Orthopaedics & MSK — MCQs
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A 38-year-old woman presents to her GP with a 16-week history of lower back pain and early morning stiffness lasting more than 1 hour. She reports improvement with exercise. Plain radiographs of the lumbar spine and pelvis are normal. HLA-B27 is positive. What is the most appropriate next investigation to support the diagnosis of axial spondyloarthropathy?
An 80-year-old man presents 6 hours after a fall with a shortened and externally rotated right leg. Radiographs confirm a displaced intracapsular neck of femur fracture. He has atrial fibrillation (on warfarin with INR 3.2), chronic kidney disease stage 4, and a history of previous stroke with mild residual left-sided weakness. He lives in residential care and mobilizes 10 metres with a frame. What is the most appropriate management?
A 52-year-old woman with a history of breast cancer treated 3 years ago presents with a 6-week history of thoracic back pain. The pain is constant, worse at night, and not relieved by analgesia. Plain radiographs show a lytic lesion in T8 vertebra with >50% loss of vertebral body height but no evidence of spinal cord compression on urgent MRI. What is the most appropriate Spinal Instability Neoplastic Score (SINS) classification for this lesion?
A 72-year-old woman with a displaced Garden IV intracapsular neck of femur fracture is assessed for surgical management. She is normally independent, walks without aids, and has no significant past medical history. Her abbreviated mental test score is 9/10. Which surgical intervention is most appropriate?
A 65-year-old man presents with a 3-week history of lower back pain. He describes the pain as constant, not relieved by rest, and rates it 8/10. He has lost 6 kg over the past 2 months and reports night sweats. Examination reveals tenderness over L3 vertebra. Temperature is 37.8°C. What is the most appropriate investigation to confirm the suspected diagnosis?
A 70-year-old woman undergoes hemiarthroplasty for a displaced intracapsular neck of femur fracture. During the procedure, the surgeon must take care to preserve which anatomical structure that provides the majority of the blood supply to the femoral head in adults?
A 74-year-old man sustains an intertrochanteric neck of femur fracture with posteromedial comminution and subtrochanteric extension. Pre-injury he was independently mobile with a frame. Radiographs show a reverse obliquity fracture pattern with lateral wall involvement. Which surgical implant is most appropriate for fixation?
A 52-year-old man with a 20-year history of chronic lower back pain presents with new onset severe pain radiating to both legs, worse in the left. He describes pain in the buttocks, thighs, and calves that worsens after walking 200 metres and is relieved by sitting or leaning forward. Straight leg raise is negative bilaterally. Peripheral pulses are palpable. What is the most likely underlying pathology?
A 63-year-old woman with metastatic breast cancer presents with a 5-week history of progressive lower back pain. Over the past 48 hours, she has developed bilateral leg weakness and difficulty initiating micturition. On examination, power is 3/5 in both legs globally, with a sensory level at T10, reduced anal tone, and a palpable bladder. Urgent MRI confirms cord compression at T9 from vertebral metastasis with >50% canal compromise. What is the most appropriate initial pharmacological management while arranging definitive treatment?
A 70-year-old woman sustains a displaced Garden III intracapsular neck of femur fracture. She was fully independent pre-injury, walks 2 miles daily, and has an AMTS of 10/10. She has well-controlled hypertension and hypothyroidism. The orthopaedic team is deciding between cemented hemiarthroplasty and total hip replacement. Which factor most strongly supports total hip replacement over hemiarthroplasty in this patient?
Orthopaedics & MSK UK Medical PG Practice Questions and MCQs
Question 41: A 38-year-old woman presents to her GP with a 16-week history of lower back pain and early morning stiffness lasting more than 1 hour. She reports improvement with exercise. Plain radiographs of the lumbar spine and pelvis are normal. HLA-B27 is positive. What is the most appropriate next investigation to support the diagnosis of axial spondyloarthropathy?
- A. Repeat plain radiographs in 3 months
- B. CT scan of the sacroiliac joints
- C. MRI of the sacroiliac joints with STIR sequences (Correct Answer)
- D. Bone scintigraphy
- E. Anti-CCP antibodies and rheumatoid factor
Explanation: ***MRI of the sacroiliac joints with STIR sequences*** - In the presence of normal radiographs but strong clinical suspicion of inflammatory back pain and **positive HLA-B27**, **MRI** is the most sensitive test to detect **active sacroiliitis**, specifically looking for **bone marrow oedema** in the sacroiliac joints. - This is crucial for diagnosing **non-radiographic axial spondyloarthropathy (nr-AxSpA)**, allowing for early intervention before structural damage is visible on X-ray. *Repeat plain radiographs in 3 months* - **Radiographic changes** in axial spondyloarthropathy, such as erosions or sclerosis of the sacroiliac joints, develop slowly and may take several years to become evident on plain films. - Repeating radiographs after only 3 months would be **premature** and is highly unlikely to show new findings, leading to a delay in definitive diagnosis and treatment. *CT scan of the sacroiliac joints* - While a **CT scan** provides excellent detailed images of **bone structure** and is superior to X-rays for detecting established chronic structural damage, it is less sensitive than MRI for **active inflammatory changes** like bone marrow oedema. - Furthermore, CT involves significant **ionizing radiation**, making it less suitable as a primary diagnostic tool for early inflammation, especially in younger patients, compared to MRI. *Bone scintigraphy* - **Bone scintigraphy**, or a bone scan, is a highly sensitive but **non-specific** imaging modality for detecting areas of increased bone turnover, which can occur in various conditions. - It has **poor specificity and sensitivity** for early sacroiliitis and is not recommended for diagnosing axial spondyloarthropathy due to its low diagnostic yield compared to MRI. *Anti-CCP antibodies and rheumatoid factor* - **Anti-CCP antibodies** and **rheumatoid factor (RF)** are serological markers primarily associated with the diagnosis of **rheumatoid arthritis (RA)**. - **Axial spondyloarthropathies** are typically **seronegative** for these autoantibodies, meaning they would not support the diagnosis of an axial spondyloarthropathy and would be an inappropriate investigation in this clinical context.
Question 42: An 80-year-old man presents 6 hours after a fall with a shortened and externally rotated right leg. Radiographs confirm a displaced intracapsular neck of femur fracture. He has atrial fibrillation (on warfarin with INR 3.2), chronic kidney disease stage 4, and a history of previous stroke with mild residual left-sided weakness. He lives in residential care and mobilizes 10 metres with a frame. What is the most appropriate management?
- A. Delay surgery for 48 hours to correct coagulopathy with vitamin K
- B. Proceed to theatre within 6 hours after prothrombin complex concentrate (Correct Answer)
- C. Conservative management with analgesia and early mobilization
- D. Arrange surgery within 36 hours after correcting INR to <1.5
- E. Emergency surgery immediately regardless of INR
Explanation: ***Proceed to theatre within 6 hours after prothrombin complex concentrate*** - This patient has a **displaced intracapsular neck of femur fracture**, which requires urgent surgical intervention to prevent complications like **avascular necrosis** and achieve the best functional outcome. - **Prothrombin complex concentrate (PCC)** rapidly reverses the effects of **warfarin** (INR 3.2), allowing safe surgery within the critical **36-hour window** (ideally sooner for displaced fractures) while minimizing risks of hemorrhage. *Delay surgery for 48 hours to correct coagulopathy with vitamin K* - **Vitamin K** takes many hours (6-24 hours) to significantly reduce **INR**, and a 48-hour delay is excessive for a hip fracture, increasing the risk of **immobility-related complications** in an elderly patient. - Prolonged pre-operative delay contributes to higher rates of **venous thromboembolism**, **pressure ulcers**, and **chest infections**. *Conservative management with analgesia and early mobilization* - For a **displaced intracapsular hip fracture** in a patient with some baseline mobility, conservative management is associated with **high mortality rates** and poor functional outcomes. - Non-operative care often results in intractable pain, non-union, and a significant inability to return to pre-injury **mobility status**. *Arrange surgery within 36 hours after correcting INR to <1.5* - While the **36-hour window** is a standard target, merely
Question 43: A 52-year-old woman with a history of breast cancer treated 3 years ago presents with a 6-week history of thoracic back pain. The pain is constant, worse at night, and not relieved by analgesia. Plain radiographs show a lytic lesion in T8 vertebra with >50% loss of vertebral body height but no evidence of spinal cord compression on urgent MRI. What is the most appropriate Spinal Instability Neoplastic Score (SINS) classification for this lesion?
- A. SINS 0-6: stable, requiring conservative management
- B. SINS 7-12: potentially unstable, requiring specialist surgical assessment (Correct Answer)
- C. SINS 13-18: unstable, requiring urgent surgical stabilization
- D. SINS classification does not apply to metastatic lesions
- E. SINS classification only applies to lesions with cord compression
Explanation: ***SINS 7-12: potentially unstable, requiring specialist surgical assessment***- The patient's **Spinal Instability Neoplastic Score (SINS)** is calculated as follows: **Tumor Location** (thoracic T8) 1 point, **Pain** (constant, worse at night) 3 points, **Bone Lesion Quality** (lytic) 2 points, and **Vertebral Body Collapse** (>50% height loss) 3 points. This totals **9 points**.- A SINS score between 7 and 12 indicates that the spine is **potentially unstable**, necessitating a **specialist spinal surgical consultation** to assess the need for stabilization or further intervention.*SINS 0-6: stable, requiring conservative management*- A score in this range denotes a **stable spine** where the risk of immediate structural failure or neurological compromise is considered low.- This patient's clinical and radiological findings, including significant **pain**, a **lytic lesion**, and **>50% vertebral collapse**, contribute to a score of 9, which exceeds the stable threshold.*SINS 13-18: unstable, requiring urgent surgical stabilization*- This score category signifies **frank instability**, where surgical intervention is almost always recommended to prevent or treat neurological deficits and maintain spinal integrity.- While the patient has significant factors indicating instability, a SINS score of 9 falls below the **definitely unstable** range of 13 or higher.*SINS classification does not apply to metastatic lesions*- This statement is incorrect. The **Spinal Instability Neoplastic Score (SINS)** was specifically developed and validated for assessing mechanical instability in patients with **vertebral metastases**.- It serves as a critical tool to help clinicians determine which patients with **neoplastic spinal disease** may benefit from surgical referral.*SINS classification only applies to lesions with cord compression*- This is incorrect. SINS is primarily designed to evaluate **mechanical stability** and the risk of **pathological fracture**, irrespective of the presence of **spinal cord compression**.- While cord compression is an important consideration for surgical urgency, the SINS system helps identify patients at risk of **spinal collapse** even without existing neurological deficits.
Question 44: A 72-year-old woman with a displaced Garden IV intracapsular neck of femur fracture is assessed for surgical management. She is normally independent, walks without aids, and has no significant past medical history. Her abbreviated mental test score is 9/10. Which surgical intervention is most appropriate?
- A. Cannulated screw fixation
- B. Dynamic hip screw
- C. Total hip replacement (Correct Answer)
- D. Cemented hemiarthroplasty
- E. Uncemented hemiarthroplasty
Explanation: ***Total hip replacement*** - In active, medically fit elderly patients (like this 72-year-old independent woman with a good mental score) with a **displaced Garden IV intracapsular fracture**, **total hip replacement (THR)** is the preferred option. - THR provides **superior long-term functional outcomes** and significantly lower **revision rates** compared to hemiarthroplasty in this patient population. *Cannulated screw fixation* - This technique is generally reserved for **undisplaced (Garden I or II) intracapsular fractures** to preserve the femoral head. - It is unsuitable for **displaced Garden IV fractures** due to the high risk of **avascular necrosis** and non-union resulting from compromised blood supply. *Dynamic hip screw* - A **dynamic hip screw (DHS)** is the primary surgical treatment for **extracapsular trochanteric fractures**. - It is not indicated for **intracapsular neck of femur fractures**, which carry a distinct risk of avascular necrosis and require different management. *Cemented hemiarthroplasty* - While cemented hemiarthroplasty is a common treatment for displaced intracapsular fractures, it is typically chosen for patients with **lower functional demands**, significant comorbidities, or **cognitive impairment**. - For a highly functional and cognitively intact patient, **total hip replacement** offers better long-term results and quality of life compared to hemiarthroplasty. *Uncemented hemiarthroplasty* - **Uncemented prostheses** are generally not recommended for hip fractures in the elderly due to a higher incidence of **postoperative pain** and increased risk of **periprosthetic fractures**. - Current guidelines typically recommend **cemented prostheses** when performing hemiarthroplasty in this patient group to improve fixation and reduce pain.
Question 45: A 65-year-old man presents with a 3-week history of lower back pain. He describes the pain as constant, not relieved by rest, and rates it 8/10. He has lost 6 kg over the past 2 months and reports night sweats. Examination reveals tenderness over L3 vertebra. Temperature is 37.8°C. What is the most appropriate investigation to confirm the suspected diagnosis?
- A. Plain radiographs of the lumbar spine
- B. CT scan of the lumbar spine
- C. MRI of the lumbar spine with gadolinium contrast (Correct Answer)
- D. Bone scintigraphy
- E. Full blood count and inflammatory markers
Explanation: ***MRI of the lumbar spine with gadolinium contrast*** - MRI with contrast is the gold standard for diagnosing **spinal infections (discitis/osteomyelitis)** or **malignancy**, as it provides superior soft tissue resolution and reveals early marrow changes. - It accurately detects complications such as **epidural abscesses** or spinal cord compression, which are critical in a patient presenting with high-intensity pain and **constitutional symptoms**. *Plain radiographs of the lumbar spine* - X-rays are often **insensitive** to early vertebral destruction and require at least 30-50% bone loss to show abnormalities. - They cannot reliably distinguish between malignancy, infection, or soft tissue pathology in the acute setting, especially with the presence of **red flag symptoms**. *CT scan of the lumbar spine* - CT is excellent for visualizing **bony architecture** and cortical destruction but lacks the sensitivity of MRI for early **marrow edema** or soft tissue infection. - It is generally reserved for patients with contraindications to MRI or those requiring CT-guided **biopsy**, not as the primary diagnostic tool in this case. *Bone scintigraphy* - This modality is highly sensitive for increased **bone turnover** but lacks the **specificity** to differentiate between infection, trauma, or metastatic disease. - It does not provide the detailed anatomical resolution necessary to evaluate the extent of **epidural involvement** or neural compression. *Full blood count and inflammatory markers* - While **ESR and CRP** are often elevated in infection and malignancy, they are **non-specific** and cannot localize the disease or confirm the diagnosis. - These tests are valuable for **monitoring treatment response** and indicating inflammation, rather than serving as the definitive primary diagnostic tool.
Question 46: A 70-year-old woman undergoes hemiarthroplasty for a displaced intracapsular neck of femur fracture. During the procedure, the surgeon must take care to preserve which anatomical structure that provides the majority of the blood supply to the femoral head in adults?
- A. Artery of ligamentum teres from the obturator artery
- B. Lateral circumflex femoral artery branches
- C. Medial circumflex femoral artery via retinacular vessels (Correct Answer)
- D. Nutrient artery from the femoral shaft
- E. Superior gluteal artery perforating branches
Explanation: ***Medial circumflex femoral artery via retinacular vessels*** - The **medial circumflex femoral artery** (MCFA) provides the majority (70-80%) of the blood supply to the adult femoral head through its **retinacular branches**. - Damage to these critical vessels during a **displaced intracapsular femoral neck fracture** is the main reason for the high risk of **avascular necrosis** (AVN). *Artery of ligamentum teres from the obturator artery* - This artery plays a more significant role in **childhood**, but its contribution to the femoral head's blood supply in adults is very small, typically less than 10%. - It enters the head at the **fovea capitis** and is generally insufficient to sustain the femoral head alone after disruption of other major supplies. *Lateral circumflex femoral artery branches* - The **lateral circumflex femoral artery** (LCFA) mainly supplies the **greater trochanter**, vastus lateralis, and anterior hip joint capsule, with a minor contribution to the femoral head. - Its contribution to the direct vascularization of the femoral head is considerably less than that of the medial circumflex femoral artery. *Nutrient artery from the femoral shaft* - The **nutrient artery** system is primarily responsible for supplying the **diaphyseal cortex** and medullary cavity of the femur. - It does not significantly supply the femoral head, particularly as it would be disrupted by an **intracapsular neck fracture**. *Superior gluteal artery perforating branches* - The **superior gluteal artery** principally supplies the gluteal muscles and contributes to the **extracapsular arterial ring** around the hip. - It does not directly provide the major blood supply to the femoral head itself via retinacular vessels.
Question 47: A 74-year-old man sustains an intertrochanteric neck of femur fracture with posteromedial comminution and subtrochanteric extension. Pre-injury he was independently mobile with a frame. Radiographs show a reverse obliquity fracture pattern with lateral wall involvement. Which surgical implant is most appropriate for fixation?
- A. Dynamic hip screw with single lag screw
- B. Cannulated screws
- C. Intramedullary cephalomedullary nail (Correct Answer)
- D. Hemiarthroplasty
- E. Dynamic hip screw with trochanteric stabilisation plate
Explanation: ***Intramedullary cephalomedullary nail*** - A **reverse obliquity pattern** and **subtrochanteric extension** characterize a highly unstable fracture, for which an **intramedullary cephalomedullary nail** is the gold standard treatment. - This implant provides superior **biomechanical stability** as a **load-sharing device**, effectively resisting **varus collapse** and medialization forces in these complex fracture types. *Dynamic hip screw with single lag screw* - This implant is **contraindicated** in **reverse obliquity** fractures because the fracture line allows the femoral shaft to displace laterally, leading to mechanical failure. - The significant **lateral wall involvement** in this case removes the necessary stable buttress for a DHS, greatly increasing the risk of **screw cut-out** or collapse. *Cannulated screws* - These are primarily indicated for **nondisplaced** or **minimally displaced intracapsular** (femoral neck) fractures, not for unstable extracapsular intertrochanteric injuries. - They lack the necessary **biomechanical strength** and stability to adequately fix a **comminuted intertrochanteric fracture** with subtrochanteric extension. *Hemiarthroplasty* - This procedure is typically reserved for **displaced intracapsular** femoral neck fractures in elderly patients, particularly those with poor bone quality or comorbidities. - It is generally not the treatment of choice for **intertrochanteric fractures**, especially with **subtrochanteric extension**, as it does not address the stability of the femoral shaft fragment effectively. *Dynamic hip screw with trochanteric stabilisation plate* - While the **trochanteric stabilization plate** enhances stability, this remains an **extramedullary device** and is biomechanically inferior to an intramedullary nail for **reverse obliquity** and **subtrochanteric extension** patterns. - It still experiences higher **bending moments** and is less effective at preventing varus collapse compared to a centrally placed intramedullary implant in these unstable fractures.
Question 48: A 52-year-old man with a 20-year history of chronic lower back pain presents with new onset severe pain radiating to both legs, worse in the left. He describes pain in the buttocks, thighs, and calves that worsens after walking 200 metres and is relieved by sitting or leaning forward. Straight leg raise is negative bilaterally. Peripheral pulses are palpable. What is the most likely underlying pathology?
- A. Bilateral L5/S1 disc prolapse with nerve root compression
- B. Peripheral vascular disease causing intermittent claudication
- C. Lumbar spinal stenosis causing neurogenic claudication (Correct Answer)
- D. Abdominal aortic aneurysm with peripheral embolisation
- E. Cauda equina syndrome
Explanation: ***Lumbar spinal stenosis causing neurogenic claudication*** - The patient presents with classic **neurogenic claudication**, where leg pain is triggered by walking and specifically relieved by **sitting or leaning forward** (which increases spinal canal diameter). - A long history of chronic back pain suggests **degenerative changes** such as facet joint hypertrophy or ligamentum flavum thickening leading to canal narrowing. *Bilateral L5/S1 disc prolapse with nerve root compression* - **Acute disc prolapse** typically causes constant radicular pain that is usually worsened by coughing or straining and is often unilateral. - The **negative straight leg raise** test helps rule out acute nerve root irritation commonly seen in lumbar disc herniation. *Peripheral vascular disease causing intermittent claudication* - While both cause walking-induced pain, vascular claudication is relieved by simply **standing still**, whereas neurogenic claudication requires **sitting or flexion**. - The presence of **palpable peripheral pulses** strongly argues against significant peripheral vascular disease as the cause of these symptoms. *Abdominal aortic aneurysm with peripheral embolisation* - **Peripheral embolisation** (e.g., "blue toe syndrome") would typically present with acute pain, skin color changes, and potentially absent distal pulses. - This patient’s symptoms are chronic, related to posture, and occur bilaterally, making a **vascular emergency** or aneurysm less likely. *Cauda equina syndrome* - **Cauda equina syndrome** is a surgical emergency characterized by **saddle anesthesia**, bladder/bowel dysfunction, and severe neurological deficits. - While this patient has bilateral leg pain, the absence of **sphincter disturbance** and the postural nature of the relief point towards stenosis rather than acute compression.
Question 49: A 63-year-old woman with metastatic breast cancer presents with a 5-week history of progressive lower back pain. Over the past 48 hours, she has developed bilateral leg weakness and difficulty initiating micturition. On examination, power is 3/5 in both legs globally, with a sensory level at T10, reduced anal tone, and a palpable bladder. Urgent MRI confirms cord compression at T9 from vertebral metastasis with >50% canal compromise. What is the most appropriate initial pharmacological management while arranging definitive treatment?
- A. Intravenous methylprednisolone 1g daily for 3 days
- B. Oral dexamethasone 16mg daily (Correct Answer)
- C. Intravenous mannitol 1g/kg
- D. Oral prednisolone 40mg daily
- E. Intravenous hydrocortisone 100mg four times daily
Explanation: ***Oral dexamethasone 16mg daily***- High-dose **dexamethasone** is the gold-standard initial treatment for **metastatic spinal cord compression (MSCC)** to reduce **vasogenic edema** and preserve neurological function.- A dose of **16mg daily** (often split as 8mg twice daily) is recommended as soon as the diagnosis is suspected to alleviate pressure before definitive **surgery or radiotherapy**.*Intravenous methylprednisolone 1g daily for 3 days*- This ultra-high dose protocol is typically reserved for **acute traumatic spinal cord injury** within a narrow time window, rather than neoplastic compression.- It carries a significantly higher risk of **gastrointestinal bleeding** and sepsis without proven superiority over dexamethasone for **malignant compression**.*Intravenous mannitol 1g/kg*- **Mannitol** is an osmotic diuretic used primarily to reduce **intracranial pressure** in cases of cerebral edema or head injury.- It has no established role in Managing **spinal cord compression** and would not address the inflammatory edema caused by the tumor.*Oral prednisolone 40mg daily*- This dose is insufficiently potent for the acute reduction of edema required in **MSCC**; dexamethasone is preferred due to its higher **glucocorticoid potency**.- **Prednisolone** also has higher **mineralocorticoid activity**, which can lead to unwanted fluid retention compared to dexamethasone.*Intravenous hydrocortisone 100mg four times daily*- **Hydrocortisone** is mainly used for **adrenal insufficiency** or acute asthma and lacks the strong anti-inflammatory profile needed for neuro-oncological emergencies.- The significant **mineralocorticoid effects** of high-dose hydrocortisone would cause excessive salt and water retention without providing adequate **neural decompression**.
Question 50: A 70-year-old woman sustains a displaced Garden III intracapsular neck of femur fracture. She was fully independent pre-injury, walks 2 miles daily, and has an AMTS of 10/10. She has well-controlled hypertension and hypothyroidism. The orthopaedic team is deciding between cemented hemiarthroplasty and total hip replacement. Which factor most strongly supports total hip replacement over hemiarthroplasty in this patient?
- A. Age under 75 years
- B. Good pre-injury functional status and cognitive function (Correct Answer)
- C. Displaced intracapsular fracture pattern
- D. Absence of significant medical comorbidities
- E. Good mobility requiring 2-mile walking capacity
Explanation: ***Good pre-injury functional status and cognitive function*** - **Total hip replacement (THR)** is recommended by **NICE guidelines** for patients with displaced intracapsular fractures who were independently mobile, have no **cognitive impairment** (AMTS 10/10), and are medically fit. - THR provides superior **long-term functional outcomes** and lower revision rates compared to hemiarthroplasty in active patients who can tolerate the longer procedure. *Age under 75 years* - While younger age is often associated with higher activity, **chronological age** alone is not a strict cut-off for THR; clinical guidelines prioritize functional and mental status. - Some patients over 75 with excellent **physiological reserve** may still be better candidates for THR than younger patients with significant comorbidities. *Displaced intracapsular fracture pattern* - A **Garden III** or IV (displaced) fracture is an indication for **arthroplasty** rather than internal fixation, but it does not specify the type of arthroplasty. - Both **hemiarthroplasty** and THR are surgical options for displaced fractures; the choice between them depends on patient-specific factors like activity level. *Absence of significant medical comorbidities* - Being **medically fit for anesthesia** is a prerequisite for the longer THR procedure, but it is not the primary factor that dictates THR over hemiarthroplasty. - Many patients without comorbidities receive a **hemiarthroplasty** if they have low mobility demands or **cognitive decline**. *Good mobility requiring 2-mile walking capacity* - High mobility is a component of the selection criteria, but the decision is a composite of **independence**, **cognition**, and **fitness** rather than a specific walking distance. - **Walking 2 miles daily** confirms the patient's high functional baseline, supporting the need for a joint that can withstand higher mechanical demand.
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