A 55-year-old woman sustains a basicervical neck of femur fracture following a fall. She is fit and active with no significant comorbidities. Radiographs confirm the fracture extends from the base of the femoral neck to the intertrochanteric region. What is the most appropriate surgical fixation method?
Q232
A 68-year-old woman with rheumatoid arthritis presents with a 3-month history of progressive lower back pain and bilateral leg weakness. She reports difficulty walking and recent episodes of urinary incontinence. On examination, she has increased tone in both lower limbs with brisk knee reflexes, upgoing plantars bilaterally, and a sensory level at T10. What is the most likely diagnosis?
Q233
A 32-year-old builder presents with acute onset lower back pain after lifting heavy equipment. The pain radiates down the posterior aspect of his left leg to the heel. He describes sharp shooting pains and reports difficulty standing on tiptoe on the left foot. On examination, there is reduced sensation over the lateral border and sole of the left foot, and weakness of plantarflexion. The ankle jerk is diminished on the left. Which nerve root is most likely affected?
Q234
What is the classification system most commonly used to describe intracapsular neck of femur fractures based on the degree of displacement?
Q235
An 82-year-old man undergoes a hemiarthroplasty for a displaced intracapsular neck of femur fracture. Post-operatively on day 1, he becomes acutely confused and agitated. His observations show: heart rate 110 bpm, blood pressure 95/60 mmHg, respiratory rate 24/min, oxygen saturations 91% on room air, temperature 37.8°C. His pain score is 8/10. What is the most appropriate immediate management priority?
Q236
A 45-year-old office worker presents with a 6-week history of lower back pain radiating down his right leg to the lateral aspect of his foot. He reports numbness over the dorsum of his foot and difficulty walking on his heels. The pain is worse at night and he has noticed unintentional weight loss of 5 kg. On examination, he has reduced power in ankle dorsiflexion and an absent ankle jerk on the right. What is the most concerning feature suggesting serious underlying pathology?
Q237
A 78-year-old woman presents to the Emergency Department following a fall at home. She complains of severe left hip pain and is unable to weight-bear. On examination, her left leg is shortened, externally rotated, and abducted. An AP radiograph of the pelvis confirms a displaced intracapsular neck of femur fracture. Her past medical history includes hypertension and osteoarthritis. She was independently mobile prior to the fall. What is the most appropriate definitive surgical management?
Orthopaedics & MSK UK Medical PG Practice Questions and MCQs
Question 231: A 55-year-old woman sustains a basicervical neck of femur fracture following a fall. She is fit and active with no significant comorbidities. Radiographs confirm the fracture extends from the base of the femoral neck to the intertrochanteric region. What is the most appropriate surgical fixation method?
A. Cannulated hip screws
B. Dynamic hip screw with plate (Correct Answer)
C. Intramedullary femoral nail
D. Total hip replacement
E. Hemiarthroplasty
Explanation: ***Dynamic hip screw with plate***
- A **basicervical fracture** is an **extracapsular fracture** of the femoral neck, located at the junction with the intertrochanteric region, making the **Dynamic Hip Screw (DHS)** the gold standard for its stable fixation.
- The DHS provides **stable compression** at the fracture site, which is crucial for promoting **secondary bone healing** in this well-vascularized region.
*Cannulated hip screws*
- These are primarily used for **intracapsular, undisplaced or minimally displaced** femoral neck fractures where rotational stability is paramount and blood supply is precarious.
- They lack the necessary **biomechanical strength** and lateral support required to adequately stabilize an **extracapsular basicervical fracture**.
*Intramedullary femoral nail*
- Intramedullary nails are typically indicated for **unstable intertrochanteric**, subtrochanteric, or **reverse obliquity** fractures, offering superior load-sharing properties for these more complex patterns.
- While an alternative, a DHS is generally considered sufficient and less invasive for a **stable basicervical fracture**, without demonstrating superior outcomes in this specific scenario.
*Total hip replacement*
- **Total hip replacement** is usually reserved for **displaced intracapsular femoral neck fractures** in active patients to minimize the risk of **avascular necrosis (AVN)** and allow early mobilization.
- Basicervical fractures are **extracapsular** with a preserved blood supply, meaning they have a high potential for healing with internal fixation, making joint replacement unnecessary.
*Hemiarthroplasty*
- **Hemiarthroplasty** involves replacing only the femoral head and is commonly indicated for **displaced intracapsular femoral neck fractures** in elderly, less active patients.
- It is inappropriate for **basicervical fractures** due to their excellent healing potential with internal fixation, as there is no need to sacrifice the native femoral head.
Question 232: A 68-year-old woman with rheumatoid arthritis presents with a 3-month history of progressive lower back pain and bilateral leg weakness. She reports difficulty walking and recent episodes of urinary incontinence. On examination, she has increased tone in both lower limbs with brisk knee reflexes, upgoing plantars bilaterally, and a sensory level at T10. What is the most likely diagnosis?
A. Cauda equina syndrome
B. Lumbar spinal stenosis
C. Thoracic cord compression (Correct Answer)
D. Diabetic amyotrophy
E. Polymyalgia rheumatica
Explanation: ***Thoracic cord compression***- The presence of **upper motor neuron (UMN) signs** (increased tone, brisk knee reflexes, and upgoing plantars) indicates a lesion above the conus medullaris, specifically affecting the spinal cord.- A **sensory level at T10** combined with urinary incontinence localizes the pathology to the thoracic spine, necessitating urgent MRI and neurosurgical evaluation.*Cauda equina syndrome*- This condition typically presents with **lower motor neuron (LMN) signs**, such as decreased reflexes and flaccid weakness, rather than UMN signs.- It is characterized by **saddle anesthesia** and absence of a trunk sensory level, which differentiates it from cord compression.*Lumbar spinal stenosis*- Usually presents with **neurogenic claudication**, where leg pain and weakness are triggered by walking and relieved by leaning forward.- It does not cause a clear **sensory level on the trunk** or UMN signs like positive Babinski (upgoing plantars).*Diabetic amyotrophy*- This is characterized by **asymmetric proximal muscle weakness** and severe pain, typically involving the quadriceps and hip flexors.- It lacks features of spinal cord involvement, such as a **sensory level**, urinary incontinence, or bilateral UMN signs.*Polymyalgia rheumatica*- Presents with symmetrical **proximal muscle pain and stiffness** in the shoulders and hips, often with an elevated ESR.- It is not a neurological condition and therefore does not cause **weakness, reflex changes, or sensory levels**.
Question 233: A 32-year-old builder presents with acute onset lower back pain after lifting heavy equipment. The pain radiates down the posterior aspect of his left leg to the heel. He describes sharp shooting pains and reports difficulty standing on tiptoe on the left foot. On examination, there is reduced sensation over the lateral border and sole of the left foot, and weakness of plantarflexion. The ankle jerk is diminished on the left. Which nerve root is most likely affected?
A. L3 nerve root
B. L4 nerve root
C. L5 nerve root
D. S1 nerve root (Correct Answer)
E. S2 nerve root
Explanation: ***S1 nerve root***- Compression of the **S1 nerve root** typically presents with weakness in **plantarflexion**, specifically causing difficulty with standing on **tiptoe** due to gastrocnemius and soleus involvement.- Physical findings include a **diminished ankle jerk** reflex and sensory loss localized to the **lateral border** and **sole of the foot**.*L3 nerve root*- **L3 radiculopathy** typically involves weakness in **hip flexion** and **knee extension** rather than foot movements.- Sensory loss is primarily found on the **anterior-medial thigh**, and it affects the **patellar (knee) reflex**.*L4 nerve root*- **L4 nerve root** involvement usually results in weakness of **knee extension** (quadriceps) and is characterized by an **absent knee jerk (patellar)** reflex.- Sensory deficits associated with **L4** are typically found along the **medial leg** and **medial malleolus**.*L5 nerve root*- **L5 radiculopathy** causes weakness in **big toe extension** (extensor hallucis longus) and **foot dorsiflexion**, leading to difficulty with **heel walking**.- Sensation is typically affected over the **dorsum of the foot** and the first web space, but the **ankle jerk** remains intact.*S2 nerve root*- **S2 compression** is rare as an isolated injury and usually involves sensory symptoms on the **posterior aspect of the thigh** and **perineum**.- It is more commonly associated with bladder/bowel dysfunction as part of **cauda equina syndrome** or pelvic plexopathy rather than specific ankle reflex changes.
Question 234: What is the classification system most commonly used to describe intracapsular neck of femur fractures based on the degree of displacement?
A. Weber classification
B. Garden classification (Correct Answer)
C. AO/OTA classification
D. Pauwels classification
E. Neer classification
Explanation: ***Garden classification***
- The **Garden classification** is the most widely used system for **intracapsular hip fractures**, categorizing them into four grades based on the degree of **displacement** observed on an AP radiograph.
- This system is clinically crucial because it guides treatment; **Grades I and II** are considered undisplaced (stable), while **Grades III and IV** are displaced (unstable) with a higher risk of **avascular necrosis**.
*Weber classification*
- The **Weber classification** (specifically the Danis-Weber system) is used to describe **ankle fractures** based on the level of the fibular fracture relative to the **syndesmosis**.
- It helps determine the stability of the ankle joint and the necessity of **surgical fixation**, but it is not applicable to femoral neck fractures.
*AO/OTA classification*
- The **AO/OTA classification** is a sophisticated, **alphanumeric system** designed to provide a universal language for all bone fractures throughout the body.
- While it includes femoral neck fractures, its high complexity makes it less commonly used in daily clinical practice compared to the simpler **Garden system**.
*Pauwels classification*
- The **Pauwels classification** describes femoral neck fractures based on the **angle of the fracture line** relative to the horizontal plane to assess shear stress.
- Although it helps predict the risk of **non-union**, it focuses on biomechanical stability rather than the degree of **displacement**.
*Neer classification*
- The **Neer classification** is the standard system used to describe fractures of the **proximal humerus**.
- It categorizes fractures based on the number of **displaced segments** (parts) and the relationship between the anatomical neck, surgical neck, and tuberosities.
Question 235: An 82-year-old man undergoes a hemiarthroplasty for a displaced intracapsular neck of femur fracture. Post-operatively on day 1, he becomes acutely confused and agitated. His observations show: heart rate 110 bpm, blood pressure 95/60 mmHg, respiratory rate 24/min, oxygen saturations 91% on room air, temperature 37.8°C. His pain score is 8/10. What is the most appropriate immediate management priority?
A. Commence intravenous antibiotics for presumed surgical site infection
B. Request urgent CT head to exclude intracranial pathology
C. Optimize analgesia and assess for reversible causes of delirium (Correct Answer)
D. Start haloperidol for acute behavioural disturbance
E. Arrange urgent chest radiograph and commence treatment dose LMWH
Explanation: ***Optimize analgesia and assess for reversible causes of delirium***- Post-operative **delirium** is highly common in elderly patients following hip surgery. The patient's acute confusion and agitation, coupled with physiological derangements, strongly suggest this diagnosis.- A high **pain score (8/10)** is a significant precipitating factor for delirium. Addressing pain, along with other reversible causes like hypoxia, hypotension, and urinary retention, is the most appropriate immediate management priority. *Commence intravenous antibiotics for presumed surgical site infection*- While the patient has a low-grade fever, a **surgical site infection** (SSI) typically does not manifest locally or systemically with acute delirium on post-operative day 1.- Although **sepsis** is a concern, immediate empirical antibiotics should follow a thorough assessment for other potential infection sources (e.g., UTI, pneumonia) and stabilization of vital parameters.*Request urgent CT head to exclude intracranial pathology*- **Acute confusion** and agitation in an elderly post-surgical patient are statistically much more likely to be **delirium** due to metabolic or surgical stress than primary intracranial pathology.- A **CT head** is generally not indicated as a first-line investigation for delirium unless there are **focal neurological deficits** or a history of recent head trauma.*Start haloperidol for acute behavioural disturbance*- **Haloperidol** or other sedatives should be considered a last resort for acute agitation, primarily if the patient poses a **risk to themselves or others**.- Pharmacological interventions can mask the underlying cause of delirium, potentially worsen it, and carry side effects; **non-pharmacological interventions** and treating the primary physiological triggers are preferred.*Arrange urgent chest radiograph and commence treatment dose LMWH*- The patient's tachycardia, tachypnoea, and hypoxia are concerning and warrant investigation for **pulmonary embolism (PE)** or **pulmonary infection/atelectasis**; a chest radiograph is a reasonable step.- However, commencing **treatment-dose LMWH** empirically without diagnostic confirmation (e.g., CTPA) is risky in a post-operative patient due to the significant risk of **bleeding**.
Question 236: A 45-year-old office worker presents with a 6-week history of lower back pain radiating down his right leg to the lateral aspect of his foot. He reports numbness over the dorsum of his foot and difficulty walking on his heels. The pain is worse at night and he has noticed unintentional weight loss of 5 kg. On examination, he has reduced power in ankle dorsiflexion and an absent ankle jerk on the right. What is the most concerning feature suggesting serious underlying pathology?
A. Difficulty with heel walking
B. Night pain with weight loss (Correct Answer)
C. Radiation to the lateral foot
D. Absent ankle jerk reflex
E. Duration of symptoms for 6 weeks
Explanation: ***Night pain with weight loss***
- **Night pain** and **unintentional weight loss** are classic **red flag symptoms** that raise suspicion for **malignancy** or **spinal infection**.
- While neurological signs indicate nerve compression, these systemic features necessitate urgent investigation with imaging and blood tests to rule out serious pathology.
*Difficulty with heel walking*
- This finding indicates weakness in **ankle dorsiflexion**, which is a sign of **L5 nerve root** compression.
- Although it represents a motor deficit, it is a feature of **radiculopathy** and not a red flag for systemic disease or malignancy.
*Radiation to the lateral foot*
- Pain radiating down the leg to the lateral foot describes **sciatica**, specifically involving the **S1 dermatome**.
- This is a common symptom of a **herniated disc** and does not inherently suggest a life-threatening or serious underlying disease.
*Absent ankle jerk reflex*
- An absent ankle jerk corresponds to an **S1 nerve root** lesion, often seen in mechanical lower back pathology.
- While an objective clinical finding of **radiculopathy**, it is not considered a red flag compared to systemic constitutional symptoms.
*Duration of symptoms for 6 weeks*
- Chronic or subacute pain is common in mechanical back issues; red flags generally emphasize **severity** and **progression** rather than a 6-week duration alone.
- A 6-week history is significant but less concerning than the **systemic features** of weight loss and non-mechanical night pain.
Question 237: A 78-year-old woman presents to the Emergency Department following a fall at home. She complains of severe left hip pain and is unable to weight-bear. On examination, her left leg is shortened, externally rotated, and abducted. An AP radiograph of the pelvis confirms a displaced intracapsular neck of femur fracture. Her past medical history includes hypertension and osteoarthritis. She was independently mobile prior to the fall. What is the most appropriate definitive surgical management?
A. Dynamic hip screw fixation
B. Total hip replacement
C. Cannulated screw fixation
D. Hemiarthroplasty (Correct Answer)
E. Intramedullary nail fixation
Explanation: ***Hemiarthroplasty***
- In elderly patients with a **displaced intracapsular** femoral neck fracture, hemiarthroplasty is the gold standard when there is a high risk of **avascular necrosis** due to disrupted blood supply.
- It is preferred over internal fixation in patients over **65 years** to allow immediate weight-bearing and reduce the risk of secondary surgeries.
*Dynamic hip screw fixation*
- This is the treatment of choice for **extracapsular** fractures, specifically **intertrochanteric** fractures.
- Using a DHS for a displaced intracapsular fracture in an elderly patient results in high rates of **non-union** and mechanical failure.
*Total hip replacement*
- While this patient was independently mobile, hemiarthroplasty is often the default choice in the very elderly unless they lead an exceptionally active lifestyle or have pre-existing **symptomatic** arthritis.
- NICE guidelines recommend THR for displaced intracapsular fractures only if the patient can **walk independently** with no more than a stick, has no cognitive impairment, and is medically fit for anesthesia.
*Cannulated screw fixation*
- This method is typically reserved for **undisplaced** (Garden I and II) intracapsular fractures or displaced fractures in **young patients** (<60 years) to preserve the native femoral head.
- In a 78-year-old with a displaced fracture, the risk of **vascular compromise** to the femoral head makes this fixation technique inappropriate.
*Intramedullary nail fixation*
- Intramedullary (IM) nails are primarily used for **subtrochanteric** fractures or unstable **intertrochanteric** fractures.
- They do not address the primary pathology of an intracapsular fracture and are not indicated for **femoral neck** replacement or stabilization in this context.
