Orthopaedics & MSK — MCQs
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A 53-year-old heavy goods vehicle driver presents with a 3-week history of mechanical lower back pain with no radiation. He has no red flag symptoms. Neurological examination is normal. He is worried about his ability to work. What is the most appropriate management advice regarding return to work?
A 69-year-old man undergoes cemented hemiarthroplasty for a displaced intracapsular neck of femur fracture. During cement insertion, he suddenly develops hypotension (BP 75/40 mmHg), hypoxia (SpO2 82%), and loss of consciousness. What is the underlying pathophysiological mechanism of this complication?
A 41-year-old woman presents with a 4-month history of lower back pain radiating down the posterior aspect of her right leg to the heel. She describes paraesthesia in the lateral aspect of her foot and weakness when walking on her toes. Straight leg raise is positive at 40 degrees on the right. Which nerve root is most likely affected?
A 76-year-old woman with Parkinson's disease sustains an undisplaced intracapsular neck of femur fracture. She was independently mobile with a walking stick prior to the fall. Her comorbidities include controlled hypertension and osteoporosis. What is the most appropriate surgical management?
Which anatomical feature determines whether a neck of femur fracture is classified as intracapsular or extracapsular?
A 65-year-old woman presents with a 6-week history of progressively worsening lower back pain. She describes the pain as constant, worse at night, and not relieved by rest. She has lost 5 kg in weight over the past 2 months. Blood tests show: Hb 102 g/L, ESR 78 mm/hr, corrected calcium 2.85 mmol/L, ALP 245 U/L. What is the single most important next investigation?
A 71-year-old man undergoes total hip replacement for a displaced intracapsular neck of femur fracture. Post-operatively on day 2, he develops acute onset confusion, respiratory distress with oxygen saturation of 88% on room air, tachycardia, and petechial rash over his chest. What is the most likely diagnosis?
A 74-year-old woman sustains a neck of femur fracture following a low-energy fall. The fracture line is located at the junction between the femoral neck and the intertrochanteric region. Which anatomical classification best describes this fracture pattern?
A 79-year-old woman sustains a displaced intracapsular neck of femur fracture. She was previously independent and walked daily without aids. She has mild cognitive impairment (AMTS 8/10) but manages her own finances and medications. Her medical history includes well-controlled hypertension. What is the most appropriate surgical management to optimize her functional outcome?
A 56-year-old builder presents with a 12-month history of lower back pain and morning stiffness. Examination reveals reduced lumbar spine flexion (modified Schober's test 3cm, normal >5cm) and reduced chest expansion (2cm, normal >5cm). Radiographs show bilateral sacroiliitis and squaring of vertebral bodies. He is HLA-B27 positive. What is the most appropriate initial pharmacological management?
Orthopaedics & MSK UK Medical PG Practice Questions and MCQs
Question 201: A 53-year-old heavy goods vehicle driver presents with a 3-week history of mechanical lower back pain with no radiation. He has no red flag symptoms. Neurological examination is normal. He is worried about his ability to work. What is the most appropriate management advice regarding return to work?
- A. Advise complete bed rest for 2 weeks before considering return to work
- B. Recommend remaining off work until pain has completely resolved
- C. Advise early return to normal activities including work, with temporary modified duties if needed (Correct Answer)
- D. Certify unfit for work for 6 weeks and arrange physiotherapy
- E. Advise against returning to driving duties and recommend permanent job modification
Explanation: ***Advise early return to normal activities including work, with temporary modified duties if needed*** - For **non-specific mechanical back pain** without **red flags** or neurological deficits, guidelines strongly recommend staying active and an **early return to work** to prevent chronicity and deconditioning. - **Temporary modified duties** or a **graded return to work** facilitates a smoother reintegration into occupational activities, managing symptoms while maintaining function. *Advise complete bed rest for 2 weeks before considering return to work* - Prolonged **bed rest** is contraindicated for mechanical back pain as it delays recovery, leads to muscle **deconditioning**, and increases the risk of chronic pain. - Current evidence advocates for **minimal or no bed rest**, with an emphasis on maintaining usual activities as tolerated. *Recommend remaining off work until pain has completely resolved* - Waiting for **complete pain resolution** is often an unrealistic goal and can foster **fear-avoidance behaviors** and increase the likelihood of long-term work disability. - Patients should be encouraged to self-manage symptoms while gradually increasing their activity levels and returning to work, as some discomfort may persist during recovery. *Certify unfit for work for 6 weeks and arrange physiotherapy* - A **6-week absence** for acute non-specific mechanical back pain is excessive and is recognized as a **yellow flag** for the development of chronic disability. - While **physiotherapy** can be helpful, it should support an active recovery and early return to work, rather than being a justification for prolonged time off. *Advise against returning to driving duties and recommend permanent job modification* - There is **no medical justification** in this clinical scenario (absence of red flags, normal neurological exam) to suggest a permanent disability or to restrict the patient from driving. - Recommending **permanent job modification** at 3 weeks is premature; focus should be on recovery, ergonomic advice, and temporary adjustments if required.
Question 202: A 69-year-old man undergoes cemented hemiarthroplasty for a displaced intracapsular neck of femur fracture. During cement insertion, he suddenly develops hypotension (BP 75/40 mmHg), hypoxia (SpO2 82%), and loss of consciousness. What is the underlying pathophysiological mechanism of this complication?
- A. Anaphylactic reaction to bone cement methylmethacrylate
- B. Embolization of fat, air, cement particles and marrow contents causing pulmonary hypertension and right heart strain (Correct Answer)
- C. Acute left ventricular failure due to cement toxicity
- D. Intraoperative cerebrovascular accident due to cement embolus
- E. Vasovagal response to surgical pain and stress
Explanation: ***Embolization of fat, air, cement particles and marrow contents causing pulmonary hypertension and right heart strain*** - This clinical presentation is characteristic of **Bone Cement Implantation Syndrome (BCIS)**, where high intramedullary pressure during cement insertion forces marrow contents into the **venous circulation**. - This leads to increased **pulmonary vascular resistance**, resulting in **pulmonary hypertension**, acute **right ventricular strain**, and subsequent **hypotension** and **hypoxia**. *Anaphylactic reaction to bone cement methylmethacrylate* - While bone cement (methylmethacrylate) can rarely cause hypersensitivity, a **true systemic anaphylactic reaction** leading to such profound cardiorespiratory collapse is extremely uncommon. - The immediate onset linked to **cement pressurization** during orthopaedic surgery points more strongly towards a mechanical embolic event rather than an immune-mediated response. *Acute left ventricular failure due to cement toxicity* - Although some components of bone cement can have minor direct **vasodilatory effects**, the primary pathophysiology in BCIS is typically **right heart strain** from pulmonary embolism, not primary acute left ventricular failure. - Systemic hypotension in BCIS is predominantly a consequence of severe right ventricular dysfunction and subsequent **reduced left ventricular preload**. *Intraoperative cerebrovascular accident due to cement embolus* - An intraoperative **cerebrovascular accident (CVA)** would typically manifest with focal neurological deficits, which are not the predominant features described here (hypotension, hypoxia, loss of consciousness). - For an embolus to reach the cerebral circulation, a **right-to-left shunt** (e.g., patent foramen ovale) would generally be required, and the primary issue is cardiorespiratory collapse. *Vasovagal response to surgical pain and stress* - A **vasovagal response** typically causes **bradycardia** and transient hypotension, but it is rarely associated with such severe and persistent **hypoxia (SpO2 82%)** and loss of consciousness. - The specific timing during the high-risk phase of **cement insertion** in an elderly patient points toward a more severe, cement-related complication.
Question 203: A 41-year-old woman presents with a 4-month history of lower back pain radiating down the posterior aspect of her right leg to the heel. She describes paraesthesia in the lateral aspect of her foot and weakness when walking on her toes. Straight leg raise is positive at 40 degrees on the right. Which nerve root is most likely affected?
- A. L3
- B. L4
- C. L5
- D. S1 (Correct Answer)
- E. S2
Explanation: ***S1*** - The patient's symptoms of pain radiating down the **posterior aspect of the leg to the heel**, paraesthesia in the **lateral aspect of the foot**, and weakness with **plantarflexion** (difficulty walking on toes) are classic signs of **S1 radiculopathy**. - A positive **straight leg raise** further indicates nerve root compression, and S1 involvement is strongly suggested by the sensory distribution and motor deficit. *L3* - **L3 radiculopathy** typically presents with pain and sensory changes in the **anterior thigh** and medial aspect of the knee. - Motor weakness would involve **hip flexion** and **knee extension**, which are distinct from the patient's symptoms. *L4* - Symptoms of **L4 radiculopathy** primarily involve pain and sensory loss over the **medial leg** and ankle. - Weakness would be noted in **knee extension** (quadriceps) and a diminished **patellar reflex** would be expected. *L5* - **L5 radiculopathy** characteristically causes pain and sensory loss in the **lateral aspect of the leg**, **dorsum of the foot**, and the first web space. - Motor weakness typically affects **foot dorsiflexion** and **big toe extension**, leading to a **foot drop**, not difficulty walking on toes. *S2* - **S2 nerve root** involvement usually presents with sensory deficits in the **posterior thigh** and perineum. - While it contributes to plantarflexion, the specific **lateral aspect of the foot** and heel sensory loss is a key differentiating feature of S1.
Question 204: A 76-year-old woman with Parkinson's disease sustains an undisplaced intracapsular neck of femur fracture. She was independently mobile with a walking stick prior to the fall. Her comorbidities include controlled hypertension and osteoporosis. What is the most appropriate surgical management?
- A. Internal fixation with cannulated screws
- B. Total hip replacement (Correct Answer)
- C. Cemented hemiarthroplasty
- D. Uncemented hemiarthroplasty
- E. Dynamic hip screw fixation
Explanation: ***Total hip replacement***- According to **NICE guidelines**, patients who are fit, medically stable, and able to **walk outdoors** independently with no more than one stick before the fracture should be offered a **total hip replacement (THR)**.- THR provides superior **long-term functional outcomes**, lower revision rates, and better quality of life compared to hemiarthroplasty in active elderly patients.*Internal fixation with cannulated screws*- While used for **undisplaced intracapsular fractures**, it carries a high risk (20-30%) of **avascular necrosis** and non-union in the elderly population.- In patients over age 65, **arthroplasty** is generally preferred over fixation to allow immediate weight-bearing and avoid late failure.*Cemented hemiarthroplasty*- This is the treatment of choice for patients who do not meet the criteria for THR, such as those with **significant cognitive impairment** or limited pre-injury mobility.- Although this patient has **Parkinson's disease**, her high functional status (mobile with one stick) makes her a better candidate for the superior longevity of **THR**.*Uncemented hemiarthroplasty*- **Uncemented hemiarthroplasty** is generally discouraged as it is associated with a higher risk of **periprosthetic fractures** and slower recovery in older patients.- **Cemented fixation** is evidence-based and preferred to ensure better implant stability and lower post-operative pain.*Dynamic hip screw fixation*- A **dynamic hip screw (DHS)** is the gold standard for **extracapsular (trochanteric)** fractures, not intracapsular fractures.- Using a DHS for an **intracapsular fracture** would be inappropriate as it does not address the risk of vascular compromise to the femoral head.
Question 205: Which anatomical feature determines whether a neck of femur fracture is classified as intracapsular or extracapsular?
- A. The attachment of the joint capsule from the intertrochanteric line anteriorly to the intertrochanteric crest posteriorly (Correct Answer)
- B. The position relative to the lesser trochanter
- C. The blood supply from the medial and lateral circumflex femoral arteries
- D. The location above or below the level of the greater trochanter
- E. The orientation of the fracture line relative to Shenton's line
Explanation: ***The attachment of the joint capsule from the intertrochanteric line anteriorly to the intertrochanteric crest posteriorly***- This anatomical boundary precisely determines whether a neck of femur fracture is **intracapsular** (within the joint capsule) or **extracapsular** (outside the joint capsule).- The **joint capsule** attaches anteriorly to the intertrochanteric line and posteriorly to a line proximal to the intertrochanteric crest.*The position relative to the lesser trochanter*- The **lesser trochanter** is a landmark for classifying fractures as subtrochanteric, which are typically **extracapsular** fractures.- While important for surgical planning and describing fracture patterns, it does not define the **capsular limits** of the hip joint itself.*The blood supply from the medial and lateral circumflex femoral arteries*- The **blood supply** is a crucial clinical consideration, as intracapsular fractures often disrupt the **retinacular vessels**, leading to a high risk of **avascular necrosis**.- However, the classification of the fracture as intracapsular or extracapsular is based on its anatomical location relative to the capsule, not on the compromise of the **femoral head blood supply**.*The location above or below the level of the greater trochanter*- The **greater trochanter** is a prominent bony landmark primarily used to define **extracapsular** fractures, such as intertrochanteric fractures.- It does not serve as the direct anatomical determinant for the boundary of the **joint capsule** itself.*The orientation of the fracture line relative to Shenton's line*- **Shenton's line** is a radiographic arc formed by the medial border of the femoral neck and the inferior border of the superior pubic ramus, used to identify hip **dislocations** or femoral neck shortening.- It is a **radiological sign** indicating the integrity of the hip joint, not an anatomical feature defining the intracapsular or extracapsular classification of a fracture.
Question 206: A 65-year-old woman presents with a 6-week history of progressively worsening lower back pain. She describes the pain as constant, worse at night, and not relieved by rest. She has lost 5 kg in weight over the past 2 months. Blood tests show: Hb 102 g/L, ESR 78 mm/hr, corrected calcium 2.85 mmol/L, ALP 245 U/L. What is the single most important next investigation?
- A. Whole spine MRI (Correct Answer)
- B. Bone density scan (DEXA)
- C. Plain radiographs of lumbar spine
- D. CT abdomen and pelvis
- E. Lumbar puncture
Explanation: ***Whole spine MRI*** - This patient presents with multiple **red flags** for spinal malignancy, including constant pain worse at night, **weight loss**, and laboratory markers like **anemia**, **hypercalcemia**, and a markedly raised **ESR**.- **Whole spine MRI** is the gold-standard investigation to detect **metastatic disease** in the spine, assess bone marrow involvement, and identify potential **spinal cord compression**, which is critical given her symptoms.*Bone density scan (DEXA)* - **DEXA scans** are used to diagnose **osteoporosis** by measuring bone mineral density and are not suitable for investigating acute, progressive back pain with systemic symptoms.- It cannot detect **malignant infiltration** or provide detailed structural information about the vertebral column in the context of suspected cancer.*Plain radiographs of lumbar spine* - X-rays are **insensitive for early malignancy**, as significant bone destruction (up to 30-50%) must occur before a lesion becomes visible.- They lack the detail to assess **soft tissue involvement**, bone marrow changes, or potential **spinal cord compression**.*CT abdomen and pelvis* - While a **CT abdomen and pelvis** may help in locating a **primary tumor**, it is not the most important *next* investigation for the direct cause of the patient's back pain.- The immediate priority is to evaluate the spine itself for malignancy and potential **neurological compromise** before staging the systemic disease.*Lumbar puncture* - This procedure is primarily used to investigate **meningitis**, encephalitis, or **subarachnoid hemorrhage**, which do not match this patient's presentation.- Performing a lumbar puncture in the presence of a potential **spinal mass** can be dangerous and provides no diagnostic value for suspected bone metastases.
Question 207: A 71-year-old man undergoes total hip replacement for a displaced intracapsular neck of femur fracture. Post-operatively on day 2, he develops acute onset confusion, respiratory distress with oxygen saturation of 88% on room air, tachycardia, and petechial rash over his chest. What is the most likely diagnosis?
- A. Pulmonary embolism
- B. Fat embolism syndrome (Correct Answer)
- C. Bone cement implantation syndrome
- D. Hospital-acquired pneumonia
- E. Acute myocardial infarction
Explanation: ***Fat embolism syndrome*** - This patient exhibits the classic triad of **fat embolism syndrome (FES)**: respiratory distress, neurological impairment (**confusion**), and a pathognomonic **petechial rash** post-orthopaedic surgery. - FES typically manifests **24-72 hours** after a long bone or pelvic fracture/surgery due to the release of fat globules into the systemic circulation. *Pulmonary embolism* - While it presents with **tachycardia** and **respiratory distress**, it does not typically cause a **petechial rash** or immediate acute confusion. - **Venous thromboembolism** usually develops slightly later in the post-operative period compared to the rapid onset seen with fat globules. *Bone cement implantation syndrome* - This typically occurs **intraoperatively** (during cementation or prosthesis insertion) or in the immediate recovery period, not 2 days post-operatively. - It is characterized by sudden **hypotension**, hypoxia, and cardiac arrhythmias due to the release of methyl methacrylate into the bloodstream. *Hospital-acquired pneumonia* - While pneumonia causes hypoxia and distress, it would usually be accompanied by **fever**, productive cough, and specific **infiltrates on chest X-ray**. - Fever and hypoxia could explain confusion in the elderly (delirium), but pneumonia does not explain the **petechial rash** on the chest. *Acute myocardial infarction* - MI should be considered in elderly post-op patients but presents primarily with **chest pain**, ECG changes, or elevated **troponins**. - It does not present with a **petechial rash**, which is a highly specific marker for fat embolization in this clinical context.
Question 208: A 74-year-old woman sustains a neck of femur fracture following a low-energy fall. The fracture line is located at the junction between the femoral neck and the intertrochanteric region. Which anatomical classification best describes this fracture pattern?
- A. Intracapsular fracture
- B. Basicervical fracture (Correct Answer)
- C. Intertrochanteric fracture
- D. Subtrochanteric fracture
- E. Transcervical fracture
Explanation: ***Basicervical fracture***- A **basicervical fracture** occurs specifically at the base of the femoral neck, representing the junction between the neck and the **intertrochanteric region**.- While technically **extracapsular**, it is physiologically unique because it lacks the cancellous bone interlocking found in intertrochanteric fractures, often requiring stable **internal fixation**.*Intracapsular fracture*- These occur within the **hip joint capsule** and include subcapital and transcervical patterns.- They carry a high risk of damaging the **medial circumflex femoral artery**, leading to **avascular necrosis (AVN)** of the femoral head.*Intertrochanteric fracture*- This fracture pattern occurs further distal than a basicervical fracture, specifically between the **greater and lesser trochanters**.- It is characterized by being **extracapsular** and typically having a better blood supply and higher **healing potential** than neck fractures.*Subtrochanteric fracture*- This occurs in the region extending from the **lesser trochanter** to approximately 5 cm distal into the femoral shaft.- These are often associated with high-energy trauma or **atypical patterns** related to long-term bisphosphonate use.*Transcervical fracture*- This is a type of **intracapsular fracture** that occurs across the mid-portion of the **femoral neck**.- Unlike basicervical fractures, these are located entirely within the capsule and are more likely to result in **non-union** if blood supply is disrupted.
Question 209: A 79-year-old woman sustains a displaced intracapsular neck of femur fracture. She was previously independent and walked daily without aids. She has mild cognitive impairment (AMTS 8/10) but manages her own finances and medications. Her medical history includes well-controlled hypertension. What is the most appropriate surgical management to optimize her functional outcome?
- A. Hemiarthroplasty
- B. Total hip replacement (Correct Answer)
- C. Cannulated screw fixation
- D. Dynamic hip screw
- E. Conservative management with early mobilisation
Explanation: ***Total hip replacement*** - This patient meets the criteria for **Total hip replacement (THR)**: she was independently mobile outdoors without an aid, has an **AMTS 8/10**, and is medically fit for the procedure. - THR is preferred in high-functioning elderly patients with **displaced intracapsular fractures** because it offers superior long-term **functional outcomes**, less pain, and lower re-operation rates compared to hemiarthroplasty. *Hemiarthroplasty* - This is typically reserved for patients who are less active, have **significant cognitive impairment**, or use mobility aids outdoors pre-injury. - While it has a lower **dislocation rate** and shorter operative time, it results in inferior long-term functional mobility and a higher risk of **acetabular wear** (erosion) in active patients. *Cannulated screw fixation* - This method of **internal fixation** is generally reserved for **undisplaced** intracapsular fractures or very young patients where preserving the femoral head is a priority. - In a 79-year-old with a **displaced** fracture, fixation carries an unacceptably high risk of **avascular necrosis** and non-union (failure of fixation). *Dynamic hip screw* - A **Dynamic hip screw (DHS)** is the gold standard surgical treatment for **extracapsular (trochanteric)** hip fractures, not intracapsular ones. - Applying a DHS to a displaced intracapsular fracture does not address the disrupted **blood supply** to the femoral head and is likely to result in surgical failure. *Conservative management with early mobilisation* - This approach is rarely indicated and is associated with high **mortality**, chronic pain, and permanent loss of mobility in hip fracture patients. - It is only considered in patients with extremely high **perioperative risk** where death is imminent and surgery would not improve comfort.
Question 210: A 56-year-old builder presents with a 12-month history of lower back pain and morning stiffness. Examination reveals reduced lumbar spine flexion (modified Schober's test 3cm, normal >5cm) and reduced chest expansion (2cm, normal >5cm). Radiographs show bilateral sacroiliitis and squaring of vertebral bodies. He is HLA-B27 positive. What is the most appropriate initial pharmacological management?
- A. Oral prednisolone 30mg daily
- B. Methotrexate 15mg weekly
- C. NSAIDs (e.g., naproxen) regularly with physiotherapy (Correct Answer)
- D. Anti-TNF biological therapy (e.g., adalimumab)
- E. Sulfasalazine 2g daily
Explanation: ***NSAIDs (e.g., naproxen) regularly with physiotherapy*** - **NSAIDs** are the **first-line pharmacological treatment** for axial spondyloarthritis, including ankylosing spondylitis, effectively reducing pain and stiffness caused by inflammation. - **Physiotherapy** is crucial alongside medication to maintain **spinal mobility**, improve posture, and prevent functional decline in patients with ankylosing spondylitis. *Oral prednisolone 30mg daily* - **Systemic corticosteroids** have limited efficacy for the axial (spinal and sacroiliac) symptoms of ankylosing spondylitis and are not recommended as initial therapy. - They are typically reserved for treating **peripheral arthritis** or **extra-articular manifestations** like acute anterior uveitis, often via local injection rather than high-dose oral administration. *Methotrexate 15mg weekly* - **Methotrexate**, a conventional DMARD, has **no proven efficacy** for the axial symptoms (sacroiliitis, spinal stiffness) that characterize this patient's presentation. - Its use is primarily limited to patients with significant **peripheral arthritis** associated with spondyloarthritis. *Anti-TNF biological therapy (e.g., adalimumab)* - **Anti-TNF biological therapies** are highly effective but are reserved for patients who have failed an adequate trial of at least **two different NSAIDs**. - They are considered when there is persistent **high disease activity** despite conventional management, not as initial treatment. *Sulfasalazine 2g daily* - **Sulfasalazine** is ineffective for managing the axial symptoms, such as **sacroiliitis** and **spinal stiffness**, which are prominent in this patient. - Like methotrexate, its role in spondyloarthritis is confined to treating **peripheral joint involvement**.
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