EMRCS 2021

Orthopedics

MRCS I.V.
Orthopedics
1/1/2021
 MRCS I.V. Course

Orthopedics

Question An
N.
s.
A 38 year old man is playing football when he slips over during a tackle.
His knee is painful immediately following the fall. Several hours later he
notices that the knee has become swollen. Following a course of non
steroidal anti inflammatory drugs and rest the situation improves.
However, complains of recurrent pain. On assessment in clinic you notice
that it is impossible to fully extend the knee, although the patient is able
1 C
to do so when asked. What is the most likely injury?
A. Anterior cruciate ligament rupture
B. Posterior cruciate ligament rupture
C. Torn meniscus
D. Medial collateral ligament tear
E. Chondromalacia patellae
A 30 year old man presents with severe pain in the left hip it has been
present on and off for many years. He was born at 39 weeks gestation by
emergency caesarean section after a long obstructed breech delivery. He
was slow to walk and as a child was noted to have an antalgic gait. He
was a frequent attender at the primary care centre and the pains dismissed
as growing pains. X-rays show almost complete destruction of the
2 femoral head and a narrow acetabulum. What is the most likely A
underlying disease process?
A. Developmental dysplasia of the hip
B. Slipped upper femoral epiphysis
C. Extra capsular fracture of the femoral neck
D. Rheumatoid arthritis
E. Perthes disease
An 80 year old woman has a hip fracture. Her calcium is normal. She has
never been given a diagnosis of osteoporosis. Apart from treating the hip
fracture what additional intervention should be considered?
A. Vitamin D and calcium supplements alone
3 B
B. Vitamin D, calcium supplements and bisphosphonates
C. Vitamin D alone
D. Calcium supplements alone
E. DEXA scan

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A 50 year old female slips on wet floor injuring her ankle. On

examination, she has tenderness over the lateral and medial malleolus. X-
rays (stress views) demonstrate an undisplaced fracture of the distal fibula
at the level of the syndesmosis and a congruent ankle mortise. What is the
most appropriate management?
4 C
A. Application of full leg cast
B. Surgical fixation
C. Application of below knee plaster cast
D. Application of external fixator
E. Bed rest, splinting and traction
A 78 year old man complains of a long history of shoulder pain and more
recently weakness. On examination, active attempts at abduction are
impaired. Passive movements are normal. What is the most likely
diagnosis?
5 A. Rotator cuff tear A
B. Osteoarthritis
C. Metastatic malignancy
D. Adhesive capsulitis
E. Calcific tendonitis
A toddler aged 3 years presents to the Emergency Department with
swelling of his leg and is found to have a spiral fracture of the tibia. His
mother reports that he had tripped and fallen the previous day but she had
not noticed any sign of injury at the time. She is a single parent with little
family support. The child is not on the child protection register. What is
6 the most likely underlying problem? B
A. Metabolic bone disease of prematurity
B. Non accidental injury
C. Hypophosphataemic rickets
D. Osteogenesis imperfecta
E. Rickets
A 24 year old man sustains a distal radius fracture during a game of
rugby. Imaging shows a comminuted fracture with involvement of the
articular surface. What is the most appropriate definitive management?
7 A. Open reduction and internal fixation A
B. Reduction under anaesthesia and place in plaster cast
C. Reduction under haematoma block and place into plaster cast
D. Place onto skeletal traction system

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E. Apply a futura splint and review in fracture clinic

A 15 year old boy is brought to the clinic by his mother who is concerned
that he has a mark overlying his lower spine. On examination, the boy has
a patch of hair overlying his lower lumbar spine and a birth mark at the
same location. Lower limb neurological examination is normal. What is
the most likely cause?
8 A
A. Spina bifida occulta
B. Meningomyelocele
C. Spondylolisthesis
D. Scheuermanns disease
E. Myelocele
A 60 year old female presents to the emergency room after tripping on a
step. She complains of shoulder pain. On examination there is pain on
initiating shoulder abduction. What is the most likely diagnosis?
A. Glenohumeral dislocation
9 D
B. Fracture of the anatomical neck of the humerus
C. Sternoclavicular dislocation
D. Supraspinatus tear
E. Infraspinatus tear
A 35 year old mechanic is hit by a fork lift truck. He sustains a Gustilo
and Anderson type IIIA fracture of the shaft of the left femur. What is the
most appropriate course of action?
A. Amputation
10 B
B. Debridement and external fixation
C. Open reduction and fixation
D. Debridement and placement of intramedullary nail
E. Debridement and placement of long leg plaster cast
A 42 year old skier falls and impacts his hand on his ski pole. On
examination, he is tender in the anatomical snuffbox and on bimanual
palpation. X-rays with scaphoid views show no evidence of fracture.
What is the most appropriate course of action?
11 A. Admission and surgical debridement C
B. Application of tubigrip bandage and fracture clinic review
C. Application of futura splint and fracture clinic review
D. Admission for open reduction and fixation
E. Discharge with reassurance
12 A 30 year old man injures his ankle playing football. On examination, he D

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has tenderness over both medial and lateral malleoli. X-ray demonstrates
a bimalleolar fracture with a displaced distal fibula fracture, at the level of
the syndesmosis and fracture of the medial malleolus with talar shift. The
ankle has been provisionally reduced and splinted in the emergency
department. What is the most appropriate management?
A. Application of external fixation device
B. Application of compression dressing and physiotherapy
C. Application of ankle boot
D. Surgical fixation
E. Below knee amputation
A 74 year old male is admitted to the Emergency Department with a fall.
He is known to have rheumatoid arthritis and is on methotrexate and
paracetamol. He lives alone in a bungalow and enjoys playing golf. He is
independent with his ADLs. He complains of left groin pain, therefore has
a hip x-ray which confirms a displaced intracapsular fracture. What is the
13 best course of action? C
A. Cemented hemiarthroplasty
B. Uncemented hemiarthroplasty
C. Total hip replacement
D. Dynamic hip screw
E. Intramedullary nail
An obese 12 year old boy is referred with pain in the left knee and hip. On
examination, he has an antaglic gait and limitation of internal rotation.
His knee has normal range of passive and active movement. What is the
most likely diagnosis?
14 A. Septic arthritis E
B. Developmental dysplasia of the hip
C. Perthes disease
D. Osteoarthritis of the hip
E. Slipped upper femoral epiphysis
A 5 month baby boy presents with swelling of his right arm and is found
to have a spiral fracture of the humerus. He had been in the care of his
mother's boyfriend who reported that he had nearly dropped him that day
15 when reaching for his bottle and had inadvertently pulled on his arm to B
save him. He was immediately taken to the Emergency Department. What
is the most likely issue?
A. Non accidental injury

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B. Accidental fracture
C. Malignant bone disease
D. Osteoporosis
E. Osteogenesis imperfecta
A 26 year old man presents to the emergency department with a swelling
over his left elbow after a fall on an outstretched hand. On examination,
he has tenderness over the proximal part of his forearm, and has severely
restricted supination and pronation movements. What is the most likely
injury?
16 B
A. Fracture of the olecranon
B. Fracture of the radial head
C. Galeazzi fracture
D. Fracture of the shaft of the radius and ulnar
E. Fracture of the coronoid process
A 19 year old sportswoman presents with knee pain which is worse on
walking down the stairs and when sitting still. On examination, there is
wasting of the quadriceps and pseudolocking of the knee. What is the
diagnosis?
17 A. Osteoarthritis D
B. Quadriceps tendon rupture
C. Undisplaced fracture patella
D. Chondromalacia patellae
E. Osgood Schlatters disease
A 58 year old man presents to the plastics team with severe burns to his
hands. He is not distressed by the burns. He has bilateral charcot joints.
On examination; there is loss of pain and temperature sensation of the
upper limbs. What is the most likely diagnosis?
18 A. Potts disease of the spine D
B. Tabes dorsalis
C. Transverse myelitis
D. Syringomyelia
E. Subacute degeneration of the cord
A 32 year old man falls from scaffolding and sustains an injury to his
forearm. Clinical examination and x-ray shows that he has sustained a
19 radial fracture with dislocation of the distal radio-ulna joint. What A
eponymous name is used to describe this injury?
A. Galeazzi

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B. Monteggia's
C. Smith's
D. Colles'
E. Barton's
A 24 year old man is brought to the emergency department having
suffered a crush injury to his forearm. Assessment demonstrates that the
arm is tender, red and swollen. There is clinical evidence of an ulnar
fracture and the patient cannot move their fingers. Which is the most
appropriate course of action?
20 E
A. Application of an external fixation device
B. Closed reduction
C. Debridement
D. Discharge and review in fracture clinic
E. Fasciotomy
A 5 year old boy presents with a painful limp. The symptoms have been
present for 8 weeks. Two hip x-rays have been performed and appear
normal. What is the best course of action?
A. Arrange a hip USS
21 C
B. Arrange a hip CT scan
C. Arrange a hip MRI
D. Arrange a further hip X-ray
E. Discharge and reassure
An 8 year old boy presents with symptoms of right knee pain. The pain
has been present on most occasions for the past three months and the pain
typically lasts for several hours at a time. On examination; he walks with
an antalgic gait and has apparent right leg shortening. What is the most
likely diagnosis?
22 A
A. Perthes Disease
B. Osteosarcoma of the femur
C. Osteoarthritis of the hip
D. Transient synovitis of the hip
E. Torn medial meniscus
A 30 year old man is admitted overnight, following a road traffic
accident. He has an open tibial fracture with a 20 cm wound and extensive
23 periosteal stripping. He is neurovascularly intact; IV antibiotics and D
wound dressing have been administered in the emergency department.
What is the most appropriate course of action?

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A. Immediate skeletal stabilisation and application of negative

pressure dressing
B. Skeletal fixation followed by vascular reconstruction
C. Immediate vascuIar shunting, followed by temporary skeletal
stabilisation and vascular reconstruction
D. Combined skeletal and soft tissue reconstruction on a scheduled
operating list
E. Fasciotomy with four compartment decompression
Which of the following types of growth plate fractures may have similar
radiological appearances?
A. Salter Harris types 1 and 5
24 B. Salter Harris types 4 and 5 A
C. Salter Harris types 3 and 5
D. Salter Harris types 1 and 2
E. Salter Harris types 1 and 3
A 60 year old male is admitted to the emergency room with a fall. He
lives with his wife and still works as a restaurant manager. He has a past
history of benign prostatic hyperplasia and is currently taking tamsulosin.
He is otherwise fit and healthy. On examination, there is right hip
tenderness on movement in all directions. A hip x-ray confirms an
25 intertrochanteric fracture. What is the best management option? C
A. Cemented hemiarthroplasty
B. Total hip replacement
C. Dynamic hip screw
D. Percutaneous pinning
E. Leg traction
Which of the following fractures names best accounts for the injury seen
in a 14 year old boy who jumps off a 10 foot wall and lands on both feet
and whose imaging shows a bimalleolar fracture of the right ankle?
A. Pott's
26 A
B. Barton's
C. Galeazzi
D. Colles'
E. Bennett's
A 22 year old rugby player falls onto an outstretched hand and sustains a
27 fracture of the distal radius. The x-ray shows a dorsally angulated B
comminuted fracture. What is the most appropriate management?

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A. Reduce under haematoma block and place in plaster

B. Admit for open reduction and internal fixation
C. Reduce using Biers block and place into plaster cast
D. Discharge home with arm sling and review in fracture clinic
E. Discharge home with futura splint and fracture clinic appointment
An athletic 15 year old boy presents with knee pain of 3 weeks duration.
It is worst during activity and settles with rest. On examination, there is
tenderness overlying the tibial tuberosity and an associated swelling at
this site. What is the diagnosis?
28 A. Chondromalacia patellae C
B. Avulsion fracture of the tibial tubercle
C. Osgood Schlatters disease
D. Quadriceps tendon rupture
E. Undisplaced fracture patella
A 23 year old rugby player falls directly onto his shoulder. There is pain
and swelling of the shoulder joint. The clavicle is prominent and there
appears to be a step deformity. What is the most likely diagnosis?
A. Acromioclavicular joint dislocation
29 A
B. Glenohumeral dislocation
C. Sternoclavicular dislocation
D. Supraspinatus tear
E. Infra spinatus tear
A 4 year boy presents with an abnormal gait. He has a history of recent
viral illness. His WCC is 11 and ESR is 30. What is the most likely
cause?
A. Perthes disease
30 B
B. Transient synovitis
C. Septic arthritis
D. Slipped upper femoral epiphysis
E. Osteomyelitis
A 13 year old boy falls onto an outstretched hand and is brought to the
emergency department. He is examined by a doctor and a bony injury is
cleared clinically. He re-presents a week later with pain in his hand. What
31 is the most likely underlying injury? B
A. Fracture of the distal radius
B. Fracture of the scaphoid
C. Dislocation of the lunate

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D. Rupture of flexor pollicis longus tendon

E. Bennett's fracture
A 45 year old man has been admitted after being knocked off his bicycle.
His ankle is grossly deformed with bilateral malleolar tenderness with
severe ankle swelling and tenting of the medial soft tissues. What is the
most appropriate initial management?
32 A. Application of compression dressing and physiotherapy C
B. Application of external fixation device
C. Immediate reduction and application of backslab
D. Surgical fixation
E. Application of full leg plaster cast
A 1 year-old is brought to the Emergency Department with a history of
failure to thrive. On examination, the child is small for age and has a large
head. X-ray shows a cupped appearance of the epiphysis of the wrist.
What is the most likely cause?
33 A. Osteoporosis D
B. Ehlers Danlos
C. Marfans
D. Rickets
E. Non accidental injury
A 40 year old marine injures his ankle on an assault course. On
examination he has a severely swollen ankle, as well as tenderness over
the medial malleolus and proximal fibula. X-rays demonstrate a medial
malleolar fracture, spiral fracture of the proximal fibula and widening of
the syndesmosis. What is the most appropriate definitive management?
34 A
A. Surgical fixation
B. Application of ankle boot
C. Application of lower leg plaster cast
D. Application of external fixation device
E. Below knee amputation
Which of the following is not a typical feature of talipes equinovarus?
A. Adducted and inverted calcaneus
B. Medial displacement of the navicular bone
35 C
C. It is nearly always unilateral
D. Wedge shaped head of talus
E. Severe Tibio-talar plantar flexion
36 Which of the following statements relating to menisceal tears is false? C

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A. The medial meniscus is most often affected

B. True locking of the knee joint may occur
C. Most established tears will heal with conservative management
D. In the chronic setting there is typically little to find on examination
if the knee is not locked
E. An arthroscopic approach may be used to treat most lesions
An obese 12 year old boy presents with knee pain. On examination, he
has pain on internal rotation of the hip. His knee is clinically normal.
What is the most appropriate investigation?
A. USS hip
37 D
B. CT scan of the hip
C. Radinucleotide scan
D. Hip X-ray
E. Anteroposterior pelvic x-ray
A 4 year old boy presents to the Emergency Department with a two-day
history of fever, difficulty walking and is unable to weight bear on the
right leg. He has been on oral Amoxycillin 250 mg three times a day for a
chest infection over the last five days. He is irritable with a temperature of
39.4oC. He does not allow examination and keeps his right hip flexed and
adducted. Blood tests are, (WBC) 18.3 (CRP) 146, haemoglobin 11.3
38 D
g/dL. What is the most likely diagnosis?
A. Acute avascular necrosis of the hip
B. Dislocation of the hip
C. Perthes disease
D. Septic arthritis
E. Slipped upper femoral epiphysis
A 12 year-old boy who is small for his age presents to the clinic with poor
muscular development and hyper-mobile fingers. His x-rays show
multiple fractures of the long bones and irregular patches of ossification.
What is the most likely diagnosis?
39 A. Osteogenesis imperfecta A
B. Osteoporosis
C. Scurvy
D. Osteopetrosis
E. Osteomalacia
An otherwise fit 74 year old man presents with pain in the right hip
40 C
following minimal trauma. On examination, his leg is shortened and

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externally rotated. Plain films demonstrate a displaced intracapsular

fracture of the femoral neck. What is the best course of action?
A. Uncemented hemi arthroplasty
B. Dynamic hip screw
C. Total hip replacement
D. Intra medullary nail
E. Percutaneous pins
Of the list below, which is not a cause of avascular necrosis?
A. Steroids
B. Sickle cell disease
41 D
C. Radiotherapy
D. Myeloma
E. Caisson disease
A 34 year old woman is a passenger in a car during an accident. Her knee
hits the dashboard. On examination, the tibia looks posterior compared to
the non injured knee. Which structure has been injured?
A. Anterior cruciate ligament
42 B
B. Posterior cruciate ligament
C. Medial collateral ligament
D. Lateral collateral ligament
E. Patella tendon
A 32 year old man presents with a painful swelling over the volar aspect
of his hand after receiving a hard blow to his palm. On examination, he
experiences pain on moving the wrist and on longitudinal compression of
the thumb. What is the most likely injury?
43 A. Bennets fracture B
B. Scaphoid fracture
C. 5th metacarpal fracture
D. Ganglion
E. Bursitis
Which of the following is the first radiological change likely to be
apparent in a plain radiograph of a 12 year old presenting with suspected
Perthes disease
44 A. Multiple bone cysts B
B. Sclerosis of the femoral head
C. Loss of bone density
D. Joint space narrowing

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E. Collapse of the femoral head

A 25 year old ski instructor who falls off a ski lift and sustains a spiral
fracture of the mid shaft of the tibia. Attempts to achieve satisfactory
position in plaster have failed. Overlying tissues are healthy. What is the
most appropriate course of action?
45 A. Amputation C
B. Open reduction and fixation using a long plate
C. Intramedullary nail
D. Skeletal traction
E. Long limb casting
A 20 year old woman sustains a Holstein-Lewis fracture. Which nerve is
at risk?
A. Ulnar
46 B. Radial B
C. Median
D. Musculocutaneous
E. Axillary
A 74 year old lady falls and injures her left arm. Following assessment
she is found to have an impacted fracture affecting the surgical neck of
the humerus. What is the most appropriate course of action?
A. Reduce the fracture and apply a plate to stabilize the fragments
47 B. Perform a hemiarthroplasty C
C. Apply a collar and cuff system for three weeks and then commence
physiotherapy
D. Apply an upper limb cast for 8 weeks
E. Apply an external fixator system
A footballer sustains a knee injury in a match and is being assessed in the
outpatient department. On examination, he has a positive valgus stress test
and minimal joint effusion. What is the most likely underlying injury?
A. Injury to the lateral collateral ligament
48 B
B. Injury to the medial collateral ligament
C. Injury to the anterior cruciate ligament
D. Injury to the posterior cruciate ligament
E. Injury to the patellar tendon
A 63 year old lady undergoes an axillary clearance for breast cancer. She
49 makes steady progress. However, 8 weeks post operatively she still B
suffers from severe shoulder pain. On examination, she has reduced active

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movements in all planes and loss of passive external rotation. What is the
most likely cause?
A. Metastatic cancer
B. Adhesive capsulitis
C. Rotator cuff tear
D. Osteoarthritis
E. Rheumatoid disease
A 63 year nurse falls on an extended and pronated wrist. An x-ray shows
a distal radial fracture with radiocarpal dislocation. Which type of fracture
is most likely?
A. Bennett's
50 B
B. Barton's
C. Pott's
D. Smith's
E. Monteggia's
A 34 year old man presents with localised spinal pain over 2 months
which is worsened on movement. He is known to be an IVDU. He has no
history suggestive of tuberculosis. The pain is now excruciating at rest
and not improving with analgesia. He has a temperature of 39 oC. What is
the most likely diagnosis?
51 B
A. Transverse myelitis
B. Osteomyelitis
C. Potts disease of the spine
D. Epidural haematoma
E. Brown-Sequard syndrome
A 19 year old female is involved in an athletics event. She has just
completed the high jump when she suddenly develops severe back pain
and weakness affecting both her legs. On examination, she has a
prominent sacrum and her lower back is painful. What is the most likely
underlying cause?
52 D
A. Structural scoliosis
B. Ankylosing spondylitis
C. Scheuermanns disease
D. Spondylolisthesis
E. Spondylolysis
A 72 year old lady stumbles and falls. On examination, she is tender in
53 A
the left groin and unable to weight bear. Attempts at internal rotation

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produce severe pain. Plain films of the hip show no obvious fracture.
What is the best course of action?
A. MRI scan
B. Bone scintigraphy
C. Conservative management
D. Hip arthrodesis
E. Total hip replacement
A 54-year-old man presents to the Emergency Department with a 2 day
history of a swollen, painful left knee. You aspirate the joint to avoid
admission to the orthopaedic wards. Aspirated joint fluid shows calcium
pyrophosphate crystals. Which of the following blood tests is most useful
in revealing an underlying cause?
54 A
A. Transferrin saturation
B. ACTH
C. ANA
D. Serum ferritin
E. LDH
A tall 18 year old male athlete is admitted to the emergency room after
being hit in the knee by a hockey stick. On examination, his knee is tense
and swollen. X-ray shows no fractures. What is the diagnosis?
A. Dislocated patella
55 A
B. Quadriceps tendon rupture
C. Patella fracture
D. Chondromalacia patellae
E. Avulsion fracture of the tibial tubercle
A 19 year old soldier has just returned from a prolonged marching
exercise and presents with a sudden onset, severe pain, in the forefoot.
Clinical examination reveals tenderness along the second metatarsal.
Plain x-rays are taken of the area, these demonstrate callus surrounding
the shaft of the second metatarsal. What is the most likely diagnosis?
56 A
A. Stress fracture
B. Mortons neuroma
C. Osteochondroma
D. Acute osteomyelitis
E. Freiberg's disease
A 65-year-old Asian female presents with an extracapsular neck of femur
57 D
fracture. Investigations show:

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Calciu 2.07 mmol/l (2.20-2.60

m mmol/l)

Phosph 0.66 mmol/l (0.8-1.40

ate mmol/l)

ALP 256 IU/l (44-147 IU/l)

What is the most likely diagnosis?

A. Bone tuberculosis
B. Hypoparathyroidism
C. Myeloma
D. Osteomalacia
E. Paget's disease
A 78-year-old woman is discharged following a fractured neck of femur.
On review, she is making good progress but consideration is given to
secondary prevention of further fractures. Unfortunately the
orthogeriatricians are all on annual leave and the consultant has asked you
to arrange suitable management. Which is the best option?
58 B
A. Alendronate
B. Alendronate, calcium and vitamin D supplementation
C. Strontium
D. Arrange a DEXA scan
E. Hormone replacement therapy
Which of the following statements relating to avascular necrosis is false?
A. When associated with fracture may occur despite the radiological
evidence of fracture union.
B. Pain and stiffness will typically precede radiological evidence of
the condition.
59 C. Drilling of affected bony fragments may be used to facilitate D
angiogenesis where arthroplasty is not warranted.
D. The earliest detectable radiological evidence is a radiolucency of
the affected area coupled with subchondral collapse.
E. It is less likely when prompt anatomical alignment of fracture
fragments is achieved.
60 A 28 year old man falls onto an outstretched hand. On examination, there C

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is tenderness of the anatomical snuffbox. However, forearm and hand x-

rays are normal. What is the most appropriate course of action?
A. Discharge with reassurance
B. Place in arm sling and discharge
C. Place in futura splint and review in fracture clinic
D. Admit for surgical exploration
E. Apply an external fixation device
A 6 year old boy presents with groin pain. He is known to be disruptive in
class. He reports that he is bullied for being short. On examination, he has
an antalgic gait and pain on internal rotation of the right hip. What is the
most likely diagnosis?
61 A. Perthes disease A
B. Transient synovitis
C. Slipped upper femoral epiphysis
D. Developmental dysplasia of the hip
E. Septic arthritis
An 86 year old retired pharmacist is admitted to Emergency Department
following a fall. She complains of right hip pain. She is known to have
hypertension and is currently on bendrofluazide. She lives alone and
mobilises with a Zimmer frame. Her right leg is shortened and externally
rotated. A hip x-ray confirms a displaced intracapsular fracture. What is
62 the best management option? D
A. Dynamic hip screw
B. Gamma nail
C. Total hip replacement
D. Hemiarthroplasty
E. Percutaneous pinning
Which type of fracture is seen when a 22 year old drunk man is involved
in a fight and injures his thumb when he punches his opponent?
A. Barton's
63 B. Bennett's B
C. Galeazzi
D. Colles'
E. Smith's
A 4 year old boy falls and sustains a fracture to the growth plate of his
64 right wrist. Which of the following systems is used to classify the injury? A
A. Salter - Harris system

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B. Weber system
C. Gustilo - Anderson system
D. Garden system
E. None of the above
A 43 year old man falls over landing on his left hand. Although there was
anatomical snuffbox tenderness no x-rays either at the time or
subsequently have shown evidence of scaphoid fracture. He has been
immobilised in a futura splint for two weeks and is now asymptomatic.
What is the most appropriate course of action?
65 E
A. Application of tubigrip bandage and fracture clinic review
B. Admission and surgical debridement
C. Application of futura splint and fracture clinic review
D. Application of below elbow cast for 6 weeks
E. Discharge with reassurance
A 28 year old professional footballer is admitted to the emergency
department. During a tackle his leg is twisted with his knee flexed. He
hears a loud crack and his knee rapidly becomes swollen. Which of the
following structures is the main site of injury?
66 A. Anterior cruciate ligament A
B. Posterior cruciate ligament
C. Meniscus
D. Medial collateral ligament
E. Lateral collateral ligament
A 25 year old man is diagnosed as having an undisplaced fracture of the
proximal pole of the scaphoid. What is the best course of action?
A. Immobilisation in future splint for 5 weeks
B. Arrange an MRI scan
67 D
C. Immobilisation in plaster cast for 4 weeks
D. Surgical fixation
E. Initial immbolisation in plaster cast for 2 weeks with check
radiographs at that stage
A 10 year old boy is referred to the orthopaedic clinic with symptoms of
right knee pain. He has suffered pain for the past 3 months and the pain
typically lasts for several hours. On examination he walks with an
68 E
antalgic gait and has apparent right leg shortening. The right knee is
normal but the right hip reveals pain on internal and external rotation.
Imaging shows flattening of the femoral head. Which of the following is

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 MRCS I.V. Course

the most likely underlying diagnosis?

A. Osteogenesis imperfecta
B. Child abuse
C. Osteosarcoma
D. Osteopetrosis
E. Perthes disease
Which of the following is least likely to impair bone fracture healing?
A. Radiotherapy
B. Osteoporosis
69 D
C. Administration of non steroidal anti inflammatory drugs
D. Preservation of periosteum
E. Presence of osteomyelitic sequestra
An obese 14 year old boy presents with difficulty running and mild knee
and hip pain. There is no antecedent history of trauma. On examination,
internal rotation is restricted but the knee is normal with full range of
passive movement possible and no evidence of effusions. Both the C-
reactive protein and white cell count are normal. What is the most likely
70 cause? B
A. Perthes disease
B. Slipped upper femoral epiphysis
C. Non accidental injury
D. Septic arthritis
E. Osteoarthritis
A 64 year old man is involved in a motor vehicle accident and is found to
have a fracture affecting the anatomical neck of his humerus which is
displaced. What is the most appropriate management?
A. Place a collar and cuff for 3 weeks and then commence
physiotherapy
B. Hemiarthroplasty
71 B
C. Place in a collar and cuff for 6 weeks and then commence
physiotherapy
D. Reduce the fracture and place in an arm sling with repeat imaging
at 14 days
E. Reduction under anaesthesia and place in collar and cuff system for
6 weeks
A 70 year old man undergoes a revision total hip replacement. 10 days
72 E
post operatively the hip dislocates and pus is discharging from the wound.

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 MRCS I.V. Course

He is systemically unwell with a temperature of 38.5 and WCC 19. What

is the most appropriate course of action?
A. Lay open wound and apply a VAC dressing
B. Hindquater amputation
C. Revision arthroplasty
D. Removal of metalwork and bone grafting
E. Removal of metalwork and implantation of local antibiotics
An 18 year old athlete attends orthopaedic clinic reporting pain and
swelling over the medial aspect of the knee joint. The pain occurs when
climbing the stairs, but is not present when walking on flat ground.
Clinically there is pain over the medial, proximal tibia and the McMurray
test is negative. What is the most likely cause of this patient's symptoms?
73 D
A. Anterior cruciate ligament tear
B. Prepatellar bursitis
C. Medial meniscus injury
D. Pes Anserinus Bursitis
E. Fracture of tibia
A 15 year-old boy presents to the out-patient clinic with tiredness,
recurrent throat and chest infections, and gradual loss of vision. Multiple
x-rays show brittle bones with no differentiation between the cortex and
the medulla. What is the most likely diagnosis?
74 A. Rickets C
B. Osteomalacia
C. Osteopetrosis
D. Ehlers Danlos type III
E. Osteogenesis imperfecta
A 73 year old lady presents with pain in her left hip. She was walking
around the house when she tripped over a rug and fell over. Apart from
temporal arteritis which is well controlled with prednisolone she is
otherwise well. On examination, her leg is shorted and externally rotated.
Her serum alkaline phosphatase and calcium are normal. What is the
75 likely underlying disease process? C
A. Pagets disease
B. Metastatic renal cancer
C. Osteoporosis
D. Osteopetrosis
E. Osteoclastoma

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 MRCS I.V. Course

A 72 year old retired teacher is admitted to A&E with a fall and hip pain.
He is normally fit and well. He lives with his son in a detached, 2 storey
house. A hip x-ray and femur views confirm a sub trochanteric fracture.
What is the best course of action?
76 A. Insertion of intra medullary nail A
B. Total hip replacement
C. Uncemented hemiarthroplasty
D. Percutaneous pinning
E. Hip arthrodesis
In paediatric orthopaedic surgery, which of the following does not fulfill
the Kocher criteria for septic arthritis?
A. ESR > 40mm/h
77 B. Positive blood culture B
C. Fever
D. White cell count > 12, 000
E. Non weight bearing on the affected side
A 28 year old man falls on the back of his hand. On x-ray, he has a
fractured distal radius demonstrating volar displacement of the fracture.
What eponymous term is used to describe this?
A. Barton's
78 C
B. Colles'
C. Smith's
D. Pott's
E. Galeazzi
A 28 year old man complains of pain and weakness in the shoulder. He
has recently been unwell with glandular fever from which he is fully
recovered. On examination there is some evidence of muscle wasting and
a degree of winging of the scapula. Power during active movements is
impaired. What is the most likely cause?
79 A
A. Parsonage-Turner syndrome
B. Adhesive capsulitis
C. Rotator cuff tear
D. Osteoarthritis
E. Calcific tendonitis
A baby is delivered in the breech position. Barlows and Ortolani tests are
80 normal. What is the most appropriate course of action? C
A. Reassure and discharge the patient

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 MRCS I.V. Course

B. Reassess the patient at 3 years

C. Arrange a hip USS
D. Arrange a hip X-ray
E. Arrange a hip CT scan
An infant is admitted with symptoms and signs of respiratory infection
and is found to have several posterior rib fractures on chest radiograph.
He was born prematurely at 37 weeks' gestation and was observed
overnight on the special care baby unit for tachypnoea which settled by
the following day. On assessment, it is also apparent that his head
circumference has increased at an excessive rate and has crossed 3
81 D
centiles since birth. What is the most likely underlying issue?
A. Accidental fracture
B. Pagets disease
C. Myeloproliferative disorder
D. Non accidental injury
E. Osteomalacia
A 22 year man is shot in the back, in the lumbar region. He has increased
tone and hyper-reflexia of his right leg. He cannot feel his left leg. What
is the most likely explanation?
A. Epidural haematoma
82 D
B. Osteomyelitis
C. Transverse myelitis
D. Brown-Sequard syndrome
E. Tabes dorsalis
A 19 year old female presents to the clinic with progressive pain in her
neck and back. The condition has been progressively worsening over the
past 6 months. She has not presented previously because she was an
inpatient with a disease flare of ulcerative colitis. On examination, she has
a stiff back with limited spinal extension on bending forwards. What is
83 the most likely explanation for this process? E
A. Spondylolysis
B. Spondylolisthesis
C. Functional scoliosis
D. Scheuermanns disease
E. Ankylosing spondylitis
A 50 year old man is admitted after falling from scaffolding. He has an
84 A
open fracture of his tibia with a 15 cm wound. He is neurovascularly

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 MRCS I.V. Course

intact. What is the best initial course of action?

A. Intravenous antibiotics, photography and application of saline
soaked gauze with impermeable dressing
B. Thorough wound debridement in the emergency department
C. Combined skeletal and soft tissue reconstruction on a scheduled
operating list
D. Application of external fixator and conversion to internal fixation
after two weeks
E. Immediate skeletal stabilisation and application of negative
pressure dressing
A 65 year old type 2 diabetic with poor glycaemic control is admitted
with forefoot cellulitis. X-ray of the foot shows some evidence of
osteomyelitis affecting the 2nd ray but overlying skin is healthy. What is
the best treatment initially?
85 A. Intravenous antibiotics A
B. Below knee amputation
C. Transfemoral amputation
D. Midfoot amputation
E. Ray amputation
With which of the conditions listed below is a Hill- Sachs lesions
classically associated?
A. Fracture of the surgical neck of the humerus
86 B. Glenohumeral dislocation B
C. Supraspinatus tear
D. Acromioclavicular dislocation
E. Sternoclavicular dislocation
A 20 year old woman trips over a step, injuring her ankle. Examination
reveals tenderness over the lateral malleolus and an x-ray demonstrates an
undisplaced fracture distal to the syndesmosis. What is the best course of
action?
87 A. Application of ankle boot A
B. Surgical fixation
C. Application of full leg plaster cast
D. Application of external fixator
E. Application of Ilizarov frame
A 56 year old lady presents with a painful swelling over the lower end of
88 D
the forearm following a fall. Imaging reveals a distal radial fracture with

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 MRCS I.V. Course

disruption of the distal radio-ulnar joint. What is the most likely fracture?
A. Fracture of the distal humerus
B. Fracture of the shaft of the radius and ulnar
C. Fracture of the coronoid process
D. Galeazzi fracture
E. Fracture of the radial head
A 10 year old boy undergoes a delayed open reduction and fixation of a
significantly displaced supracondylar fracture. On the ward he complains
of significant forearm pain and paraesthesia of the hand. Radial pulse is
normal. What is the most appropriate course of action?
89 A. Fasciotomy A
B. Arrange a CT angiogram
C. Provide stronger analgesia
D. Arrange repeat limb x-rays
E. Arrange a forearm duplex scan
A 5 year old boy is playing in a tree when he falls and lands on his right
forearm. He is brought to the emergency department by his parents. On
examination he has bony tenderness and bruising. An X-ray is taken and
shows unilateral cortical disruption and development of periosteal
haematoma. What is the most likely diagnosis?
90 B
A. Buckle fracture
B. Greenstick fracture
C. Toddlers fracture
D. Complete fracture
E. None of the above
Which of the following is not typically seen in patients with a femoral
neck fracture?
A. Malunion
91 B. Non union A
C. Avascular necrosis
D. Shortening
E. External rotation
A 6 year old boy presents with pain in the hip it is present on activity and
has been worsening over the past few weeks. There is no history of
92 trauma. He was born by normal vaginal delivery at 38 weeks gestation On A
examination he has an antalgic gait and limitation of active and passive
movement of the hip joint in all directions. C-reactive protein is mildly

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 MRCS I.V. Course

elevated at 10 but the white cell count is normal. What is the most likely
diagnosis?
A. Perthes disease
B. Septic arthritis
C. Slipped upper femoral epiphysis
D. Developmental dysplasia of the hip
E. Osteoarthritis
A 38 year old window cleaner falls from his ladder. He lands on his left
arm and notices an obvious injury. An x-ray and clinical examination
demonstrate that he has a fracture of the proximal ulna and associated
radial dislocation. What eponymous name is used to describe this injury?
93 A. Galeazzi E
B. Smith's
C. Bennett's
D. Pott's
E. Monteggia's
A 40 year old woman is admitted after being knocked off her bike. She
has an open fracture of her tibia, with a 10 cm wound. No peripheral
pulses are palpable. Intravenous antibiotics have been administered in the
emergency department and the wound has been dressed. What is the best
course of action?
A. Immediate skeletal stabilisation and application of negative
94 pressure dressing E
B. Intravenous antibiotics, photography and application of saline
soaked gauze with impermeable dressing
C. Skeletal fixation followed by vascular reconstruction
D. Immediate amputation
E. Immediate vascuIar shunting, followed by temporary skeletal
stabilisation and vascular reconstruction
95 A 17-year-old girl presents with a swelling over her right knee. A
Movements of her knee are restricted. A plain x-ray of the affected site
shows multiple lytic and lucent lesions with clearly defined borders.
What is the most likely diagnosis?
A. Osteoclastoma
B. Osteoblastoma
C. Osteosarcoma
D. Ewings sarcoma

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 MRCS I.V. Course

E. Osteoid osteoma
96 A 16 year old boy develops a painful swelling of his distal femur. An E
osteoblastic sarcoma is diagnosed. To which of the following sites is this
lesion most likely to metastasise?
A. Inguinal lymph nodes
B. Common iliac lymph nodes
C. Liver
D. Brain
E. Lung
97 Which one of the following confers the least risk of developing A
osteoporosis?
A. Obesity
B. Long term unfractionated heparin therapy
C. Gastrectomy
D. Osteogenesis imperfecta
E. Diabetes
98 A 16 year-old boy presents to his GP with loss of weight, pain and fever. C
On examination, a mass is palpable over the mid-thigh region. What is
the most likely diagnosis?
A. Fibrosarcoma
B. Osteosarcoma
C. Ewing sarcoma
D. Osteoid osteoma
E. Synovial sarcoma
99 A 75 year old lady presents with weight loss, pain and a swelling over her B
left knee. She has been treated for Pagets disease of the bone for some
time. What is the most likely diagnosis?
A. Ewings sarcoma
B. Osteosarcoma
C. Myeloma
D. Septic arthritis
E. Osteoclastoma
100 A 72 year old lady falls and lands on her left hip. She attends the E
emergency department and is given some paracetamol by the junior
doctor and discharged. Several months later she presents with ongoing
pain and discomfort of the hip. Avascular necrosis of the femoral head is
suspected. Which of the following features is least likely to be present?
A. Union of the fracture
B. Angiogenesis at the fracture site
C. Increased numbers of fibroblasts at the fracture site

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 MRCS I.V. Course

D. Osteochondritis dissecans
E. Apoptosis of osteoblasts
101 What is the most common cause of osteolytic bone metastasis in B
children?
A. Osteosarcoma
B. Neuroblastoma
C. Leukaemia
D. Rhabdomyosarcoma
E. Nephroblastoma
102 Which of the metastatic bone tumours described below is at the greatest C
risk of pathological fracture ?
A. Proximal humeral lesion from a prostate cancer
B. Vertebral body lesions from a prostate cancer
C. Peritrochanteric lesion from a carcinoma of the breast
D. Proximal humeral lesion from a carcinoma of the breast
E. Peritrochanteric lesion from a prostate cancer
103 A 73 year old man presents with pain in the right leg. It is most B
uncomfortable on walking. On examination, he has a deformity of his
right femur, which on x-ray is thickened and sclerotic. His serum alkaline
phosphatase is elevated, but calcium is within normal limits. What is the
most probable underlying diagnosis?
A. Rickets
B. Pagets disease
C. Metastatic lung cancer
D. Osteoclastoma
E. Chondrosarcoma
104 A 78 year old man presents with unilateral deafness which has been C
present for the past 3 months. On examination, Webers test localises to
the contralateral side and a CT scan of his head shows a thickened
calvarium with areas of sclerosis and radiolucency. His blood tests show
an elevated alkaline phosphatase, normal serum calcium and normal PTH
levels. Which of the following is the most likely underlying diagnosis?
A. Multiple myeloma with skull involvement
B. Osteoporosis
C. Pagets disease with skull involvement
D. Lung cancer with skull metastasis
E. Osteopetrosis with skull involvement
105 Which of the following best describes the main pathological feature of A
generalized osteoporosis?
A. Reduction in volume of normally mineralized osteoid matrix

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 MRCS I.V. Course

B.Increase in volume of normally mineralized osteoid matrix

C.Reduction in volume of abnormally mineralized osteoid matrix
D.Increase in volume of abnormally mineralized osteoid matrix
E.Significant increase in bony trabeculae that are excessively
mineralised
106 A 20 year old male presents with a tense, swollen knee joint. There is no D
history of antecedent trauma. On examination the joint is tense and
swollen but there is no sign of injury. Plain x-rays show no fracture or
arthritis. What is the most likely explanation?
A. Rupture of the anterior cruciate ligament
B. Rupture of the medial collateral ligament
C. Tibial plateau fracture
D. Haemophilia A
E. von Willebrands disease
107 Which of the following structures attaches periosteum to bone? A
A. Sharpeys fibres
B. Peripheral lamellae
C. Elastic fibres
D. Fibrolamellar bundles
E. Purkinje fibres

EMRCS, Orthopedics 27 MRCS I.V. Course