Orthopaedics & MSK — MCQs
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A 68-year-old woman underwent total hip replacement for a displaced intracapsular neck of femur fracture 6 weeks ago. She now presents with sudden onset severe hip pain and inability to weight-bear. On examination, the affected leg is shortened, flexed, adducted and internally rotated. What is the most likely complication?
A 66-year-old man with Paget's disease of bone affecting the proximal femur sustains a subtrochanteric fracture following minimal trauma. Radiographs show a transverse fracture pattern with lateral cortical thickening. He has been taking alendronic acid 70mg weekly for 8 years for osteoporosis. Which feature of the fracture most strongly suggests an atypical femoral fracture rather than a typical osteoporotic fracture?
A 44-year-old woman with a 12-week history of inflammatory back pain has normal plain radiographs of the lumbar spine and sacroiliac joints. MRI of the sacroiliac joints shows bilateral bone marrow oedema in the subchondral bone. She tests positive for HLA-B27. Inflammatory markers show CRP 34 mg/L and ESR 42 mm/hr. What is the most appropriate next step in management?
A 73-year-old man undergoes cemented hemiarthroplasty for a displaced intracapsular neck of femur fracture. During cementation of the femoral component, the patient suddenly becomes hypotensive (BP 75/40 mmHg) with oxygen saturations dropping to 88% on high-flow oxygen. The anaesthetist notes increased pulmonary artery pressures on monitoring. What is the most likely underlying mechanism?
A 59-year-old man with newly diagnosed multiple myeloma presents to the Emergency Department with a 2-week history of lower back pain and new onset faecal incontinence. He reports reduced perianal sensation but denies leg weakness. On examination, anal tone is reduced and perianal sensation is absent. What is the most critical time-dependent factor affecting prognosis in this patient?
A 78-year-old woman sustains an undisplaced Garden I intracapsular neck of femur fracture. She has good pre-injury mobility, normal cognitive function, and an ASA grade of 2. Following successful internal fixation with cannulated screws, at what time point is the risk of avascular necrosis of the femoral head highest?
A 51-year-old woman with a history of breast cancer treated 5 years ago presents with a 3-week history of progressive lower back pain. The pain is constant, severe, and disturbs her sleep. She has no neurological symptoms. Plain radiographs show a lytic lesion in the L3 vertebral body with >50% loss of vertebral height and involvement of the posterior elements. What is the most appropriate immediate management?
A 67-year-old woman undergoes dynamic hip screw fixation for a stable two-part intertrochanteric fracture. Intraoperatively, the tip-apex distance is measured at 28mm on the final fluoroscopic images. What is the significance of this measurement?
A 43-year-old man presents with a 6-month history of lower back pain and morning stiffness lasting approximately 90 minutes. The pain improves with exercise but returns with rest. He has no history of trauma. Plain radiographs of the lumbar spine show no abnormality. What is the most appropriate next investigation to support the suspected diagnosis?
An 82-year-old man with severe cognitive impairment (Abbreviated Mental Test Score 4/10) sustains a displaced intracapsular neck of femur fracture. He was independently mobile with a walking frame prior to the fall. He has multiple comorbidities including chronic kidney disease stage 4 (eGFR 22ml/min/1.73m²), ischaemic heart disease, and atrial fibrillation. What is the most appropriate surgical management?
Orthopaedics & MSK UK Medical PG Practice Questions and MCQs
Question 21: A 68-year-old woman underwent total hip replacement for a displaced intracapsular neck of femur fracture 6 weeks ago. She now presents with sudden onset severe hip pain and inability to weight-bear. On examination, the affected leg is shortened, flexed, adducted and internally rotated. What is the most likely complication?
- A. Periprosthetic fracture
- B. Deep infection with prosthetic loosening
- C. Posterior hip dislocation (Correct Answer)
- D. Aseptic loosening of the acetabular component
- E. Heterotopic ossification causing joint stiffness
Explanation: ***Posterior hip dislocation*** - The classic presentation of a **shortened**, **flexed**, **adducted**, and **internally rotated** leg is pathognomonic for a **posterior dislocation** following total hip replacement. - It is a common early complication occurring within the first few weeks to months, often triggered by movements like **leaning forward** while sitting or excessive hip flexion. *Periprosthetic fracture* - While it presents with pain and inability to weight-bear, it typically lacks the specific limb deformity of flexion, adduction, and internal rotation unless combined with dislocation. - Diagnosis is confirmed by **radiographic evidence** of a fracture around the implant, which is not primarily indicated by the described physical exam. *Deep infection with prosthetic loosening* - Typically presents with **systemic symptoms** (fever, malaise) and localized signs such as **warmth**, swelling, or a discharging sinus, not an acute mechanical deformity. - This complication is usually a **subacute or chronic process**, lacking the sudden onset of characteristic limb malposition. *Aseptic loosening of the acetabular component* - This is a long-term complication presenting as **gradual onset** mechanical pain, typically years after the initial surgery, not an acute event 6 weeks post-op. - It is caused by **wear debris** or mechanical failure and does not result in an acute flexed/rotated deformity of the limb. *Heterotopic ossification causing joint stiffness* - This condition involves **extraskeletal bone formation** in soft tissues, leading to a progressive loss of **range of motion** and stiffness over time. - It does not cause acute, severe pain with a **sudden change in limb position** or shortening as dramatically described in this case.
Question 22: A 66-year-old man with Paget's disease of bone affecting the proximal femur sustains a subtrochanteric fracture following minimal trauma. Radiographs show a transverse fracture pattern with lateral cortical thickening. He has been taking alendronic acid 70mg weekly for 8 years for osteoporosis. Which feature of the fracture most strongly suggests an atypical femoral fracture rather than a typical osteoporotic fracture?
- A. The presence of underlying Paget's disease
- B. The transverse fracture pattern with lateral cortical thickening (Correct Answer)
- C. The subtrochanteric location
- D. Association with prolonged bisphosphonate use
- E. Occurrence following minimal trauma
Explanation: ***The transverse fracture pattern with lateral cortical thickening*** - These are **major radiographic criteria** for diagnosing **atypical femoral fractures (AFF)**, specifically the non-comminuted transverse or short oblique morphology. - **Lateral cortical thickening** (beaking or flaring) represents a localized stress reaction that is highly specific for a prodromal or impending atypical fracture, distinguishing it from typical osteoporotic fractures. *The presence of underlying Paget's disease* - While **Paget's disease** increases bone fragility and the risk of pathological fractures, it typically causes fractures on the convex surface of bowed bones, often with an oblique pattern. - The specific **transverse fracture pattern** and **lateral cortical thickening** described are more characteristic of AFFs, which are often related to bisphosphonate use, rather than a direct feature of Paget's disease itself. *The subtrochanteric location* - Although AFFs are primarily located in the **subtrochanteric region** and femoral shaft, this location alone is not diagnostic because **typical osteoporotic fractures** can also occur in this region. - The **fracture morphology** (transverse, simple) is a much stronger discriminator for AFFs than the anatomical location alone. *Association with prolonged bisphosphonate use* - Long-term use of **bisphosphonates** (like alendronic acid for >5 years) is a known **epidemiological risk factor** for AFFs, but it's not a direct radiological feature of the fracture itself. - Some patients can develop AFFs without bisphosphonate exposure, and conversely, many bisphosphonate users never develop AFFs, highlighting the importance of radiographic features for diagnosis. *Occurrence following minimal trauma* - Fractures following **minimal trauma** are characteristic of both **atypical femoral fractures** and **typical osteoporotic fractures**, making this feature non-specific for differentiating between the two. - The defining characteristic of an AFF is its specific radiographic appearance, not just the low-energy mechanism of injury.
Question 23: A 44-year-old woman with a 12-week history of inflammatory back pain has normal plain radiographs of the lumbar spine and sacroiliac joints. MRI of the sacroiliac joints shows bilateral bone marrow oedema in the subchondral bone. She tests positive for HLA-B27. Inflammatory markers show CRP 34 mg/L and ESR 42 mm/hr. What is the most appropriate next step in management?
- A. Commence anti-TNF biological therapy immediately
- B. Prescribe a non-steroidal anti-inflammatory drug and arrange rheumatology follow-up (Correct Answer)
- C. Arrange for IL-17 inhibitor therapy
- D. Commence methotrexate as first-line disease-modifying therapy
- E. Prescribe long-term oral corticosteroids
Explanation: ***Prescribe a non-steroidal anti-inflammatory drug and arrange rheumatology follow-up*** - **NSAIDs** are the first-line treatment for **non-radiographic axial spondyloarthritis (nr-axSpA)** and should be trialed at the maximum tolerated dose for at least 2–4 weeks for symptomatic relief. - Referral to **rheumatology** is essential for diagnostic confirmation, disease monitoring, and guiding further treatment escalation if NSAIDs prove ineffective. *Commence anti-TNF biological therapy immediately* - **Anti-TNF therapy** is reserved for patients who have failed an adequate trial of at least two different **NSAIDs** and continue to have high disease activity (e.g., BASDAI ≥4). - Initiating biologics immediately bypasses standard treatment guidelines and algorithms for axial spondyloarthritis. *Arrange for IL-17 inhibitor therapy* - **IL-17 inhibitors** (e.g., secukinumab) are **biologic DMARDs** used in axial spondyloarthritis, typically after **NSAID failure** or as an alternative to anti-TNF agents. - Like anti-TNF agents, they are not indicated as the initial management step for a patient presenting with new onset inflammatory back pain. *Commence methotrexate as first-line disease-modifying therapy* - **Conventional synthetic DMARDs** like **methotrexate** have no proven efficacy in treating the **axial (spinal and sacroiliac joint)** symptoms of spondyloarthritis. - These medications are only utilized if there is significant **peripheral joint** involvement, which is not the primary presentation in this patient. *Prescribe long-term oral corticosteroids* - **Long-term oral corticosteroids** are not recommended in axial spondyloarthritis due to a lack of efficacy for spinal disease and a high risk of significant **adverse effects**. - While localized **corticosteroid injections** might be used for peripheral flares, systemic long-term use is not a standard of care for axial disease.
Question 24: A 73-year-old man undergoes cemented hemiarthroplasty for a displaced intracapsular neck of femur fracture. During cementation of the femoral component, the patient suddenly becomes hypotensive (BP 75/40 mmHg) with oxygen saturations dropping to 88% on high-flow oxygen. The anaesthetist notes increased pulmonary artery pressures on monitoring. What is the most likely underlying mechanism?
- A. Anaphylactic reaction to bone cement methylmethacrylate
- B. Embolisation of marrow fat and cement particles causing pulmonary vasoconstriction (Correct Answer)
- C. Myocardial infarction precipitated by surgical stress
- D. Haemorrhage from cement extrusion into the femoral vessels
- E. Tension pneumothorax from positive pressure ventilation
Explanation: ***Embolisation of marrow fat and cement particles causing pulmonary vasoconstriction***- This patient is presenting with **Bone Cement Implantation Syndrome (BCIS)**, characterized by the hallmark triad of **hypoxia**, **hypotension**, and increased **pulmonary artery pressures** during cementation.- The mechanism involves high **intramedullary pressure** forcing fat, marrow, and cement into the venous system, causing **mechanical obstruction** and a chemical-mediated **pulmonary vasoconstriction** leading to right heart strain.*Anaphylactic reaction to bone cement methylmethacrylate*- While methylmethacrylate (MMA) can cause **vasodilation**, a true IgE-mediated **anaphylaxis** is extremely rare and typically presents with rash, bronchospasm, or angioedema.- BCIS is more definitively linked to the **embolic load** and the release of biochemical mediators rather than an allergic response.*Myocardial infarction precipitated by surgical stress*- Although surgical stress can trigger a **myocardial infarction (MI)**, it would not typically cause a sudden spike in **pulmonary artery pressure** specifically during the cementation phase.- ECG changes and cardiac enzymes would be required for diagnosis, and **hypoxia** is less likely to be the primary presenting feature compared to BCIS.*Haemorrhage from cement extrusion into the femoral vessels*- Cement extrusion could cause local **vascular injury**, but this would result in **hypovolemic shock** rather than immediate pulmonary hypertension and severe oxygen desaturation.- There is no clinical evidence of massive blood loss or a hematoma in the surgical field mentioned in this scenario.*Tension pneumothorax from positive pressure ventilation*- A **tension pneumothorax** causes hypotension and hypoxia, but it would typically present with **unilateral absent breath sounds** and tracheal deviation.- The temporal relationship specifically to **femoral cementation** makes an embolic phenomenon much more likely than a ventilation-induced barotrauma.
Question 25: A 59-year-old man with newly diagnosed multiple myeloma presents to the Emergency Department with a 2-week history of lower back pain and new onset faecal incontinence. He reports reduced perianal sensation but denies leg weakness. On examination, anal tone is reduced and perianal sensation is absent. What is the most critical time-dependent factor affecting prognosis in this patient?
- A. Duration of symptoms before presentation
- B. Time from presentation to MRI scanning
- C. Time from symptom onset to surgical decompression (Correct Answer)
- D. Timing of commencement of high-dose dexamethasone
- E. Time to initiation of chemotherapy for the underlying malignancy
Explanation: ***Time from symptom onset to surgical decompression***- The prognosis for **neurological recovery**, particularly bladder and bowel function, is most critically linked to the **total duration** of nerve root compression.- Clinical evidence indicates that performing **emergency surgical decompression** within **24–48 hours** of the onset of autonomic symptoms like **faecal incontinence** significantly improves the chances of recovery.*Duration of symptoms before presentation*- While the delay before seeking help is part of the total time, it is not the **modifiable clinical factor** that defines the quality of modern emergency care standards.- Highlighting only the time before presentation ignores the critical role of **hospital efficiency** in achieving definitive management.*Time from presentation to MRI scanning*- Rapid **MRI imaging** is a crucial diagnostic step to confirm **Cauda Equina Syndrome**, but it is a means to an end rather than the prognostic endpoint itself.- Even if an MRI is obtained quickly, prognosis will be poor if there is a subsequent delay in moving the patient to the **operating theater**.*Timing of commencement of high-dose dexamethasone*- **High-dose dexamethasone** is essential adjunctive therapy to reduce **peritumoral oedema** in malignant spinal cord compression.- While steroids help stabilize the patient, they do not provide the **mechanical relief** of compression that is the primary determinant of long-term functional outcome.*Time to initiation of chemotherapy for the underlying malignancy*- **Chemotherapy** for Multiple Myeloma is vital for **systemic disease control**, but it acts far too slowly to rescue acutely compressed nerve roots.- In the setting of an acute neurologic emergency, **mechanical decompression** takes precedence over medical management of the primary hematological malignancy.
Question 26: A 78-year-old woman sustains an undisplaced Garden I intracapsular neck of femur fracture. She has good pre-injury mobility, normal cognitive function, and an ASA grade of 2. Following successful internal fixation with cannulated screws, at what time point is the risk of avascular necrosis of the femoral head highest?
- A. Within the first 6 weeks post-operatively
- B. At 3-6 months post-operatively
- C. At 12-24 months post-operatively (Correct Answer)
- D. At 3-5 years post-operatively
- E. The risk remains constant throughout the post-operative period
Explanation: ***At 12-24 months post-operatively***- **Avascular necrosis (AVN)** of the femoral head typically follows a latent period, with clinical and radiological signs appearing most frequently between **1 to 2 years** post-injury.- This timeframe reflects the process of **creeping substitution**, where the ischemic bone undergoes remodeling and structural collapse after the initial vascular insult to the **medial circumflex femoral artery**.*Within the first 6 weeks post-operatively*- Complications at this early stage are usually related to **surgical site infections**, deep vein thrombosis, or acute mechanical **fixation failure**.- Bone **ischemia** occurs immediately at the time of fracture, but the necrotic process does not manifest radiographically or clinically within such a short window.*At 3-6 months post-operatively*- While **non-union** may become evident during this period, symptomatic **AVN** and femoral head collapse are less common this early in the recovery process.- Radiographs during this window may still appear normal despite the underlying vascular insult, as the **subchondral collapse** hasn't typically reached a detectable threshold.*At 3-5 years post-operatively*- While the risk of AVN can persist for several years, the peak incidence significantly **tapers off** after the 24-month mark.- Most cases are identified earlier due to the onset of **groin pain** and weight-bearing difficulties that prompt medical evaluation before the 3-year mark.*The risk remains constant throughout the post-operative period*- The risk of AVN follows a **temporal pattern** dictated by the blood supply's ability to recover or the bone's eventual collapse under physiological loads.- Once the femoral head has successfully **revascularized** or remodeled without collapse over the first few years, the risk of developing fracture-related AVN decreases significantly.
Question 27: A 51-year-old woman with a history of breast cancer treated 5 years ago presents with a 3-week history of progressive lower back pain. The pain is constant, severe, and disturbs her sleep. She has no neurological symptoms. Plain radiographs show a lytic lesion in the L3 vertebral body with >50% loss of vertebral height and involvement of the posterior elements. What is the most appropriate immediate management?
- A. Commence oral analgesia and arrange outpatient oncology review
- B. Urgent MRI whole spine and referral to spinal surgery (Correct Answer)
- C. Arrange CT-guided biopsy of the lesion before any further management
- D. Commence radiotherapy to the lumbar spine
- E. Prescribe bisphosphonates and arrange outpatient follow-up
Explanation: ***Urgent MRI whole spine and referral to spinal surgery*** - The patient's history of breast cancer, combined with a **lytic vertebral lesion** exhibiting **>50% height loss** and **posterior element involvement**, indicates significant **biomechanical instability** and a high risk of impending **spinal cord compression**. - An urgent **MRI of the whole spine** is critical to fully assess the extent of neural involvement, and immediate **spinal surgical consultation** is necessary to consider stabilization. *Commence oral analgesia and arrange outpatient oncology review* - While pain control is important, a progressive, severe pain pattern with radiographic evidence of significant **vertebral destruction** requires more urgent assessment than an **outpatient review**. - Delaying definitive evaluation of **spinal instability** and potential neural compromise could lead to irreversible neurological deficits. *Arrange CT-guided biopsy of the lesion before any further management* - Although tissue diagnosis is generally necessary for cancer management, the patient's known history of breast cancer makes **metastatic disease** highly probable in this context. - Prioritizing a biopsy over urgent assessment for **spinal instability** and potential cord compression is inappropriate, as protecting the **spinal cord** is the immediate goal. *Commence radiotherapy to the lumbar spine* - **Radiotherapy** is effective for pain control and local tumor regression but does not address the immediate **structural instability** of a vertebra with significant collapse and posterior element involvement. - In cases of severe **vertebral destruction** with instability, **surgical stabilization** is often required before or in conjunction with radiotherapy to prevent neurological deterioration. *Prescribe bisphosphonates and arrange outpatient follow-up* - **Bisphosphonates** help reduce skeletal-related events in metastatic bone disease but do not provide immediate **mechanical support** for an acutely compromised and unstable vertebral body. - **Outpatient follow-up** is insufficient for a patient with severe pain and radiological signs of significant **vertebral collapse** and **instability**, which demands urgent inpatient management.
Question 28: A 67-year-old woman undergoes dynamic hip screw fixation for a stable two-part intertrochanteric fracture. Intraoperatively, the tip-apex distance is measured at 28mm on the final fluoroscopic images. What is the significance of this measurement?
- A. It indicates optimal screw position with minimal risk of cutout
- B. It is within acceptable limits but carries moderate risk of fixation failure (Correct Answer)
- C. It indicates suboptimal positioning requiring screw repositioning
- D. It predicts high risk of femoral head penetration requiring conversion to arthroplasty
- E. It has no clinical relevance to postoperative outcomes
Explanation: ***It is within acceptable limits but carries moderate risk of fixation failure*** - A **Tip-Apex Distance (TAD)** greater than **25mm** is a well-established predictor of **lag screw cutout** and mechanical fixation failure. - At **28mm**, the risk of failure is higher than the optimal threshold (<25mm) but is often considered the upper limit of clinical acceptability, suggesting a moderate risk, especially with potentially reduced bone quality in a 67-year-old. *It indicates optimal screw position with minimal risk of cutout* - Optimal positioning is defined as a **TAD ≤25mm**, which correlates with a cutout rate of less than **1%**. - A measurement of 28mm increases the mechanical leverage on the femoral head, increasing the statistical likelihood of **screw migration** or cutout, thus not indicating minimal risk. *It indicates suboptimal positioning requiring screw repositioning* - Internal fixation is generally only repositioned if the TAD significantly exceeds **30mm** or if the screw is in a clearly unsafe position. - Repositioning at 28mm is often avoided to prevent creating **multiple tracks** in the femoral head, which could further weaken the bone and increase surgical morbidity. *It predicts high risk of femoral head penetration requiring conversion to arthroplasty* - TAD specifically predicts **cutout** (superior migration through the femoral head due to poor biomechanical purchase) rather than immediate **femoral head penetration** into the joint space. - Conversion to **arthroplasty** is typically a salvage procedure for failed fixation, not a direct intraoperative response to a TAD of 28mm. *It has no clinical relevance to postoperative outcomes* - The **Baumgaertner criteria** for TAD is a critically important and clinically significant predictor of success in **intertrochanteric fracture** repair. - Higher TAD values are directly linked to poor outcomes, including increased rates of **nonunion**, **malunion**, and the need for **revision surgery** due to mechanical collapse.
Question 29: A 43-year-old man presents with a 6-month history of lower back pain and morning stiffness lasting approximately 90 minutes. The pain improves with exercise but returns with rest. He has no history of trauma. Plain radiographs of the lumbar spine show no abnormality. What is the most appropriate next investigation to support the suspected diagnosis?
- A. MRI sacroiliac joints (Correct Answer)
- B. HLA-B27 testing
- C. CT lumbar spine
- D. Bone scan
- E. Rheumatoid factor and anti-CCP antibodies
Explanation: ***MRI sacroiliac joints***- MRI is the most sensitive imaging modality for detecting early **inflammatory changes** such as **bone marrow edema** and synovitis, which define **non-radiographic axial spondyloarthritis**.- Since the plain radiographs are normal, an MRI is the gold standard next step to confirm **sacroiliitis** as part of the ASAS classification criteria.*HLA-B27 testing*- While **HLA-B27** is associated with axial spondyloarthritides, it is not a diagnostic test on its own because it is present in approximately **8% of the healthy population**.- It serves as a supportive marker rather than a definitive investigation for visualizing the active **pathological process** in the joints.*CT lumbar spine*- CT provides excellent detail of **bony erosions** and sclerosis but lacks the sensitivity to detect early **active inflammation** (marrow edema) seen on MRI.- It also exposes the patient to significant **ionizing radiation** without offering the diagnostic superiority of MRI in early disease stages.*Bone scan*- Bone scans have high sensitivity for increased bone turnover but demonstrate **low specificity** for inflammatory back pain and cannot distinguish between various types of arthritis.- It is generally not recommended in the routine diagnostic workup for **spondyloarthropathies** due to its poor anatomical resolution.*Rheumatoid factor and anti-CCP antibodies*- These markers are diagnostic for **Rheumatoid Arthritis**, which primarily affects **peripheral small joints** and is characterized by pain that worsens with activity.- Axial spondyloarthritides are typically **seronegative**, meaning these markers are expected to be negative in this clinical scenario.
Question 30: An 82-year-old man with severe cognitive impairment (Abbreviated Mental Test Score 4/10) sustains a displaced intracapsular neck of femur fracture. He was independently mobile with a walking frame prior to the fall. He has multiple comorbidities including chronic kidney disease stage 4 (eGFR 22ml/min/1.73m²), ischaemic heart disease, and atrial fibrillation. What is the most appropriate surgical management?
- A. Uncemented hemiarthroplasty
- B. Cemented hemiarthroplasty (Correct Answer)
- C. Total hip replacement
- D. Cannulated screw fixation
- E. Conservative non-operative management
Explanation: ***Cemented hemiarthroplasty***- Per **NICE guidelines (CG124)** and evidence from the **WHiTE 5 trial**, cemented implants are preferred as they offer better **post-operative pain relief**, improved mobility, and lower mortality compared to uncemented options.- **Hemiarthroplasty** is more appropriate than Total Hip Replacement in patients with **severe cognitive impairment** (AMTS 4/10) to minimize the risk of post-operative **dislocation**.*Uncemented hemiarthroplasty*- Uncemented components are associated with a higher risk of **periprosthetic fractures** and increased persistent **thigh pain**.- Current orthopedic consensus favors **cemented fixation** even in the presence of comorbidities like stage 4 CKD, provided the anesthetic team manages **Bone Cement Implantation Syndrome** risks.*Total hip replacement*- While suitable for active patients, it is contraindicated here due to **cognitive impairment**, which significantly increases the risk of **dislocation** and poor compliance with post-op precautions.- Benefits of THR, such as reduced **acetabular erosion**, are less relevant in this elderly patient with a limited functional demand.*Cannulated screw fixation*- This approach is typically reserved for **undisplaced fractures** or very young patients where preserving the femoral head is a priority.- In **displaced intracapsular fractures** in the elderly, internal fixation has an unacceptably high rate of **non-union** and **avascular necrosis**.*Conservative non-operative management*- This is associated with a mortality rate exceeding **80% at one year** due to complications of prolonged immobility like **pressure sores** and **pneumonia**.- Since the patient was **independently mobile** prior to the fall, surgery is the best option to facilitate early mobilization and improve quality of life.
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