Orthopaedics & MSK — MCQs
On this page
A 76-year-old woman sustains a displaced intracapsular neck of femur fracture and undergoes cemented hemiarthroplasty. At 18 months post-operatively, she presents with progressive hip pain, especially on weight-bearing. Radiographs show progressive acetabular wear with protrusio acetabuli and superior migration of the prosthetic head. What is the most appropriate management strategy at this stage?
A 44-year-old man presents to the Emergency Department with a 6-hour history of severe lower back pain that started suddenly while coughing. He describes severe pain radiating down the posterior aspect of his right leg to the heel. He is unable to stand on his tiptoes on the right foot. Examination reveals reduced right ankle jerk and numbness over the lateral border of the foot. Straight leg raise is positive at 30° on the right. Which nerve root is most likely compressed?
A 68-year-old man undergoes cannulated screw fixation for an undisplaced Garden II intracapsular neck of femur fracture. Post-operative radiographs show three parallel screws in inverted triangle configuration with good position. At 6 weeks post-operatively, he reports increasing hip pain and inability to weight bear. Radiographs show screw cut-out with varus collapse of the femoral head. Which biomechanical principle was most likely violated during the initial fixation?
A 52-year-old woman with metastatic breast cancer presents with a 3-week history of progressive thoracic back pain. She now reports difficulty walking, with weakness in both legs. Neurological examination reveals grade 4/5 power in hip flexion bilaterally, brisk knee reflexes, upgoing plantars, and a sensory level at T8. Anal tone and perianal sensation are normal. What is the most likely anatomical site of pathology?
A 75-year-old man sustains an undisplaced Garden I intracapsular neck of femur fracture. He has a history of previous hip surgery on the same side for developmental dysplasia treated with multiple osteotomies 40 years ago, resulting in distorted anatomy. Pre-injury he was independently mobile. What is the most appropriate surgical management considering the anatomical distortion?
A 58-year-old man presents with a 12-week history of lower back pain and morning stiffness lasting over 2 hours. He reports the pain improves with exercise but worsens with rest. Examination shows reduced lumbar spine flexion (Schober's test <15cm expansion). Plain radiographs of the lumbar spine and pelvis are normal. ESR is 45 mm/hr, CRP 28 mg/L, and HLA-B27 is positive. What is the most appropriate next investigation to establish the diagnosis?
A 66-year-old woman undergoes cemented hemiarthroplasty for a displaced intracapsular neck of femur fracture. During cement insertion, she suddenly becomes hypotensive (BP 75/40 mmHg), hypoxic (SpO2 85%), loses consciousness, and develops cardiac arrest. CPR is commenced immediately. What is the most likely underlying pathophysiological mechanism?
A 71-year-old man with multiple myeloma presents with a 4-week history of progressive lower back pain, now with new onset bilateral leg weakness making walking impossible. He has urinary frequency but denies retention. Examination reveals grade 3/5 power in hip flexion bilaterally, grade 4/5 in knee extension, intact perianal sensation, and normal anal tone. Plain radiographs show lytic lesions in L2 and L3 vertebrae with >50% loss of vertebral body height at L2. What is the most appropriate next step in management?
What is the primary mechanism by which bisphosphonates reduce the risk of fragility fractures in patients with osteoporosis?
A 79-year-old woman with osteoporosis sustains a displaced Garden IV intracapsular neck of femur fracture. She was previously independently mobile with a walking stick. Her past medical history includes atrial fibrillation (on warfarin), stage 3b chronic kidney disease (eGFR 38 ml/min), and a mechanical aortic valve replacement 10 years ago. What is the most appropriate surgical management?
Orthopaedics & MSK UK Medical PG Practice Questions and MCQs
Question 61: A 76-year-old woman sustains a displaced intracapsular neck of femur fracture and undergoes cemented hemiarthroplasty. At 18 months post-operatively, she presents with progressive hip pain, especially on weight-bearing. Radiographs show progressive acetabular wear with protrusio acetabuli and superior migration of the prosthetic head. What is the most appropriate management strategy at this stage?
- A. Revision to total hip replacement with acetabular component (Correct Answer)
- B. Conservative management with analgesia and walking aids
- C. Excision arthroplasty (Girdlestone procedure)
- D. Revision to uncemented hemiarthroplasty
- E. Hip arthrodesis
Explanation: ***Revision to total hip replacement with acetabular component***- This patient's symptoms of progressive hip pain, **acetabular wear**, and **protrusio acetabuli** indicate a failure of the hemiarthroplasty due to erosion of the native acetabular cartilage and bone.- **Conversion to total hip replacement (THR)**, which involves implanting an acetabular component, is the definitive treatment to provide a durable articulation, relieve pain, and restore function.*Conservative management with analgesia and walking aids*- This approach does not address the underlying **mechanical failure** and progressive bone loss from the worn acetabulum.- Given the **progressive nature** of the condition and severe weight-bearing pain, conservative measures are unlikely to provide adequate long-term relief or prevent further damage.*Excision arthroplasty (Girdlestone procedure)*- The **Girdlestone procedure** is a salvage operation involving removal of the femoral head/prosthesis without replacement, leading to a flail, shortened, and often painful limb.- It is typically reserved for severe complications like **recurrent infection** or when other reconstruction options are not feasible, not for primary acetabular wear in an otherwise healthy elderly patient.*Revision to uncemented hemiarthroplasty*- A revision hemiarthroplasty would only replace the femoral component, leaving the **damaged and worn native acetabulum** to articulate with the new prosthetic head.- This would inevitably lead to continued **acetabular erosion** and recurrence of the patient's symptoms, as the core problem is not resolved.*Hip arthrodesis*- **Hip arthrodesis**, or surgical fusion of the hip, eliminates pain but results in the **complete loss of hip joint motion**, severely impacting daily activities.- While it can provide pain relief, it offers a significantly poorer functional outcome compared to **total hip replacement**, especially for an active elderly individual.
Question 62: A 44-year-old man presents to the Emergency Department with a 6-hour history of severe lower back pain that started suddenly while coughing. He describes severe pain radiating down the posterior aspect of his right leg to the heel. He is unable to stand on his tiptoes on the right foot. Examination reveals reduced right ankle jerk and numbness over the lateral border of the foot. Straight leg raise is positive at 30° on the right. Which nerve root is most likely compressed?
- A. S1 (Correct Answer)
- B. L4
- C. L3
- D. L5
- E. S2
Explanation: ***S1*** - Compression of the **S1 nerve root** is characterized by weakness in **plantarflexion**, making it difficult to **stand on tiptoes**. - Key clinical markers include a **diminished ankle jerk reflex** (Achilles reflex) and sensory loss or numbness localized to the **lateral border of the foot** and heel. *L4* - An **L4 nerve root** injury specifically affects the **quadriceps**, leading to weakness in **knee extension** and difficulty climbing stairs. - Clinical examination would typically reveal a **reduced knee jerk reflex** (patellar reflex) and numbness along the **medial malleolus** and medial aspect of the leg. *L3* - **L3 radiculopathy** presents with sensory changes over the **anterior thigh** and the medial aspect of the knee. - It is associated with **hip flexion** weakness (iliopsoas) and may also contribute to a **diminished patellar reflex** alongside the L4 root. *L5* - **L5 nerve root** compression characteristically involves weakness in **great toe extension** (extensor hallucis longus) and difficulty **walking on heels** (dorsiflexion). - Sensory deficits are found on the **dorsum of the foot** and the first web space, but the **ankle reflex remains intact**. *S2* - Compression of the **S2 nerve root** is relatively rare and typically presents with sensory loss along the **posterior aspect of the thigh**. - Motor deficits are less distinct than higher levels but may involve some weakness in **knee flexion** or minor intrinsic foot muscle dysfunction.
Question 63: A 68-year-old man undergoes cannulated screw fixation for an undisplaced Garden II intracapsular neck of femur fracture. Post-operative radiographs show three parallel screws in inverted triangle configuration with good position. At 6 weeks post-operatively, he reports increasing hip pain and inability to weight bear. Radiographs show screw cut-out with varus collapse of the femoral head. Which biomechanical principle was most likely violated during the initial fixation?
- A. Inadequate reduction with posterior tilt of the femoral head fragment (Correct Answer)
- B. Use of cortical screws instead of cancellous screws
- C. Insufficient screw purchase in the femoral head with threads not crossing the fracture
- D. Screws positioned too anteriorly missing the posterosuperior quadrant
- E. Excessive screw length causing penetration through the articular surface
Explanation: ***Inadequate reduction with posterior tilt of the femoral head fragment***- Successful internal fixation of femoral neck fractures is highly dependent on **anatomical reduction**; a **posterior tilt** greater than 20 degrees is associated with a high rate of fixation failure and **varus collapse**.- Even if screw placement appears ideal, a **malreduced fracture** creates unstable biomechanical forces and eccentric loading that the implants cannot withstand during weight-bearing.*Use of cortical screws instead of cancellous screws*- Standard practice for neck of femur fractures involves **cannulated cancellous screws** because they are designed to provide compression and better purchase in the metaphyseal bone.- While using the wrong screw type would be a technical error, it would not specifically lead to **varus collapse** if the initial positioning and reduction were perfect.*Insufficient screw purchase in the femoral head with threads not crossing the fracture*- To provide compression, the **screw threads** must completely cross the fracture line and reside within the **femoral head**.- If threads were across the fracture line (staying in the distal fragment), the screw would act as a **peg**, but this error would be visible on immediate post-operative films, unlike the gradual collapse described.*Screws positioned too anteriorly missing the posterosuperior quadrant*- Screws should ideally be placed in the **posterosuperior** and **inferior** regions to engage the dense bone and resist mechanical loads.- However, the prompt states the screws were in a **good position** and an **inverted triangle configuration**, suggesting this technical placement was initially documented as correct.*Excessive screw length causing penetration through the articular surface*- **Intra-articular penetration** causes immediate joint damage and pain rather than a delayed **varus collapse** at 6 weeks.- While serious, this is a complication of **over-drilling** or improper measurement, not a biomechanical violation leading to the gradual displacement of the fracture fragment.
Question 64: A 52-year-old woman with metastatic breast cancer presents with a 3-week history of progressive thoracic back pain. She now reports difficulty walking, with weakness in both legs. Neurological examination reveals grade 4/5 power in hip flexion bilaterally, brisk knee reflexes, upgoing plantars, and a sensory level at T8. Anal tone and perianal sensation are normal. What is the most likely anatomical site of pathology?
- A. Thoracic spinal cord compression above the conus medullaris (Correct Answer)
- B. Cauda equina compression below L2
- C. Bilateral lumbar nerve root compression at L2-L4
- D. Central disc prolapse at thoracolumbar junction
- E. Multiple peripheral nerve lesions
Explanation: ***Thoracic spinal cord compression above the conus medullaris***- The presence of **upper motor neuron (UMN)** signs, such as **brisk knee reflexes** and **upgoing plantars (Babinski sign)**, indicates pathology involving the spinal cord itself rather than nerve roots.- A **sensory level at T8** and progressive thoracic back pain strongly localize the compression to the **thoracic spine**, which is the most common site for **metastatic spinal cord compression**.*Cauda equina compression below L2*- This condition involves **lower motor neuron (LMN)** signs, such as diminished or absent reflexes and flaccid paralysis, which contradicts this patient's presentation.- Key features typically include **saddle anesthesia** and loss of **anal tone**, neither of which are present in this case.*Bilateral lumbar nerve root compression at L2-L4*- Compression of lumbar nerve roots would present with **LMN signs** specifically in the distribution of those roots, such as a **reduced knee-jerk reflex**.- It would not explain the **sensory level at T8** or the presence of **upgoing plantars**, which require a lesion above the lumbar spine.*Central disc prolapse at thoracolumbar junction*- A prolapse at this junction typically affects the **conus medullaris**, which usually presents with a mix of UMN and LMN signs and early **autonomic dysfunction** (bowel/bladder).- The high **sensory level at T8** suggests a more superior lesion than the thoracolumbar transition area (L1-L2).*Multiple peripheral nerve lesions*- Peripheral nerve pathology presents with **weakness and sensory loss** in specific nerve distributions without a clear **truncal sensory level**.- This would result in **absent or diminished reflexes** rather than the **hyperreflexia** and extensor plantar responses seen here.
Question 65: A 75-year-old man sustains an undisplaced Garden I intracapsular neck of femur fracture. He has a history of previous hip surgery on the same side for developmental dysplasia treated with multiple osteotomies 40 years ago, resulting in distorted anatomy. Pre-injury he was independently mobile. What is the most appropriate surgical management considering the anatomical distortion?
- A. Cemented total hip replacement (Correct Answer)
- B. Cannulated screw fixation
- C. Uncemented total hip replacement
- D. Dynamic hip screw fixation
- E. Cemented hemiarthroplasty
Explanation: ***Cemented total hip replacement***- In a patient with **distorted anatomy** from previous osteotomies for **developmental dysplasia**, primary arthroplasty provides a more predictable outcome than internal fixation despite it being a Garden I fracture.- **Cementing** the components is preferred over uncemented options to ensure immediate stability and better long-term fixation in an elderly patient with potentially compromised bone quality.*Cannulated screw fixation*- While normally used for **Garden I fractures**, the **distorted anatomy** and likely poor bone stock from multiple previous surgeries make screw trajectory and stability technically difficult.- There is a high risk of **non-union** or failure of fixation in a hip with a history of significant structural alteration.*Uncemented total hip replacement*- The **distorted femoral canal** and previous bone scarring from osteotomies make achieving a stable "press-fit" with an **uncemented prosthesis** technically challenging.- Uncemented stems in patients over 75 are associated with a higher risk of **periprosthetic fractures** compared to cemented stems.*Dynamic hip screw fixation*- A **Dynamic Hip Screw (DHS)** is typically the management of choice for **extracapsular (intertrochanteric)** fractures, not intracapsular ones.- It provides suboptimal rotational stability for **femoral neck fractures** and would be particularly difficult to place correctly in this distorted femur.*Cemented hemiarthroplasty*- **Hemiarthroplasty** is less ideal for a patient who was **independently mobile** and active pre-injury, as a Total Hip Replacement (THR) offers better functional outcomes.- Given the existing **hip dysplasia** and previous surgeries, there is a high likelihood of pre-existing **acetabular wear**, making a THR the more appropriate reconstructive choice.
Question 66: A 58-year-old man presents with a 12-week history of lower back pain and morning stiffness lasting over 2 hours. He reports the pain improves with exercise but worsens with rest. Examination shows reduced lumbar spine flexion (Schober's test <15cm expansion). Plain radiographs of the lumbar spine and pelvis are normal. ESR is 45 mm/hr, CRP 28 mg/L, and HLA-B27 is positive. What is the most appropriate next investigation to establish the diagnosis?
- A. MRI of sacroiliac joints and spine (Correct Answer)
- B. Bone scintigraphy (technetium-99m)
- C. CT scan of pelvis and lumbar spine
- D. Repeat plain radiographs in 6 months
- E. Rheumatoid factor and anti-CCP antibodies
Explanation: ***MRI of sacroiliac joints and spine*** - In patients with strong clinical features of **inflammatory back pain** and a **positive HLA-B27** but normal plain radiographs, **MRI** is the gold standard for detecting **early sacroiliitis** (bone marrow edema) and active inflammation in the spine. - This investigation is crucial for diagnosing **non-radiographic axial spondyloarthritis**, which allows for early intervention and management, preventing disease progression as per **ASAS criteria**. *Bone scintigraphy (technetium-99m)* - Bone scintigraphy has **low specificity** for diagnosing axial spondyloarthritis and may show false positives from various inflammatory or degenerative conditions. - It cannot accurately visualize early **bone marrow edema** in the sacroiliac joints, which is the hallmark of active inflammation in early disease. *CT scan of pelvis and lumbar spine* - While CT is sensitive for detecting established **bony erosions** and structural changes in advanced disease, it is **inferior to MRI** for identifying early **active inflammation** (bone marrow edema). - Furthermore, it exposes the patient to **ionizing radiation**, making MRI a preferred initial imaging modality for suspected early inflammatory spondyloarthritis. *Repeat plain radiographs in 6 months* - Plain radiographs often remain normal in the early stages of axial spondyloarthritis, and waiting 6 months would lead to a significant **diagnostic delay**. - Early diagnosis and treatment are critical to prevent **irreversible structural damage** and preserve function, which would be missed by delaying further imaging. *Rheumatoid factor and anti-CCP antibodies* - These serological markers are specific for **Rheumatoid Arthritis**, which presents differently, typically affecting peripheral joints in a symmetrical pattern, and is not indicated by the patient's axial symptoms. - Axial spondyloarthropathies, including the suspected condition in this patient, are generally **seronegative**, meaning these markers are not expected to be positive.
Question 67: A 66-year-old woman undergoes cemented hemiarthroplasty for a displaced intracapsular neck of femur fracture. During cement insertion, she suddenly becomes hypotensive (BP 75/40 mmHg), hypoxic (SpO2 85%), loses consciousness, and develops cardiac arrest. CPR is commenced immediately. What is the most likely underlying pathophysiological mechanism?
- A. Embolisation of fat, bone marrow, cement, and air causing right heart strain and pulmonary hypertension (Correct Answer)
- B. Anaphylactic reaction to methylmethacrylate monomer causing systemic vasodilation
- C. Acute myocardial infarction triggered by surgical stress and blood loss
- D. Massive pulmonary thromboembolism from dislodged deep vein thrombus
- E. Exothermic reaction of cement causing thermal injury to surrounding tissues
Explanation: ***Embolisation of fat, bone marrow, cement, and air causing right heart strain and pulmonary hypertension*** - This clinical presentation, characterized by sudden **hypotension**, **hypoxia**, loss of consciousness, and cardiac arrest during cemented arthroplasty, is highly consistent with **Bone Cement Implantation Syndrome (BCIS)**. - The high intramedullary pressure created during cement insertion forces **fat**, **bone marrow**, **cement**, and **air** into the venous circulation, leading to a sudden increase in **pulmonary vascular resistance**, acute **right ventricular failure**, and subsequent cardiovascular collapse. *Anaphylactic reaction to methylmethacrylate monomer causing systemic vasodilation* - While **methylmethacrylate monomer** can cause cardiovascular effects, a true **anaphylactic reaction** is extremely rare and typically presents with cutaneous manifestations, bronchospasm, and profound **systemic vasodilation**, which would not primarily cause **pulmonary hypertension** and **right heart strain** as seen in BCIS. - The immediate, severe cardiopulmonary collapse during cementation points more specifically to a mechanical embolic event rather than a widespread allergic response. *Acute myocardial infarction triggered by surgical stress and blood loss* - Although surgical stress and blood loss can precipitate an **acute myocardial infarction (AMI)**, the abrupt onset of symptoms precisely at the moment of **cement insertion** is a hallmark of BCIS. - An AMI would typically involve **coronary artery occlusion** and manifest with specific **ECG changes** and cardiac enzyme elevation, which are less likely to present with such an immediate, dramatic cardiopulmonary collapse without prior signs directly at the moment of cementation. *Massive pulmonary thromboembolism from dislodged deep vein thrombus* - Patients undergoing hip surgery are at risk for **venous thromboembolism (VTE)**, but a massive **pulmonary thromboembolism (PTE)** from a dislodged **deep vein thrombus** would be less directly tied to the precise moment of **cement pressurization**. - BCIS involves a distinct type of emboli (fat, marrow, cement, air) and its acute onset is directly related to the mechanical process of cementation, distinguishing it from a typical PTE. *Exothermic reaction of cement causing thermal injury to surrounding tissues* - The polymerization of polymethylmethacrylate cement is an **exothermic reaction**, generating heat that can cause localized **thermal injury** and **bone necrosis**. - However, this is a local tissue complication and does not explain the acute systemic cardiopulmonary collapse, including severe **hypotension**, **hypoxia**, and **cardiac arrest**, which are characteristic of BCIS.
Question 68: A 71-year-old man with multiple myeloma presents with a 4-week history of progressive lower back pain, now with new onset bilateral leg weakness making walking impossible. He has urinary frequency but denies retention. Examination reveals grade 3/5 power in hip flexion bilaterally, grade 4/5 in knee extension, intact perianal sensation, and normal anal tone. Plain radiographs show lytic lesions in L2 and L3 vertebrae with >50% loss of vertebral body height at L2. What is the most appropriate next step in management?
- A. Arrange urgent whole spine MRI and refer to spinal surgery within 24 hours (Correct Answer)
- B. Start high-dose oral dexamethasone 16mg daily and arrange MRI within 1 week
- C. Refer to oncology for chemotherapy and radiotherapy planning
- D. Arrange urgent CT spine and interventional radiology for vertebroplasty
- E. Prescribe analgesia, bed rest, and arrange urgent DEXA scan
Explanation: ***Arrange urgent whole spine MRI and refer to spinal surgery within 24 hours*** - This patient presents with signs of **Metastatic Spinal Cord Compression (MSCC)**, characterized by progressive neurological deficits (bilateral leg weakness) and vertebral collapse, requiring **urgent imaging and referral** within 24 hours. - A **whole spine MRI** is the gold standard to identify all potential compression sites and assess the degree of cord involvement; early surgical intervention is crucial to preserve ambulatory function and neurological status.*Start high-dose oral dexamethasone 16mg daily and arrange MRI within 1 week* - While **high-dose dexamethasone** is indicated to reduce peritumoral edema and swelling, delaying the MRI for one week is inappropriate for a suspected **oncological emergency** like MSCC. - NICE guidelines emphasize that imaging and definitive management decisions must be made within **24 hours** for patients with new or rapidly progressing neurological signs.*Refer to oncology for chemotherapy and radiotherapy planning* - **Chemotherapy and radiotherapy** are important long-term treatments for multiple myeloma and can be used for spinal metastases without cord compression, but they do not address the acute mechanical compression causing **rapidly progressing lower limb weakness**. - Immediate **surgical decompression or stabilization** is the priority when mechanical instability or rapid neurological decline is present, as their effects are not immediate enough for acute cord compression.*Arrange urgent CT spine and interventional radiology for vertebroplasty* - **Vertebroplasty** may help with pain from osteoporotic or malignant vertebral fractures and improve stability but does not relieve **neural element compression** (spinal cord or nerve roots) caused by tumor invasion. - **MRI** is superior to CT for visualizing the spinal cord and soft tissue involvement in MSCC, making it the preferred initial imaging modality in this scenario.*Prescribe analgesia, bed rest, and arrange urgent DEXA scan* - A **DEXA scan** is used for osteoporosis screening and is irrelevant in the acute management of a **malignancy-related spinal emergency** with neurological deficits. - **Bed rest** alone does not address the underlying cord compression and may exacerbate neurological deficits or lead to complications like venous thromboembolism without definitive treatment.
Question 69: What is the primary mechanism by which bisphosphonates reduce the risk of fragility fractures in patients with osteoporosis?
- A. Inhibition of osteoclast-mediated bone resorption (Correct Answer)
- B. Stimulation of osteoblast proliferation and bone formation
- C. Increase intestinal calcium absorption
- D. Enhancement of vitamin D synthesis
- E. Promotion of parathyroid hormone secretion
Explanation: ***Inhibition of osteoclast-mediated bone resorption***- **Bisphosphonates** bind to **hydroxyapatite** crystals in the bone and are internalized by **osteoclasts**, where they inhibit the enzyme **farnesyl pyrophosphate synthase**.- This action disrupts the **mevalonate pathway**, leading to **osteoclast apoptosis** and reduced bone turnover, which preserves bone mineral density.*Stimulation of osteoblast proliferation and bone formation*- This describes the **anabolic** mechanism of action characteristic of **teriparatide** (PTH analog) rather than bisphosphonates.- **Bisphosphonates** are primarily **anti-resorptive** agents and do not directly stimulate new bone matrix production.*Increase intestinal calcium absorption*- This is the primary function of **Vitamin D** (calcitriol), which enhances the expression of calcium transport proteins in the gut.- **Bisphosphonates** focus on bone mineral stabilization and do not have a direct effect on the **gastrointestinal absorption** of minerals.*Enhancement of vitamin D synthesis*- **Vitamin D synthesis** occurs in the skin via **UV-B radiation** and is further processed in the liver and kidneys; it is not influenced by bisphosphonate therapy.- While adequate vitamin D is necessary for bisphosphonates to be effective, the drugs themselves do not alter **endogenous synthesis**.*Promotion of parathyroid hormone secretion*- **Parathyroid hormone (PTH)** secretion is regulated by serum calcium levels; promoting its secretion would actually increase bone resorption via high levels of **RANKL**.- **Bisphosphonates** may actually cause a transient, secondary increase in PTH due to mild lowering of serum calcium, but this is not their therapeutic mechanism.
Question 70: A 79-year-old woman with osteoporosis sustains a displaced Garden IV intracapsular neck of femur fracture. She was previously independently mobile with a walking stick. Her past medical history includes atrial fibrillation (on warfarin), stage 3b chronic kidney disease (eGFR 38 ml/min), and a mechanical aortic valve replacement 10 years ago. What is the most appropriate surgical management?
- A. Cemented total hip replacement (Correct Answer)
- B. Cemented hemiarthroplasty
- C. Uncemented total hip replacement
- D. Cannulated screw fixation
- E. Non-operative management with analgesia
Explanation: ***Cemented total hip replacement***- NICE guidelines recommend **total hip replacement (THR)** for patients with displaced intracapsular fractures who were **independently mobile** (with no more than a stick) and have no cognitive impairment.- **Cementing** is mandatory in elderly patients with **osteoporosis** to provide immediate primary stability and reduce the risk of **periprosthetic fractures**.*Cemented hemiarthroplasty*- This is reserved for patients with significant **cognitive impairment** or those who were not previously mobile enough to benefit from a THR.- While technically easier, it results in poorer functional outcomes and potential **acetabular wear** over time compared to THR.*Uncemented total hip replacement*- Uncemented components carry a higher risk of **intraoperative fracture** and late thigh pain in elderly patients with lower **bone mineral density**.- Current evidence favors **cemented fixation** in this age group as it ensures better long-term implant survival and fewer revisions.*Cannulated screw fixation*- This is inappropriate for a **displaced Garden IV fracture** in an elderly patient due to an extremely high risk of **avascular necrosis** and non-union.- Internal fixation is generally reserved for **undisplaced fractures** or very young patients who require femoral head preservation.*Non-operative management with analgesia*- Conservative management is associated with high rates of **pneumonia**, **pressure sores**, and mortality due to prolonged immobility.- It is only considered in **moribund patients** where the risk of any anesthesia outweigh the benefits of surgical stabilization.
Practice by Chapter
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free