necrosis of the spinal nerve roots. - Lack of timely decompression guarantees poor long-term outcome and **permanent functional disability**, thus a time limit is essential.

Question 4: A 72-year-old man presents with confusion and agitation 3 days after hip surgery. He sees people who aren't there and is disoriented to time and place. What is the most likely diagnosis?

A. Dementia
B. Postoperative delirium (Correct Answer)
C. Alcohol withdrawal
D. Depression
E. Anxiety

Explanation: ***Postoperative delirium*** - This diagnosis perfectly fits the clinical picture: an acute onset of confusion, agitation, and **visual hallucinations** (seeing people who aren't there) in an elderly patient following a major stressor like hip surgery. - Delirium is an **acute, fluctuating disturbance** of attention and cognition, and advanced age combined with recent surgery is the most common risk factor for the postoperative subtype.*Dementia* - Dementia is characterized by a **chronic, progressive decline** in memory and other cognitive domains, which is inconsistent with the acute change observed over 3 days. - While individuals with pre-existing dementia are at high risk for delirium, the acute change itself is defined as **superimposed delirium**, not just dementia.*Alcohol withdrawal* - This diagnosis (especially **delirium tremens**) can cause agitation and prominent visual or tactile hallucinations, but it requires a history of **heavy chronic alcohol use** which is not specified. - Symptoms typically peak 48–96 hours after cessation, and while the timing is plausible, the recent major surgery provides a more direct and common cause for the observed presentation in the absence of a known history of substance abuse.*Depression* - Depression presents with mood disturbances, anhedonia, and vegetative symptoms, but it does **not cause acute, global disorientation** or **frank visual hallucinations**. - Although severe depression can cause cognitive slowing (**pseudodementia**), it lacks the acute-onset, hyperactive agitated state frequently seen in delirium.*Anxiety* - Anxiety is characterized by excessive worry, tension, and autonomic symptoms, but it does **not cause acute disorientation** to time and place or complex **visual hallucinations**. - The patient's confusion and disorientation indicate a global disturbance of cortical function, which is not characteristic of primary anxiety disorders.

Question 5: A 25-year-old man presents with acute onset severe lower back pain radiating down his left leg to the foot. He has difficulty walking and reports numbness in his left foot. Straight leg raise test is positive at 30 degrees. What is the most likely diagnosis?

A. Mechanical back pain
B. Lumbar disc herniation (Correct Answer)
C. Spinal stenosis
D. Cauda equina syndrome
E. Ankylosing spondylitis

Explanation: ***Lumbar disc herniation*** - The presentation of **acute onset severe lower back pain** radiating down the left leg to the foot, along with **numbness in the left foot** and difficulty walking, are classic signs of nerve root compression. - A **positive straight leg raise test at 30 degrees** is a strong indicator of nerve root irritation, highly suggestive of lumbar disc herniation. *Mechanical back pain* - **Mechanical back pain** is typically localized axial pain, aggravated by movement, and **does not cause radicular symptoms** or objective neurological deficits such as foot numbness or weakness. - This diagnosis would not explain the **positive straight leg raise test** or the specific neurological symptoms in the left leg and foot. *Spinal stenosis* - **Spinal stenosis** usually affects older patients, presenting with **neurogenic claudication** (leg pain relieved by sitting or forward flexion) rather than acute, severe unilateral radiculopathy in a 25-year-old. - The onset is typically insidious and chronic, not acute, and it often involves bilateral leg symptoms. *Cauda equina syndrome* - **Cauda equina syndrome** is a serious emergency characterized by **saddle anesthesia**, **bowel or bladder dysfunction** (e.g., urinary retention), and often bilateral leg weakness, none of which are reported here. - While it can cause severe lower back pain and leg symptoms, the absence of these hallmark

Question 6: A 33-year-old man presents with acute onset severe lower back pain radiating down both legs. He has bilateral leg weakness and urinary retention. MRI shows large central disc herniation at L4-L5. What is the most appropriate management?

A. Conservative management
B. Epidural steroid injection
C. Emergency surgical decompression (Correct Answer)
D. Physiotherapy
E. Bed rest

Explanation: ***Emergency surgical decompression***- The combination of **bilateral leg weakness**, severe pain, and most critically, **urinary retention**, secondary to a **large central disc herniation**, indicates **Cauda Equina Syndrome (CES)**.- **Cauda Equina Syndrome** is a **neurosurgical emergency** requiring **immediate surgical decompression** to prevent permanent neurological deficits, such as irreversible bladder and bowel dysfunction.*Conservative management*- This approach is appropriate for patients with uncomplicated **radiculopathy** (sciatica) without progressive motor deficits or sphincter dysfunction.- Delaying surgery in the presence of **Cauda Equina Syndrome** leads to a high risk of permanent and debilitating neurological damage.*Epidural steroid injection*- These injections are used for managing persistent, isolated **radicular pain** due to disc herniation that does not respond to oral medication and rest.- They do not address the urgent **mechanical compression** on the cauda equina nerves that is causing the emergent neurological deficit and sphincter dysfunction.*Physiotherapy*- Physiotherapy is crucial for rehabilitation following surgery or for managing subacute and chronic mechanical back pain.- Starting therapy immediately in acute **Cauda Equina Syndrome** is inappropriate and risks delaying necessary **surgical decompression**.*Bed rest*- Prolonged bed rest is generally discouraged for acute lower back pain due to risks of **deconditioning** and stiffness.- It is an ineffective and harmful action in a patient presenting with an **acute neurosurgical emergency** like **Cauda Equina Syndrome**.

Question 7: A 31-year-old man presents with acute severe lower back pain and bilateral leg weakness developing over 6 hours. He has urinary retention and saddle anesthesia. What is the most appropriate immediate management?

A. MRI lumbar spine
B. High-dose corticosteroids
C. Emergency surgical decompression (Correct Answer)
D. Bed rest and analgesia
E. Physiotherapy referral

Explanation: ***Emergency surgical decompression*** - The presentation of acute severe back pain, bilateral leg weakness, **urinary retention**, and **saddle anesthesia** defines **Cauda Equina Syndrome (CES)**, which is a life-threatening surgical emergency. - **Urgent surgical decompression** (laminotomy/discectomy) is the most critical immediate management step, typically required within 48 hours, to alleviate nerve root compression and preserve neurological function. *MRI lumbar spine* - While an **MRI** is the definitive imaging modality required to confirm the diagnosis, the treatment (decompression) based on the clear clinical findings must be initiated simultaneously and not wait for the scan. - Delaying treatment while focusing solely on imaging can lead to irreversible damage to the lower motor neurons controlling bladder and bowel function. *High-dose corticosteroids* - Corticosteroids may be used in cases of **spinal cord trauma** or inflammatory conditions (e.g., transverse myelitis) to reduce edema, but they are not the primary treatment for mechanical CES. - Steroids lack proven efficacy in improving outcomes for CES caused by **acute mechanical compression** (e.g., massive disc herniation). *Bed rest and analgesia* - This conservative approach is appropriate for simple, self-limiting **lumbago** or uncomplicated radiculopathy, but it is wholly inadequate for CES. - CES requires immediate intervention; relying on bed rest guarantees progression of neurological deficits and permanent loss of **bladder and bowel control**. *Physiotherapy referral* - Physiotherapy is essential for rehabilitation *after* definitive surgical decompression and stabilization has been achieved. - Referral in the acute setting would delay emergency intervention and is contraindicated as movement could potentially worsen the underlying **mass effect** compressing the nerve roots.

Question 8: A 23-year-old man presents with acute onset severe lower back pain after lifting heavy weights. He has bilateral leg weakness, saddle anesthesia, and urinary retention. What is the most appropriate immediate management?

A. MRI lumbar spine
B. Emergency surgical decompression (Correct Answer)
C. High-dose corticosteroids
D. Bed rest and analgesia
E. Physiotherapy

Explanation: ***Emergency surgical decompression***- The combination of **acute severe lower back pain**, **bilateral leg weakness**, **saddle anesthesia**, and **urinary retention** is the classic presentation of **Cauda Equina Syndrome (CES)**, which is a neurosurgical emergency.- Immediate surgical decompression is the definitive treatment required to relieve pressure on the cauda equina nerve roots and prevent **permanent neurological deficits**, especially irreversible **bladder and bowel dysfunction**.*MRI lumbar spine*- While an **MRI lumbar spine** is crucial for diagnosing **Cauda Equina Syndrome** and localizing the lesion, it is a diagnostic tool, not the immediate management itself.- Delaying definitive surgical treatment by solely ordering an MRI can lead to **worsening neurological outcomes** if decompression is not performed urgently.*High-dose corticosteroids*- **High-dose corticosteroids** are typically used in conditions like acute spinal cord injury to reduce inflammation, but their benefit in **Cauda Equina Syndrome** is not established and they do not address the mechanical compression.- They are not a substitute for **surgical decompression** in CES and can have significant side effects, further delaying appropriate treatment.*Bed rest and analgesia*- **Bed rest and analgesia** are appropriate for uncomplicated low back pain or minor disc herniations without neurological compromise.- In the presence of **bilateral leg weakness, saddle anesthesia, and urinary retention**, indicating **Cauda Equina Syndrome**, this management is wholly insufficient and will lead to **permanent neurological damage**.*Physiotherapy*- **Physiotherapy** is beneficial for chronic back pain and rehabilitation after an injury or surgery, but it is contraindicated in the acute phase of **Cauda Equina Syndrome**.- Performing physiotherapy without addressing the underlying **compressive lesion** can exacerbate symptoms and worsen neurological deficits.

Question 9: A 49-year-old woman presents with an 18-month history of lower back pain and bilateral buttock pain. She reports morning stiffness lasting 75 minutes that improves with activity. She has a history of psoriasis and inflammatory bowel disease. HLA-B27 is positive. MRI sacroiliac joints shows bilateral bone marrow oedema and erosions. She has tried NSAIDs with partial relief. What is the most appropriate next step in management according to NICE guidelines?

A. Add sulfasalazine to current treatment
B. Commence anti-TNF biological therapy (e.g., adalimumab)
C. Add methotrexate to current treatment
D. Trial of two different NSAIDs at maximum dose for 4 weeks each with physiotherapy before considering biologics (Correct Answer)
E. Commence oral prednisolone 20mg daily

Explanation: ***Trial of two different NSAIDs at maximum dose for 4 weeks each with physiotherapy before considering biologics*** - According to **NICE guidelines (NG65)** for axial spondyloarthritis, patients must demonstrate an inadequate response to at least **two different NSAIDs** used at the maximum tolerated dose for 4 weeks each before escalating therapy to biologics. - **Physiotherapy** and a structured exercise program are fundamental **first-line non-pharmacological interventions** that should be maximized alongside NSAIDs. *Add sulfasalazine to current treatment* - **Sulfasalazine** is a disease-modifying antirheumatic drug (DMARD) that is effective for **peripheral arthritis** associated with spondyloarthritis but has **no proven efficacy for axial (spinal) disease**. - While the patient has IBD, adding sulfasalazine specifically for her **sacroiliitis** is not the appropriate next step in management according to guidelines. *Commence anti-TNF biological therapy (e.g., adalimumab)* - **Anti-TNF biological therapy** is indicated only if the disease remains active (e.g., **BASDAI score ≥4**) after the failure of conventional treatment, which includes an adequate trial of **two different NSAIDs**. - Starting biologics prematurely, without completing the **NICE-mandated NSAID trial**, is not in line with current guidelines. *Add methotrexate to current treatment* - Similar to sulfasalazine, **methotrexate** is considered ineffective for the treatment of **axial spondyloarthritis** and spinal inflammation. - It may be used for **psoriatic skin disease** or peripheral joint involvement, but it is not the recommended next step for managing worsening **inflammatory back pain**. *Commence oral prednisolone 20mg daily* - **Oral corticosteroids** are generally not recommended for the long-term management of axial spondyloarthritis due to a lack of strong evidence for sustained efficacy in axial symptoms and the risk of significant **side effects**. - Systemic steroids are not part of the standard **NICE treatment algorithm** for axial spondyloarthritis. Local corticosteroid injections might be considered for specific peripheral joints, but not systemic use for axial disease.

Question 10: A 74-year-old woman undergoes hemiarthroplasty for a displaced intracapsular neck of femur fracture. She has a history of atrial fibrillation, ischaemic heart disease, and type 2 diabetes mellitus. Post-operatively she develops confusion, pyrexia of 38.2°C, and a wound with purulent discharge on day 4. Blood cultures grow Staphylococcus aureus sensitive to flucloxacillin. What is the most appropriate definitive management?

A. Six weeks of intravenous flucloxacillin
B. Revision surgery to remove prosthesis with antibiotic spacer insertion (Correct Answer)
C. Washout of joint and debridement with prosthesis retention and long-term antibiotics
D. Two weeks intravenous flucloxacillin followed by four weeks oral flucloxacillin
E. Arthroscopic washout and two weeks intravenous antibiotics

Explanation: ***Revision surgery to remove prosthesis with antibiotic spacer insertion***- In the context of an acute **prosthetic joint infection (PJI)** with systemic sepsis and **Staphylococcus aureus** bacteraemia, removing the infected hardware is the definitive step to achieve **source control**.- A **two-stage revision** or a Girdlestone-type procedure with an **antibiotic spacer** is indicated when the risk of biofilm persistence is high, ensuring the highest rate of infection eradication.*Six weeks of intravenous flucloxacillin*- Systemic antibiotics alone are insufficient for **definitive management** because bacteria form a protective **biofilm** on the surface of the prosthetic material.- Failure to surgically address the hardware will inevitably lead to **treatment failure** and recurrence of infection once antibiotics are ceased.*Washout of joint and debridement with prosthesis retention and long-term antibiotics*- This protocol, known as **DAIR** (Debridement, Antibiotics, and Implant Retention), is typically reserved for early infections (<3-4 weeks) with organisms less virulent than **S. aureus** and without systemic sepsis, having a high failure rate in such cases.- Given the patient's **systemic symptoms** (pyrexia, confusion) and **Staphylococcus aureus** bacteraemia, a more aggressive surgical intervention involving implant removal is preferred for definitive clearance due to the high risk of biofilm persistence.*Two weeks intravenous flucloxacillin followed by four weeks oral flucloxacillin*- This antibiotic duration is often used post-operatively for prophylaxis or minor infections but does not constitute **definitive management** in the presence of an infected prosthesis with systemic signs.- Without removing the nidus of infection (the **hemiarthroplasty**), oral step-down therapy will not penetrate the established **biofilm** effectively, leading to treatment failure.*Arthroscopic washout and two weeks intravenous antibiotics*- **Arthroscopic debridement** is inadequate for prosthetic joint infections, especially in the hip, as it does not allow for thorough **synovectomy** or exchange of modular components, which is crucial for infection control.- **Open debridement** or full revision is required to adequately reduce the bacterial load and manage the infected tissue effectively, particularly with established **purulent discharge** and systemic infection.

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