1.

 Bones act as a storage reservoir for all of the following substances except:

A. Magnesium
B. Calcium
C. Phosphate
D. Glycogen
Well done, you have selected the right answer.
The correct answer is D. Bones act as a large reservoir for storage of calcium
and phosphate. Other trace elements are also stored in bone, including
magnesium, copper and zinc. Glycogen, the storage form of glucose is stored in
the liver and skeletal muscle.

2. Bones act as a storage reservoir for all of the following substances except:

A. Magnesium
B. Calcium
C. Phosphate
D. Glycogen
Well done, you have selected the right answer.
The correct answer is D. Bones act as a large reservoir for storage of calcium
and phosphate. Other trace elements are also stored in bone, including
magnesium, copper and zinc. Glycogen, the storage form of glucose is stored in
the liver and skeletal muscle.

3. Concerning periosteum, which of the statements is false?

A. Periosteum is made of two layers
B. Periosteum provides the predominant blood supply to bone in
adults
C. Periosteum is thicker in children than in adults
D. Periosteum is continuous with the joint capsule
E. Periosteum contains many cells
Well done, you have selected the right answer.
The correct answer is B. The surface of bones is covered with periosteum. This is
composed of an inner cambial layer, which is very vascular and contains many
osteoblasts, contributing to circumferential growth. The outer fibrous layer is
strong and tough. It is continuous with joint capsules and ligament insertions. In
children the periosteum is very thick, which is of clinical relevance when treating
fractures. In adults the principal blood supply to the long bones comes from the
nutrient arteries in the medullary canal. This artery supplies the inner 2/3 of the
cortex. The periosteal blood supply is lower pressure and supplies only the outer
1/3. In children the opposite is true: the thick periosteum is the major blood
supply to the cortex, whereas the nutrient artery system is a minor contributor.

4. Which of the following statements is true regarding lamellar bone?

 A. Lamellar bone is the first type of bone to form during
secondary fracture healing.
B. Lamellar cortical bone is the least dense bone type.
C. Lamellar cancellous bone is the strongest type of bone.
D. Lamellar cancellous bone has a honeycomb appearance and
contains many cells.
E. Lamellar bone is the principal bone type in the neonate.
Well done, you have selected the right answer.
The correct answer is D. Woven bone is found in callus and the developing
skeleton. Lamellar bone comprises two types: cortical and cancellous. Cortical
bone is the densest and strongest form and makes up the hard outer surfaces of
a long bone. The lamellae are arranged in rings called osteons. Cancellous bone
is found in the centre and metaphyseal regions of long bones. It is less strong
and less dense, with a ‘spongy’ appearance. It contains many cells.

5. Osteoblasts:
A. Produce acid to resorb bone.
B. Are dormant cells trapped within the layers of lamellar bone.
C. Are bone-forming cells.
D. Are found within the synovium of joints.
Well done, you have selected the right answer.
The correct answer is C. Osteoclasts resorb bone; osteocytes are dormant
osteoblasts trapped within the bone matrix; osteoblasts are not found within
synovium.

6. Which of the following types of cartilage lines healthy synovial joints?

A. Fibrocartilage
B. Hyaline cartilage
C. Elastic cartilage
Well done, you have selected the right answer.
The correct answer is B. Hyaline is the most common cartilage type, found in the
articular cartilage, nose, larynx and trachea, and is a precursor of bone.
Fibrocartilage is found in intervertebral discs, joint capsules and ligaments.
Elastic cartilage is springy and makes up the pinna of the ear and epiglottis.

 7. Articular cartilage:
A. Is a poorly structured substance.
B. Has eight distinct zones.
C. Is very good at resisting shear.
D. Generates high levels of friction to stabilise the joint.
E. Has an extremely good blood supply.
Sorry, you have selected the wrong answer.
The correct answer is C. Articular cartilage is highly structured and can be
divided into four distinct zones. This specialised structure resists shear at the
surface, and compression at the base. It functions to reduce friction between joint
surfaces, assist in producing lubricating fluid and distribute load evenly across the
joint surface. It is aneural, avascular and alymphatic, deriving its nutrition via
diffusion from the synovial fluid.

 8. Articular cartilage has all of the following properties except:

A. Avascular
B. Alymphatic
C. Aneural
D. Acellular
Sorry, you have selected the wrong answer.
The correct answer is D. Articular cartilage is aneural, avascular and alymphatic,
deriving its nutrition via diffusion from the synovial fluid. It contains chondrocytes,
so is not acellular.

9. Which of the following statements is true regarding the menisci of the knee?
A. A normal knee has one horseshoe-shaped meniscus.
B. Menisci are composed of elastic cartilage.
C. Menisci help with distribution of load across the knee.
D. The meniscus has a good blood supply and tears therefore often
heal effectively.
E. The medial meniscus is generally much larger than the lateral
meniscus.
Well done, you have selected the right answer.
The correct answer is C. The normal knee has two menisci, lateral and medial.
They are made of fibrocartilage arranged in longitudinal and radial bands. They
serve to: evenly distribute load across the knee joint, especially in flexion; absorb
shock; aid in stabilising the knee, especially if the anterior cruciate ligament
(ACL) is injured. They also contribute to proprioception. In adults, only the
peripheral 1/3 of the meniscus has a blood supply. Tears in this region may be
amenable to repair and may heal, but the majority of tears are in the avascular
region so will not heal. The lateral meniscus is larger and more mobile than the
smaller relatively fixed medial meniscus.

10. Which of the following statements is false?

A. Ligaments connect bone to bone.
B. Tendons connect muscle to bone.
C. Tendons and ligaments are made of longitudinally arranged
collagen fibres.
D. Overstretching a ligament results in a sprain.
E. Ligaments are less elastic than tendons.
Sorry, you have selected the wrong answer.
The correct answer is E. Ligaments have more elasticity and ‘spring’ in them than
tendons. This allows a degree of ‘give’ in a joint, although overstretching a
ligament results in a sprain. Tendons have very little elasticity, so are very
efficient at conducting the pull of a muscle.

11. Regarding calcium, which statement is false?

A. Calcium is a vital part of muscle function and abnormal levels
may result in tetany or cardiac arrhythmia.
B. 75% of total body calcium is stored in bone.
C. Plasma proteins bind around 50% of circulating calcium, the
exact level dependent on pH.
D. In its stored state, calcium is stored bound to phosphate.
Sorry, you have selected the wrong answer.
The correct answer is B. Calcium (Ca) is vital for muscle and nerve function. 99%
of the body's calcium is stored within bone as hydroxyapatite, a calcium and
phosphate compound. Only 1% is free to circulate and half of this is bound to
plasma proteins. pH affects protein binding.

12. Which of the following statements is true regarding vitamin D?

A. Vitamin D is absorbed from oily fish in its active form.
B. 25-Hydroxycholecalciferol is hydroxylated for a second time in
the kidney.
C. Active vitamin D acts on the duodenum to stimulate dietary
absorption of Ca and PO4 and also stimulates osteoclasts.
D. The net effect of vitamin D is to decrease serum Ca and
PO4 levels.
E. Vitamin D is degraded by UV light acting on the skin.
Well done, you have selected the right answer.
The correct answer is C. Vitamin D is a steroid hormone that has to be activated
in order to have effect. It is found in fish oil or can be created by the action of UV
light on 7-dehydrocholesterol in the skin. The resulting cholecalciferol is then
hydroxylated in the liver to form 25-hydroxycholecalciferol and hydroxylated a
second time in the kidney to form 1,25-dihydroxycholecaciferol. This is the active
form. It acts on the duodenum to stimulate dietary absorption of Ca and PO4, and
also stimulates osteoclasts to break down hydroxyapatite. The net effect is to
increase serum Ca and PO4 levels.

13. Which vitamin is involved with calcium and phosphate homeostasis?

a. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
E. Vitamin E
Well done, you have selected the right answer.
The correct answer is D. Vitamin D, once activated by the liver and kidney, acts
on the duodenum to stimulate dietary absorption of Ca and PO4, and also
stimulates osteoclasts to break down hydroxyapatite. The net effect is to increase
serum Ca and PO4 levels.

14. Select which substance best matches the description: ‘Polypeptide produced

in chief cells in response to hypocalcaemia, it acts to stimulate osteoclasts to
release Ca and PO4 from bone, increases hydroxylation of vitamin D in the
kidneys and increases renal excretion of PO4.’
A. Parathyroid hormone (PTH)
B. 25-hydroxycholecalciferol
C. 1,25-dihydroxycholecalciferol
D. Calcitonin
E. Oestrogen
Well done, you have selected the right answer.
The correct answer is A. Parathyroid hormone is produced in the chief cells of the
parathyroid glands and acts as described.

 15. Select which substance best matches the description: ‘Produced by clear

cells in response to hypercalcaemia, it directly inhibits osteoclasts.’
A. Parathyroid hormone (PTH)
B. 25-hydroxycholecalciferol
C. 1,25-dihydroxycholecalciferol
D. Calcitonin
E. Oestrogen
Sorry, you have selected the wrong answer.
The correct answer is D. Calcitonin is produced in the thyroid. It inhibits
osteoclasts from breaking down bone stores of calcium and phosphate and
therefore acts to reduce serum calcium and phosphate levels.

16. Which substance is produced by an enzyme in the liver?

A. Parathyroid hormone (PTH)
B. 25-hydroxycholecalciferol
C. 1,25-dihydroxycholecalciferol
D. Calcitonin
E. Thyroxine
Sorry, you have selected the wrong answer.
The correct answer is B. Vitamin D starts as cholecalciferol, which is inactive. In
order to become activated it is hydroxylated twice. The first hydroxylation occurs
in the liver to make 25-hydroxycholecalciferol. The second hydroxylation occurs
in the kidney to make 1,25-dihydroxycholecalciferol. This is the active form. The
hydroxylation process is controlled by PTH and therefore the whole process is
closely regulated.
17. A five-year-old black child presents to the clinic with a 1-year history of painful
legs. Examination reveals short stature, bowing of both tibia and enlarged
costochondral junctions. X-rays reveal lateral tibial bow, enlarged physes and
codfish vertebrae. The most likely diagnosis is:
A. Osteoporosis
B. Rickets
C. Paget's disease
D. Osteomalacia
E. Tuberculosis
Well done, you have selected the right answer.
The correct answer is B. In the UK, rickets is commonest in dark-skinned children
who do not get enough UV exposure and may have a deficient diet. All of the
described features are typical of rickets. Osteoporosis, Paget's and osteomalacia
are not diseases of children.

18. An octogenarian suffers a vertebral wedge fracture when sitting down heavily.
She subsequently has a DEXA scan to evaluate for the presence of osteoporosis.
According to the WHO, what defines severe osteoporosis?
A. T-score >0.5
B. T-score −0.5 to −1.5
C. Z-score >0.5
D. T-score −2.5
E. Z-score −2.5
Sorry, you have selected the wrong answer.
The correct answer is D. The DEXA scan produces two numbers. The Z-score
compares the patient to an age- and sex-matched peer and is not used in the
definition of osteoporosis. The T-score compares the patient's bone density to her
expected peak bone density (T-score = bone density aged twenty). The WHO
has defined severe osteoporosis as a T-score −2.5.

19. All of the following are risk factors for osteoporosis except:

A. Female sex
B. Dietary deficiency of calcium
C. High body mass index
D. Smoking
E. Family history
Well done, you have selected the right answer.
The correct answer is C. High body mass index is protective against
osteoporosis. Other risk factors include increasing age, late menarche or early
menopause, low body mass index (especially in the second and third decade
when bone mass is peaking, therefore anorexia nervosa is a major risk factor),
alcohol intake, Northern European descent.

20. All of the following are treatments for osteoporosis except:

 A. Bisphosphonates
B. Oestrogen replacement therapy
C. Vitamin D supplements
D. Calcium supplements
E. A period of non-weightbearing
Sorry, you have selected the wrong answer.
The correct answer is E. Weightbearing and exercise help to prevent
osteoporosis. Prolonged periods of non-weightbearing may result in loss of bone
mass, known as disuse osteopenia.

21. The condition that results in a quantitative reduction of qualitatively normal

bone is:
A. Osteopetrosis
B. Osteomalacia
C. Osteoporosis
D. Osteomyelitis
E. Oteogenesis imperfecta
Well done, you have selected the right answer.
The correct answer is C. Osteopetrosis is a defect of osteoclasts resulting in
abnormally dense bone. Osteomalacia is a qualitative defect of bone whereas
osteoporosis is a quantitative reduction in bone mass. There is no qualitative
defect in osteoporosis. Osteomyelitis is bone infection and osteogenesis
imperfecta is an inherited collagen defect resulting in abnormally brittle bone.

22. Radiographic findings in osteoarthritis include all the of the following except:

A. Loss of joint space
B. Osteophyte formation
C. Subchondral sclerosis
D. Subchondral cysts
E. Periarticular osteopenia
Well done, you have selected the right answer.
The correct answer is E. LOSS is the acronym to help remember the radiographic
findings. Periarticular osteopenia occurs in rheumatoid arthritis. In osteoarthritis
the bone around the joints is often sclerotic and hard, appearing as dense white
on the X-ray

22. Radiographic findings in osteoarthritis include all the of the following except:

A. Loss of joint space
B. Osteophyte formation
C. Subchondral sclerosis
D. Subchondral cysts
E. Periarticular osteopenia
Well done, you have selected the right answer.
The correct answer is E. LOSS is the acronym to help remember the radiographic
findings. Periarticular osteopenia occurs in rheumatoid arthritis. In osteoarthritis
the bone around the joints is often sclerotic and hard, appearing as dense white
on the X-ray

24. The Outerbridge staging system is used to grade:

A. Function after TKR.
B. Risk of fracture in metastatic bone tumours.
C. Severity of cartilage damage when viewed in knee arthroscopy
D. Degree of osteoporosis.
E. Primary bone tumours.
Well done, you have selected the right answer.
The correct answer is C. The Outerbridge system is a descriptive way of
quantifying severity of cartilage damage in the knee when viewed through an
arthoscope:
· •
Grade 0 – normal
· · •
Grade I – cartilage softening (chondromalacia)
· · •
Grade II – partial-thickness defect with surface fissures
· · •
Grade III – fissures extending down to subchondral bone
· · •
Grade IV – exposed subchondral bone

25. All of the following are risk factors for osteoarthritis, except:

A. Septic arthritis
B. Fracture with intra-articular extension
C. Obesity
D. Smoking
E. Ruptured anterior cruciate ligament
Well done, you have selected the right answer.
The correct answer is D. Infection within the joint results in production of
inflammatory mediators that damage cartilage and result in secondary
osteoarthritis. A fracture extending into the joint may result in development of
secondary arthritis, especially if it is not reduced and fixed anatomically. Obesity
does appear to confer increased risk of arthritis and several epidemiological
studies support this. Smoking is more controversial but there are no studies
clearly linking smoking with OA. Some studies even suggest a protective effect of
smoking – but it is still not to be recommended! Rupture of the anterior cruciate
ligament (ACL) results in instability in the knee and this in turn increases the risk
of future arthritis.

26. Clinical signs of osteoarthritis include all of the following except:

A. Swelling of multiple joints in a symmetrical distribution.
B. Pain disturbing sleep at night.
C. Loss of movement and stiffness.
D. Crepitus.
E. Knee effusion.
Sorry, you have selected the wrong answer.
The correct answer is A. Although multiple joints may be affected in OA, the
involvement of multiple joints in a symmetrical distribution is more typical of
inflammatory arthropathy such as rheumatoid arthritis. All of the other signs listed
are typical of OA.

27. In addition to synovial joints, rheumatoid arthritis also affects:

A. Skin
B. Eyes
C. Kidneys
D. Spleen
E. All of the above
Well done, you have selected the right answer.
The correct answer is E. Rheumatoid arthritis is a multisystem disease. It also
affects blood, nervous, cardiovascular and bronchopulmonary systems.

28. The following features commonly occur in rheumatoid arthritis except:

A. Two or more swollen joints.
B. Morning stiffness lasting more than an hour for at least 6
weeks.
C. Positive rheumatoid factor.
D. The presence of osteophytes on X-ray.
Well done, you have selected the right answer.
The correct answer is D. Although the exact diagnostic criteria vary between
countries, the presence of two or more swollen joints, morning stiffness and RhF
is diagnostic of rheumatoid arthritis. RhF is only present in 80% of cases,
however. Osteophytes are more typical of osteoarthritis.

29. Rheumatoid factor:
A. Is present in 100% cases of rheumatoid arthritis (RA).
 B. Is an IgF autoantibody.
C. Is present in 2% of the normal population.
D. May be transmitted between individuals via the haematogenous
route.
Well done, you have selected the right answer.
The correct answer is C. Present in 80% of people with RA and 2% of the normal
population, RhF is an IgM to IgG antibody. It is not contagious.

30. Felty's syndrome includes which of the following?

A. Atrophic spleen
B. Rheumatoid arthritis
C. Thrombocytopenia
D. Raised neutrophil count
E. Portal hypertension
Sorry, you have selected the wrong answer.
The correct answer is B. Felty's syndrome is the triad of splenomegaly, RA and
neutropenia.

31. Rheumatoid arthritis:
A. Is more common in men.
B. Affects 12% of the population.
C. Is a B-cell-driven autoimmune condition.
D. Is associated with major histocompatibility complex antigen
HLA-DR4.
Well done, you have selected the right answer.
The correct answer is D. RA is more than twice as common in women and affects
1% of the population. It is driven by T-cells. It has a strong genetic component
and is associated with HLA-DR4.

 32. Which of the following neurological conditions may be associated with

rheumatoid arthritis?
A. Carpal tunnel syndrome
B. Cubital tunnel syndrome
C. Tarsal tunnel syndrome
D. Only A and B
E. All of the above
Well done, you have selected the right answer.
The correct answer is E. RA may affect the nerves directly resulting in peripheral
neuropathy but compression neuropathies are much more common. The nerves
can be compressed as they pass joints due to pressure exerted by synovitis and
instability of the joint. Carpal tunnel syndrome is the result of median nerve
compression at the wrist. Cubital tunnel syndrome is due to ulnar nerve
compression at the elbow, and tarsal tunnel syndrome is caused by tibial nerve
compression at the ankle. Treatment is decompression.
33. The following drugs are accepted disease-modifying anti-rheumatoid drugs
(DMARDs) except:
A. NSAIDs
B. Methotrexate
C. Gold
D. Anti-TNF alpha
E. Anti-IL1
Sorry, you have selected the wrong answer.
The correct answer is A. There are a myriad of different DMARDs, many of which
are still in the clinical trial stage. NSAIDs are not disease modifying, but are used
in symptomatic control.

34. X-ray findings in rheumatoid arthritis include all of the following except:

A. Periarticular osteopenia
B. Soft-tissue swelling
C. Joint subluxation
D. Subchondral sclerosis
E. Periarticular erosions and cysts
Well done, you have selected the right answer.
The correct answer is D. Subchondral sclerosis is typical of osteoarthritis.

35. A 50-year-old lady with severe rheumatoid arthritis complains of a sudden

inability to extend the little finger of her left hand. There is no history of trauma.
There is warmth and swelling over the dorsal aspect of the wrist. There is no loss
of sensation. The likely diagnosis is:
A. Compression neuropathy of the posterior interosseous nerve or
radial nerve.
B. Rupture of the extensor tendons at the wrist.
C. Carpal tunnel syndrome.
D. Dislocation of the little finger metacarpophalangeal joint
(MCPJ).
E. Fracture of the little finger proximal phalanx.
Well done, you have selected the right answer.
The correct answer is B. The extensor tendons can rupture as they pass over the
dorsum of the wrist joint. This is called Vaughan-Jackson syndrome.

36. When considering total knee replacement in the presence of rheumatoid

arthritis, which of the following statements is true?
A. Management of the airway is usually easy because the
temporomandibular joint is very mobile, allowing easy intubation.
B. Disease-modifying anti-rheumatoid drugs (DMARDs) should always
be continued during the perioperative period in order to maintain
disease control.
C. Risk of infection in surgical wounds is the same or lower as
in patients without rheumatoid arthritis.
 D. Significant varus or valgus deformity may make surgery
technically demanding.
Well done, you have selected the right answer.
The correct answer is D. Surgery in rheumatoid arthritis presents unique
challenges. The airway may be difficult to manage due to limited jaw opening,
small mandible and the presence of atlantoaxial instability in the spine, which
may result in spinal cord injury if not protected. Some DMARDs, particularly the
biological agents, must be stopped several weeks before surgery and the advice
of a rheumatologist is essential. The risk of infection is higher due to
immunosuppressive drugs and impairment of the immune system due to the
disease itself. Technically, the presence of ligamentous instability, thin skin,
fragile bones and significant deformity makes arthroplasty technically demanding.

37. X-rays are:
A. Generated by a stream of photons striking a charged metal
plate.
B. Part of the electromagnetic spectrum between infrared and UV.
C. Incapable of passing through tissue.
D. Ionising radiation and may damage DNA.
E. Used during a radiolabelled bone scan.
Sorry, you have selected the wrong answer.
The correct answer is D. X-rays lie between UV and gamma on the EM spectrum
and are generated by electrons striking a positively charged metal plate. They
pass through tissues, but are absorbed or attenuated to different extents,
depending on the radiodensity of the tissue. DNA may be damaged resulting in
mutations. A radiolabelled bone scan uses a gamma-emitting isotope, not X-rays.

38. From most radiodense to least radiodense, the correct sequence is:

A. Air, bone, fat, muscle, lead.
B. Lead, bone, muscle, fat, air.
C. Lead, bone, fat, muscle, air.
D. Air, fat, bone, muscle, lead.
E. All are of equal radiodensity.
Sorry, you have selected the wrong answer.
The correct answer is B. Higher radiodensity means that more X-rays are
attenuated. Fewer X-rays pass through to the plate and the radiograph therefore
appears whiter.

39. On a chest radiograph:

A. The mediastinum appears biggest on an AP film.
B. The mediastinum appears biggest on a PA film.
C. There is no difference in apparent size between AP and PA.
Well done, you have selected the right answer.
The correct answer is A. The abbreviations AP or PA refer to the direction that
the beam is fired. From anterior to posterior or vice versa. The mediastinum is
closer to the front of the thorax. In an AP film, the plate is behind the patient and
therefore a long way from the mediastinum. The ‘shadow’ cast by the
mediastinum is therefore large. In a PA film, however, the plate is in front of the
patient and the beam directed from behind. The mediastinal ‘shadow’ is therefore
smaller.

40. Computed tomography (CT):

A. Uses a magnetic field to align the axes of hydrogen ions.
B. Has a lower radiation dose than plain radiographs.
C. Is a good modality to assess soft tissue.
D. May be used to visualise blood vessels.
E. Takes longer to obtain than MRI scans.
Sorry, you have selected the wrong answer.
The correct answer is D. CT scans are a series of X-rays collated by a computer
to generate a 3D representation of complex structures. The radiation dose is
higher than plain radiographs. They are poor at assessing soft tissue, but
vascular structures can be visualised with the use of IV contrast. CTs are usually
much faster than MRI scans, especially with modern ‘spiral’ scanners.

41. Magnetic resonance imaging:

A. Produces images representing the density of helium ions within
tissues.
B. Uses a very strong radiation source.
C. Is suitable for patients who have recently undergone
ophthalmic or brain surgery.
D. May be distorted by metallic artefacts.
E. Is better than CT at imaging complex bony anatomy such as
fractures.
Well done, you have selected the right answer.
The correct answer is D. MRI uses strong magnets to align hydrogen ions. Metal
implants may present problems. Fine vascular clips in the eye or brain may
become dislodged with catastrophic results. Metal plates, screws or implants
such as hip or knee replacements generate significant artefacts, which makes
interpretation of images difficult. Special software can reduce this effect. Imaging
of complex bony anatomy is often better obtained using CT, which has higher
resolution of bone.

42. Ultrasound:
A. Detects echoes of sound waves from boundaries between tissues
of different density.
B. Is easy to use and interpret.
C. Is contraindicated in patients with pneumothorax.
D. Should be avoided in children due to risk of malignancy.
Well done, you have selected the right answer.
The correct answer is A. Ultrasonic waves bounce off the boundaries between
different tissues. The images are hard to obtain and interpret and the process is
very operator dependent. Pneumothorax is not a contraindication (in fact,
ultrasound is extremely good at detecting pneumothoraces). There is no risk of
malignancy as there is with ionising radiation.

43. On a T1-weighted MRI, which of the following tissues are bright (high signal)?
A. CSF
B. Pleural effusion
C. Fat
D. Blood
E. Oedema
Sorry, you have selected the wrong answer.
The correct answer is C. T1 shows fat as white, water as dark.

44. On a T2-weighted MRI, which of the following structures are white?

A. Nucleus pulposus in healthy disc.
B. Nucleus pulposus in degenerate disc.
C. Annulus fibrosus in healthy disc.
D. Spinal cord.
E. Subcutaneous fat.
Sorry, you have selected the wrong answer.
The correct answer is A. Healthy nucleus pulposus contains a high concentration
of water, which shows as high signal (bright white) on T2-weighted sequences.
Degenerate nucleus pulposus is dehydrated and therefore appears dark.

 45. The following are risk factors for acute haematogenous osteomyelitis

(AHO) except:
A. IV drug use
B. Diabetes
C. Renal failure
D. Sickle-cell disease
E. Penicillin allergy
Well done, you have selected the right answer.
The correct answer is E. Although penicillin allergy makes treatment more
difficult, it is not a risk factor for AHO.

46. A 15-year-old boy presents with a swollen, painful knee and fever. He has no
history of trauma but is unable to weightbear and is unwilling to move the knee.
Inflammatory markers and white cell count are raised and the knee is red,
swollen and held in 15° flexion. Passive movement exacerbates pain. The
optimal first-line treatment is:
A. NSAIDs
B. Above-knee backslab.
C. Immediate aspiration in theatre
D. Immediately start IV amoxicillin
 E. MRI scan of the knee
Sorry, you have selected the wrong answer.
The correct answer is C. The history and examination findings are extremely
suggestive of septic arthritis. This is an emergency. Although antibiotics are
indicated, the optimal treatment is an initial aspiration and proceed to washout of
the joint. Antibiotics should be withheld if there is no delay in getting the child to
theatre so that culture results are not misleading. If there is a delay, antibiotics
are indicated before the joint is aspirated, but the first line should
cover Staphylococcus aureus (usually high-dose flucloxacillin or co-amoxiclav,
depending on local policy).

47. Intra-articular extension of the physeal growth plate may allow osteomyelitis

to extend to the joint, resulting in septic arthritis. All of the following physes are
intra-articular except:
A. Proximal humerus
B. Distal humerus
C. Proximal femur
D. Distal fibula
E. Distal ulnar
Sorry, you have selected the wrong answer.
The correct answer is B. The shoulder, hip, ankle and wrist all have intra-articular
physes. The distal humerus physis does not extend into the joint.

48. Tuberculosis of the spine:

A. Is never seen in the UK.
B. Results in extensive disc destruction with relative sparing of
the vertebrae.
C. Rarely results in deformity.
D. May result in spinal instability and neurological injury.
E. Is quickly and effectively treated with a short course of
antituberculous drugs.
Well done, you have selected the right answer.
The correct answer is D. TB of the spine is increasingly common in the UK,
especially in immigrant populations and the immunosuppressed. There is
characteristically extensive bone destruction with sparing of the disc space. This
results in marked deformity (gibbus) and instabiity, which may compromise the
spinal cord. Treatment is a prolonged course of combinations of drugs and
surgical stabilisation of damaged spinal segments.

49. Necrotising fasciitis:
A. Is usually caused by a single organism within soft tissues.
B. Is rarely seen in diabetics.
C. Results in rapid septic shock, haemodynamic instability and
sometimes death due to toxin production.
D. Always presents with impressive skin changes and large
 abscesses.
E. Is best treated without surgery.
Well done, you have selected the right answer.
The correct answer is C. Necrotising fasciitis is a rare but catastrophic infection,
usually due to multiple organisms that spread within tissue planes. It is
commoner in the immunocompromised and diabetics. Septic shock may be
severe and overwhelming but the local skin signs are often subtle and
unimpressive. Radical debridement surgery and high-dose antibiotics are
indicated.

50. Osteomyelitis in children:
A. Is commonest in the metaphysis of the bone.
B. Is always associated with penetrating trauma.
C. Should always be treated with surgery.
D. Usually produces very striking X-ray changes within the first
few days.
E. Never results in septic arthritis.
Well done, you have selected the right answer.
The correct answer is A. Osteomyelitis in children is usually due to
haematogenous spread of organisms, which become lodged in the bone where
blood flow is slowest – in the metaphysis. Penetrating trauma is a rare cause in
children. Surgery is only indicated if an abscess forms, there is a large focus of
necrotic bone or septic arthritis occurs. X-ray findings are usually subtle and take
several weeks to appear. Septic arthritis may occur if the affected physis is intra-
articular, such as the shoulder, wrist, hip or ankle.

 51. The commonest organism to infect postoperative wounds is:

A. Clostridium perfringens
B. Pseudomonas aeruginosa
C. Streptococcus pyogenes
D. Eikenella corrodens
E. Staphylococcus aureus
Well done, you have selected the right answer.
The correct answer is E. Staph. aureus is the commonest postoperative infective
organism.

52. Septic arthritis in neonates is typically caused by:

A. Neisseria gonorrhoea
B. Mycobacterium tuberculosis
C. Salmonella
D. Group B streptococci
E. Haemophilus influenzae
Well done, you have selected the right answer.
The correct answer is D. Group B streptococci and Staph. aureus commonly
cause osteomyelitis or septic arthritis in neonates. Children may be affected
by Staph. aureus, Streptococcus pneumoniae, group A streptococci
or Haemophilus influenzae; adolescents by Neisseria gonorrhoea, and sickle-cell
disease sufferers by Salmonella.

 53. Discitis:
A. Should be treated with a short course of oral antibiotics.
B. May require laminectomy and decompression.
C. Is a very rare cause of back pain in the elderly.
E. Is easily treated with antibiotics due to the excellent blood
supply of the disc allowing rapid antibiotic delivery.
E. Is a common complication of lumbar puncture.
Well done, you have selected the right answer.
The correct answer is B. Discitis is a cause of chronic back pain in the elderly and
immunosuppressed and is often misdiagnosed and under-recognised. Surgery in
the form of decompression may be required if an abscess forms. The poor blood
supply to the disc means that antibiotic delivery is difficult and prolonged courses
are required. Lumbar puncture is unlikely to cause discitis as the disc is anterior –
meningitis is more likely.

54. Human bite wounds are most commonly infected with:

A. E. coli
B. Salmonella
C. Pseudomonas
D. Haemophilus
E. Eikenella corrodens
Sorry, you have selected the wrong answer.
The correct answer is E. Although the commonest infectious organism
is Staphylococcus aureus, Eikenella corrodens is a frequent organism in human
bite wounds.

55. The most important factor in preventing transmission of infection between

hospital inpatients is:
A. Being bare below the elbows.
B. Hand washing before and after every patient contact.
C. Individual side rooms for patients.
D. Reducing inappropriate antibiotic prescribing.
E. ‘Ring-fencing’ elective beds.
Well done, you have selected the right answer.
The correct answer is B. All of these factors help reduce cross-infection, but good
hand washing practice is the most effective.

56. X-ray findings in osteomyelitis include:

A. Periosteal reaction
B. Soft-tissue swelling
C. Lucent lesion within bone
 D. Moth-eaten appearance of cortex
E. All of the above
Sorry, you have selected the wrong answer.
The correct answer is E.

57. The rotator cuff is composed of all of the following muscles except:

A. Supraspinatus
B. Teres minor
C. Infraspinatus
D. Teres major
E. Subscapularis
Well done, you have selected the right answer.
The correct answer is D. All the other muscles form the rotator cuff around the
head of the humerus.

58. The deltoid muscle is innervated by:

A. Radial nerve
B. Long thoracic nerve
C. Axillary nerve
D. Median nerve
E. Suprascapular nerve
Well done, you have selected the right answer.
The correct answer is C. The axillary nerve loops around the neck of the humerus
and may be injured in shoulder dislocation or humeral neck fracture.

59. The humeral head is stabilised in the glenoid by all of the following

structures except:
A. Deltoid muscle
B. Rotator cuff muscles
C. Glenohumeral ligaments
D. Short head of biceps
E. Negative pressure (‘suction’) within the joint space
Sorry, you have selected the wrong answer.
The correct answer is D. All of these structures stabilise the shoulder and prevent
dislocation, with the exception of the short head of biceps, which inserts into the
coracoid, distal to the glenohumeral joint.

60. Supraspinatus:
A. Inserts into the lesser tuberosity of the humerus.
B. Adducts the arm.
C. Internally rotates the arm.
D. Is innervated by the suprascapular nerve.
E. Lies in the infraspinous fossa of the scapula.
Well done, you have selected the right answer.
The correct answer is D. Supraspinatus is innervated by the suprascapular nerve,
inserts into the greater tuberosity, abducts the arm and lies in the supraspinous
fossa. It forms part of the rotator cuff.

61. A patient sustains a posterior dislocation of the hip, which is reduced by

closed reduction. When he recovers from the anaesthetic he has foot drop and
numbness in the foot. The most likely cause is:
A. Injury to the femoral nerve
B. Injury to the obturator nerve
C. Injury to the sciatic nerve
D. Injury to the popliteal nerve
E. Injury to the tibial nerve
Well done, you have selected the right answer.
The correct answer is C. The sciatic nerve runs closely to the posterior aspect of
the hip and may be damaged in a dislocation.

62. What is the main action on the hip of gluteus medius and gluteus minimus?
A. Adduction
B. Abduction
C. External rotation
D. Internal rotation
E. Flexion
Sorry, you have selected the wrong answer.
The correct answer is B. The abductor muscles (gluteus medius and gluteus
minimus) are important because they insert into the greater trochanter and act to
abduct the hip. They can be damaged following fracture or during surgery.
Incompetent abductors lead to a Trendelenberg gait.

63. Gluteus medius and minimus are innervated by:

A. Superior gluteal nerve
B. Inferior gluteal nerve
C. Femoral nerve
D. Lateral cutaneous nerve of the thigh
E. Genitofemoral nerve
Sorry, you have selected the wrong answer.
The correct answer is A. The nerve can be damaged during surgical approaches
to the hip, which may result in a Trendelenberg gait.

64. Which muscle inserts into the lesser trochanter?

A. Gluteus minimus
B. Tensor fascia lata
C. Quadriceps
D. Iliopsoas
E. Biceps femoris
Sorry, you have selected the wrong answer.
The correct answer is D. The iliopsoas acts to flex the hip.
 65. The quadriceps is innervated by:
A. Femoral nerve
B. Sciatic nerve
C. Inferior gluteal nerve
D. Pudendal nerve
E. Tibial nerve
Well done, you have selected the right answer.
The correct answer is A. The quadriceps extends the knee and is innervated by
the femoral nerve.

66. Which of these muscles has an intra-articular insertion?

A. Iliopsoas
B. Rectus femoris
C. Popliteus
D. Biceps femoris
E. Sartorius
Sorry, you have selected the wrong answer.
The correct answer is C. There are only two muscles in the body that insert within
joints. The other one is the long head of biceps in the shoulder. The popliteus
acts to unlock the knee from full extension.

67. A medical student falls whilst skiing and his bindings fail to release. He feels a
sudden pop in his left knee and is unable to continue. Within an hour there is
large amount of swelling. On returning to the UK, examination reveals a positive
anterior drawer test. The knee is stable to varus and valgus stress. X-rays are
normal. The most likely injury is:
A. Posterior cruciate ligament injury
B. Anterior cruciate ligament injury
C. Tibial plateau fracture
D. Lateral collateral ligament injury
E. Medial collateral ligament injury
Well done, you have selected the right answer.
The correct answer is B. The anterior drawer test detects excessive anterior
translation of the tibia in relation to the femur. It is a common skiing injury.

 68. A rugby player is tackled hard from the left side. His opponent strikes the
lateral side of his left knee, whilst his boots remain planted in the ground. He
feels a sudden pain in the knee, which buckles beneath him. He is able to
continue the game, but the knee is painful. There is minimal swelling.
Examination reveals pain and laxity on valgus stress. Anterior and posterior
drawer tests are negative. The most likely diagnosis is:
A. Isolated posterior cruciate ligament injury
B. Isolated anterior cruciate ligament injury
C. Tibial plateau fracture
 D. Lateral collateral ligament injury
E. Medial collateral ligament injury
Sorry, you have selected the wrong answer.
The correct answer is D. The lateral impact forced the knee into valgus and
sprained the lateral collateral ligament (LCL). Although sometimes associated
with an anterior cruciate ligament (ACL) injury as well, that is not the case here –
the giveaway is that the knee did not swell and the anterior drawer test is
negative.

69. The gastrocnemius muscle:

A. Flexes the knee and dorsiflexes the ankle.
B. Flexes the knee and plantarflexes the ankle.
C. Acts only to plantarflex the ankle.
D. Acts only to dorsiflex the ankle.
E. Extends the knee.
Well done, you have selected the right answer.
The correct answer is B. The gastrocnemius crosses the knee and ankle. Its
principal action is ankle plantarflexion, but it also acts to flex the knee.

0. The lateral meniscus:

A. Is smaller than the medial meniscus.
B. Is more mobile than the medial meniscus.
C. Has an excellent blood supply across its entire width.
D. Is torn more frequently than the medial meniscus.
Well done, you have selected the right answer.
The correct answer is B. The lateral meniscus is larger and more mobile than the
medial meniscus. This increased mobility makes it less prone to tears than the
medial meniscus. The blood supply is only present in the peripheral third.

71. The lateral ligaments of the ankle include all of the following, except:

A. Anterior talofibular ligament
B. Posterior talofibular ligament
C. Deltoid ligament
D. Calcaneofibular ligament
Well done, you have selected the right answer.
The correct answer is C. The deltoid ligament is a medial structure. The other
three ligaments make up the lateral ligament complex, which may be sprained in
an inversion injury.

72. Which muscle inserts into the base of the fifth metatarsal, may be avulsed in
an inversion injury (known as a Jones' fracture), and is a powerful everter of the
ankle?
A. Peroneus longus
B. Peroneus brevis
C. Peroneus tertius
 D. Tibialis posterior
E. Tibialis anterior
Sorry, you have selected the wrong answer.
The correct answer is B. The tendon runs behind the lateral malleolus and inserts
into the base of the fifth metatarsal.

73. In adults, the spinal cord terminates at:

A. T12
B. L1
C. L4
D. L5
E. S1
Sorry, you have selected the wrong answer.
The correct answer is B. The cord ends at the lower border of L1, but nerve roots,
in the form of the cauda equina, occupy the spinal canal below this level.

74. In the spinal cord, the spinothalamic tract is composed of nerves that
conduct:
A. Motor power to the lower limbs
B. Vibration sense
C. Proprioception
D. Pain, temperature and light touch
E. Sympathetic drive
Well done, you have selected the right answer.
The correct answer is D. Dorsal columns conduct vibration and proprioception.
Corticospinal tracts conduct motor signals.

75. How many cervical roots are there?

A. 5
B. 6
C. 7
D. 8
E. 9
Well done, you have selected the right answer.
The correct answer is D. There are eight cervical roots but only seven cervical
vertebrae. C7 nerve therefore exits between C6 and C7 vertebrae. C8 nerve exits
between C7 and T1 vertebrae.

76. A far lateral L5-S1disc prolapse would be expected to cause:

A. Foot drop
B. Weak big toe extension
C. Weak ankle plantarflexion
D. Weak knee extension
E. Weak hip flexion
Well done, you have selected the right answer.
The correct answer is B. A far lateral L5-S1 disc will compress the L5 nerve root,
which supplies extensor hallucis longus ( EHL). A paracentral disc prolapse at
this level would compress S1 resulting in weak ankle plantarflexion and absent
ankle jerk.

 77. When examining the rotator cuff, one test is to assess resisted internal
rotation by asking the patient to press their hand into their abdomen against your
resistance. This is known as the belly press test. The muscle being tested is:
A. Supraspinatus
B. Infraspinatus
C. Subscapularis
D. Teres minor
E. Biceps
Well done, you have selected the right answer.
The correct answer is C. This muscle internally rotates the shoulder.
Supraspinatus abducts, infraspinatus and teres minor externally rotate. Biceps is
not part of the rotator cuff.

78. Finkelstein's test consists of tucking the patient's thumb into their clenched fist
and ulnar deviating the wrist. It is used to test for:
A. Carpal tunnel syndrome
B. de Quervain's tenosynovotis
C. Dupuytren's contracture
D. Tennis elbow
E. Golfer's elbow
Well done, you have selected the right answer.
The correct answer is B. de Quervain's tenosynovitis is inflammation in the first
extensor compartment of the wrist.

79. Claw-hand deformity is caused by:

A. Median nerve compression or carpal tunnel syndrome.
B. Radial nerve injury in the upper arm.
C. Ulnar nerve injury at the wrist.
D. Anterior interosseous nerve injury.
E. Posterior interosseous nerve injury.
Well done, you have selected the right answer.
The correct answer is C. The ulnar nerve supplies the hypothenar muscles and
most of the intrinsic muscles of the hand as well as flexor carpi ulnaris (FCU) and
half of flexor digitorum profundus (FDP) in the forearm. Injury to the nerve at the
wrist results in muscle imbalance and claw-hand deformity.

80. Trendelenburg gait may be caused by all of the following except:

A. Superior gluteal nerve injury.
B. Failure of gluteus medius and minimus repair after hip
 surgery.
C. Disc prolapse affecting L3 nerve root.
D. Fracture of greater trochanter.
E. L5 radiculopathy.
Sorry, you have selected the wrong answer.
The correct answer is C. Trendelenburg gait results from abductor incompetence.
All of the answers affect the abductors apart from disc prolapse affecting L3,
which would result in weakness of quadriceps.

81. When examining the hip, Thomas' test detects:

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A. True leg length discrepancy
B. Weakness of abductor muscles
C. Weakness of hip flexors
D. Fixed flexion of the hip
E. Labral tear
Well done, you have selected the right answer.
The correct answer is D. Lie the patient flat, bring the unaffected knee to the
chest to obliterate lumbar lordosis, and ask the patient to push the affected leg
into the couch. Fixed flexion will then become apparent.
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82. Lachmann's test of the knee is used to detect:
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A. Lateral collateral ligament injury.
B. Medial collateral ligament injury.
C. Meniscal tears.
D. Anterior or posterior cruciate ligament injury.
E. Patellar instability.
Well done, you have selected the right answer.
The correct answer is D. With the knee in 30° flexion and the patient relaxed, grip
the tibia in one hand and the femur in the other and move to detect excessive
anterior or posterior translation of the tibia. Although this is a very sensitive test
for cruciate ligament injury it is difficult if you have small hands or the patient is
not relaxed.
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83. When performing a neurological examination, an MRC power grade of 2
indicates:
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A. No movement
B. Movement with gravity eliminated
C. Full power
D. Mild weakness
E. Flicker of movement.
Sorry, you have selected the wrong answer.
The correct answer is B. It is important to remember the MRC power grading:
· •
0 – no movement
· · •
1 – flicker of movement
· · •
2 – active movement with gravity eliminated
· · •
3 – active movement against gravity
· · •
4 – mild weakness
· · •
5 – normal
· · •
NT – not testable due to concomitant injury or immobilisation
· 窗体底端
84. When assessing the neurological status of the upper limb, finger flexion is
used to test:
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A. C5
B. C6
C. C7
D. C8
E. T1
Well done, you have selected the right answer.
The correct answer is D. Myotomes must be learned to perform a reliable
neurological examination.
· •
C5 – elbow flexion
· · •
C6 – Wrist extension
· · •
C7 – Elbow extension
· · •
C8 – Finger flexion
· · •
T1 – finger abduction
· 窗体底端
85. Sensation to the tip of the middle finger is used to test which dermatome?
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A. C5
B. C6
C. C7
D. C8
E. T1
Well done, you have selected the right answer.
The correct answer is C. Knowledge of dermatomes is vital when performing a
neurological examination.
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86. The biceps tendon reflex correlates with which nerve root?
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A. C5
B. C6
C. C7
D. C8
E. T1
Well done, you have selected the right answer.
The correct answer is A. C6 is supinator at the wrist, C7 is triceps at the elbow.
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87. Extensor hallucis longus is innervated by:
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A. L3
B. L4
C. L5
D. S1
E. S2
Well done, you have selected the right answer.
The correct answer is C. Big toe extension is L5.
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88. The brachial plexus arises from which nerve roots?
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A. C5-C7
B. C5-T1
C. C4-T4
D. L2-L5
E. L5-S1
Well done, you have selected the right answer.
The correct answer is B. You should be able to draw out the brachial plexus.
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89. A cyclist hits a tree root and lands on his shoulder, experiencing severe
lateral flexion of the neck. He has global weakness and paraesthesia in his left
arm. After 12 hours some function returns, but he is unable to abduct the arm,
externally rotate at the shoulder, supinate the wrist or flex the elbow. The most
likely diagnosis is:
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A. Injury to the upper portion of the brachial plexus (Erb's
palsy).
B. Injury to the lower part of the brachial plexus (Klumpke's
palsy).
C. Global brachial plexus injury.
D. Cervical spine transection.
E. Central cord syndrome.
Well done, you have selected the right answer.
The correct answer is A. In Erb's palsy, the C5 and C6 roots are affected,
resulting in loss of axillary, suprascapular, musculocutaneous and radial nerves.
The arm is held adducted, internally rotated, pronated and extended at elbow in
the ‘waiter's tip’ position.
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90. A 26-year-old rugby player experiences recurrent anterior dislocations of his
shoulder following a rugby injury 2 years ago. His shoulder now dislocates
whenever he externally rotates the shoulder beyond 30°. No other joints are
unstable and there is no family history of joint instability. A CT shows that the
anterior one-third of the glenoid has been fractured off. There is no defect in the
humeral head. The recurrent dislocation is most likely due to:
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A. A bony Bankart lesion
B. An engaging Hill–Sachs lesion
C. A massive rotator cuff tear
D. A brachial plexus injury
E. Generalised hypermobility syndrome
Sorry, you have selected the wrong answer.
The correct answer is A. A bony Bankart lesion is a defect of the front of the
glenoid and labrum. The result is instability. The treatment of large lesions like
this is usually surgical in the form of a procedure to build up the front of the
glenoid with bone from the acromion. This is called a Bristow–Laterjet procedure.
All of the other answers are potential causes of instability, but can be excluded by
the history. A Hill–Sachs lesion is a divot in the humeral head (CT has excluded
this). There is nothing in the history to suggest massive rotator cuff tear. There is
no evidence of brachial plexus injury in the history. There is nothing to suggest
hypermobility syndrome, nor any family history to suggest genetic conditions
such as Ehlers–Danlos.
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91. The Beighton scoring system is used to assess hypermobility. All of the
following features are awarded points, except:
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A. Hyperextension of little finger metacarpophalangeal joint
(MCPJ) beyond 90°.
B. History of more than three large joint dislocations.
C. Hyperextension of elbow beyond 10°.
D. Thumb can be dorsiflexed to flexor surface of forearm.
E. Knee hyperextension beyond 10°.
Sorry, you have selected the wrong answer.
The correct answer is B. The score is based purely on examination, not history.
The score is made up as follows:

1 point for each side, left or right:

· •
Hyperextension of little finger MCPJ beyond 90°
· · •
Hyperextension of elbow beyond 10°
· · •
Thumb can be dorsiflexed to flexor surface of forearm
· · •
Knee hyperextension beyond 10°

· Plus one point for:

· •
Palms touch flat on floor with knees straight
· Total out of 9. Score greater than 4 is abnormal.
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92. A 63-year-old woman with type II diabetes presents to the shoulder clinic with
a 6-month history of a stiff painful shoulder. There is no history of trauma. She
describes an insidious onset of pain and stiffness in the shoulder. The pain is
worse in the evenings and at night. She is unable to lift her arm above her head.
Other than metformin-controlled type 2 diabetes, mild hypertension and obesity
she is fit and well. Examination reveals that she is systemically well, there are no
skin changes over the shoulder but generalised wasting of the muscles of the
shoulder girdle. Active and passive range of movement (ROM) of the shoulder is
abduction to 30°, flexion to 40°, internal rotation to the buttock, zero degrees
external rotation. The cuff appears strong. Neurological examination of the neck
and limb is normal. X-rays (AP and axillary) are normal. The most likely diagnosis
is:
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A. Osteoarthritis
 B. Adhesive capsulitis (frozen shoulder)
C. Charcot arthropathy
D. Cuff arthropathy
E. Posterior dislocation of the shoulder
Sorry, you have selected the wrong answer.
The correct answer is B. This is a typical history for frozen shoulder, which is
much commoner in diabetics. The giveaway in the examination is the lack of
external rotation. There are only three causes of a complete block to external
rotation: OA, posterior dislocation and frozen shoulder. The normal X-rays allow
you to exclude all but one of these!
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93. Tennis elbow affects:
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A. The common flexor origin of the elbow
B. The common extensor origin of the elbow
C. The olecranon bursa
D. The annular ligament
E. Novak Djokovic
Well done, you have selected the right answer.
The correct answer is B. Tennis elbow is lateral epicondylitis. The
pathophysiology is microtears of the common extensor origin, which is the broad
aponeurosis from which all the extensor muscles of the forearm originate on the
lateral prominence of the distal humerus. Remember: Tennis elbow: laTeral
epicondyle; common exTensor origin. I don't think Djokovic suffers tennis elbow,
because it is usually due to poor technique.
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94. The ulnar nerve may be compressed at each of the following points, except:
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A. Arcade of Struthers
B. Ligament of Struthers
C. Cubital tunnel retinaculum
D. Osteophytes associated with elbow arthritis
E. Between the heads of flexor carpi ulnaris (FCU).
Sorry, you have selected the wrong answer.
The correct answer is B. The ulnar nerve can be trapped beneath the arcade of
Struthers, which is an opening of the intermuscular septum as the nerve passes
from anterior to posterior compartments of the arm. The ligament of Struthers,
present in a small minority of people, is an abnormal fibrous band, extending from
a supracondylar spur of the humerus, which can trap the median nerve.
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95. The carpal tunnel contains all of the following, except:
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A. Tendon of flexor pollicis longus (FPL)
 B. Tendons of flexor digitorum profundus (FDP)
C. Tendons of flexor digitorum superficialis (FDS)
D. Tendon of flexor carpi ulnaris (FCU)
E. Median nerve
Well done, you have selected the right answer.
The correct answer is D. The carpal tunnel contains nine tendons and one nerve.
The FCU tendon inserts into the pisiform bone and does not pass through the
carpal tunnel.
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96. In severe carpal tunnel syndrome, weakness and wasting of all of the
following muscles occurs, except:
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A. Lateral two lumbricals
B. Opponens pollicis
C. Abductor pollicis
D. Flexor pollicis brevis
E. Flexor digiti minimi brevis
Sorry, you have selected the wrong answer.
The correct answer is E. Carpal tunnel syndrome is compression of the median
nerve at the wrist. This nerve innervates the muscles that can be remembered by
the mnemonic LOAF: lateral two lumbricals, opponens pollicis, abductor pollicis,
flexor pollicis brevis. FDMB is in the hypothenar eminence and innervated by the
ulnar nerve.
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97. The commonest site for the median nerve to be compressed is the carpal
tunnel. It may also be compressed at all of these other sites, except:
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A. Cervical spine
B. Ligament of Struthers
C. Beneath the bicepital aponeurosis
D. In the cubital tunnel
E. Between the heads of pronator teres
Sorry, you have selected the wrong answer.
The correct answer is D. All of these sites may be causes of median nerve
compression, except the cubital tunnel, which is a site of ulnar nerve
compression.
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8. A 42-year-old manual labourer presents to the clinic with a 3-month history of
numbness in the little finger and ulnar half of the ring finger and weakness of grip
strength. He has also noticed some clawing of the little and ring fingers. His
symptoms are exacerbated by using a pneumatic drill. Examination reveals
wasting of the intrinsic muscles and paraesthesia in the volar aspect of the little
and half of the ring fingers. Sensation on the dorsal aspect of the hand is normal.
Hypothenar muscles function normally. There is marked tenderness to palpation
over the hook of hamate. The diagnosis is:
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A. Carpal tunnel syndrome
B. Vibration ‘white finger’ syndrome
C. Compression of the ulnar nerve in Guyon's canal
D. Compression of the ulnar nerve in the cubital tunnel
E. de Quervain's tenosynovitis
Well done, you have selected the right answer.
The correct answer is C. The symptoms are of ulnar nerve neuropathy. Sensation
is normal on the dorsum of the hand suggesting that the dorsal cutaneous nerve
is spared. The dorsal cutaneous nerve comes off the main ulnar nerve just above
the wrist. The fact that it is still functioning means that the compression must be
distal to this point. The site of compression must therefore be in Guyon's canal (in
the hand), rather than the cubital tunnel (at the elbow).) A common cause of ulnar
nerve compression in Guyon's canal is fracture of the hook of hamate, the
resulting swelling compressing the nerve. Workers who use vibrating tools may
sustain stress fractures of the hook of the hamate.
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99. Whilst on board a ferry to Norway, you meet a 50-year-old man who is
struggling to pick up his change in the bar. He tells you he is going to visit his
Norwegian uncle. He is troubled by the flexed position of his ring and little fingers
of the left hand and is finding it increasingly difficult to inject his insulin (he is type
1 diabetic). Examination reveals skin pits and contractures of the little finger
proximal interphalangeal joint (PIPJ) of 100°, little finger metacarpophalangeal
joint (MCPJ) 50°, ring finger PIPJ 40°and ring finger MCPJ 20°. The fingers have
good perfusion, digital Allen's test is normal and sensation intact. He wants to
have these corrected and asks what you would recommend:
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A. Splinting
B. Needle fasciectomy
C. Collagenase injection
D. Partial fasciectomy
E. Amputation of the little finger
Well done, you have selected the right answer.
The correct answer is D. This man has Dupuytren's disease: progressive
contracture of the palmar fascia, more common in those with Scandinavian
descent, diabetics and alcoholics (could it be more obvious?!). He has quite
advanced disease, which is interfering with his daily activities. The fact that he
cannot get the hand flat to the tabletop to pick up change illustrates this. Splinting
is not effective. Needle fasciectomy is useful in mild cases with a single cord, but
not when there is significant contracture as the digital nerves are at risk.
Collagenase is an increasingly popular treatment for less severe disease but
long-term results are uncertain. Partial fasciectomy is the treatment of choice.
Amputation is not indicated for sensate perfused fingers.
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100. de Quervain's tenosynovitis is inflammation and narrowing of the first dorsal
compartment of the wrist. Which tendons pass through this structure?
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A. Abductor pollicis longus, extensor pollicis brevis
B. Extensor carpi radialis longus, extensor carpi radialis
brevis.
C. Extensor pollicis longus
D. Extensor indicis proprius, extensor digitorum communis
E. Extensor digiti minimi
F. Extensor carpi ulnaris
Sorry, you have selected the wrong answer.
The correct answer is A. The wrist has six fibrous tunnels through which the
extensor tendons run. The answers above are the contents of each tunnel 1–6.
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101. You are asked to see a patient on the ward, day 2 after a right total hip
replacement (THR). He has Parkinson's disease and had been slow to get out of
bed after the operation. Whilst climbing off a commode he suddenly complained
of pain in the right groin and was unable to weightbear. The nurses hoisted him
into bed and noticed that the right leg was externally rotated and shorter than the
left. The most likely cause of his pain is:
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A. Infected THR
B. Anterior dislocation of the prosthesis
C. Posterior dislocation of the prosthesis
D. Referred pain from the spine
E. Poor postoperative pain control
Well done, you have selected the right answer.
The correct answer is B. Dislocation can occur in the immediate postoperative
period due to poor implant positioning, poor soft-tissue repair, abnormalities in
muscle tone such as cerebrovascular accident (CVA) or Parkinson's, or the
patient putting their hip in an ‘at risk’ position, including excessive flexion,
adduction or rotation. Climbing out of a low seat is a classic cause of dislocation,
which is why postoperative THR patients are given seat raises before going
home. This man's THR has dislocated. The direction is described as anterior or
posterior, depending on which side of the acetabulum the femoral head is lying. If
the leg is externally rotated, the head of the femur will be anterior to the
acetabulum, so this is an anterior dislocation.
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102. A patient returns to clinic 8 weeks after a total hip replacement (THR) with
severe pain in the hip, weight loss, malaise and inability to bear weight on the leg.
X-rays reveal a well-positioned uncemented THR with a lucent line around the
acetabulum. The patient has a temperature of 38.2°C, HR 95, BP 130/80.
Inflammatory markers reveal CRP 220 and ESR 80. The next course of action
should be
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A. Oral antibiotics for 6 weeks.
B. Continue to monitor with serial X-rays and bloods every 2
weeks.
C. Start IV antibiotics in clinic before arranging for urgent
admission for further doses of antibiotics.
D. Admit immediately for the first stage of a two-stage revision
THR, monitor closely but try to hold off antibiotics until
intraoperative specimens have been obtained.
E. Put the patient on the elective waiting list for single-stage
revision THR.
Well done, you have selected the right answer.
The correct answer is D. This patient has deep infection of the THR. The
treatment is a two stage revision THR – removal of the infected hip and insertion
of an antibiotic-loaded spacer in the first stage, followed by several weeks of IV
antibiotics until inflammatory markers are normal. Only at this stage will a revision
hip be performed. In order to choose the most appropriate antibiotics, it is
preferable to obtain deep tissue specimens before any treatment has been
started. Therefore, if the patient is systemically well, hold off antibiotics if possible
until he gets to theatre. If the patient becomes unwell or septic before the
operation can be performed, antibiotics should be started immediately.
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103. In gout, polarised light arthroscopy of a joint aspirate reveals:
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A. Negatively birefringent rhomboidally shaped crystals.
B. Negatively birefringent needle-shaped crystals.
C. Positively birefringent rhomboid crystals.
D. Positively birefringent needle-shaped crystals.
E. Snowflake-shaped crystals.
Well done, you have selected the right answer.
The correct answer is B. Gout produces negatively birefringent needle-shaped
crystals of uric acid. Pseudogout is positively birefringent rhomboid-shaped
crystals of pyrophosphate. A blizzard produces snowflakes and this has nothing
to do with orthopaedics.
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104. A 26-year-old junior doctor returns from a skiing trip with a painful knee. He
had a couple of bad falls but was able to ski for the whole week. Over the next
few weeks he notices painful clicking along the medial joint line, particularly when
bending the knee coming down stairs. The knee is stable and does not give way.
One afternoon he is getting off the sofa in the doctors' mess, feels a sudden
sharp pain and is unable to extend the knee for around a minute before it
spontaneously releases itself. Examination by the orthopaedic registrar will most
likely reveal:
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A. Positive anterior drawer sign
B. Positive Lachmann's test
C. Positive posterior drawer sign
D. Positive McMurray's test
E. Positive pivot shift test
Well done, you have selected the right answer.
The correct answer is D. The patient has a torn meniscus, evidenced by the joint
line pain, clicking in flexion and the episode of locking. There is nothing to
suggest anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL)
injury. All of the tests listed are for ACL or PCL injuries, apart from McMurray's
test, which is used to detect meniscal tears.
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105. A 50-year-old dinner lady attends the orthopaedic clinic complaining of pain
around the medial aspect of her heel and ankle. She has pain and swelling
behind the medial malleolus, worse at the end of the day. She has noticed that
her arch has collapsed over the last couple of years. She is otherwise well.
Examination reveals that the hindfoot lies in valgus. The arch is flat. There is
swelling and pain to palpation behind the medial malleolus. The hindfoot is
flexible. She is unable to do a single stance heel raise. X-rays reveal the
planovalgus deformity but no arthritis of the subtalar or ankle joint. The diagnosis
is:
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A. Tibialis posterior insufficiency
B. Congenital talipes equinovarus (club foot)
C. Congenital vertical talus
D. Plantar fasciitis
E. Charcot's arthropathy
Sorry, you have selected the wrong answer.
The correct answer is A. She has grade 2 tibialis posterior insufficiency. The
tendon becomes degenerate, most commonly in middle-aged women. Initially it is
just inflamed and tender (grade 1) but eventually ruptures resulting in collapse of
the arch and valgus deformity of the hindfoot (grade 2). If left untreated arthritis of
the subtalar (grade 3) and ankle joint (grade 4) result.
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106. A 50-year-old dinner lady attends the orthopaedic clinic complaining of pain
around the medial aspect of her heel and ankle. She has pain and swelling
behind the medial malleolus, worse at the end of the day. She has noticed that
her arch has collapsed over the last couple of years. She is otherwise well.
Examination reveals that the hindfoot lies in valgus. The arch is flat. There is
swelling and pain to palpation behind the medial malleolus. The hindfoot is
flexible. She is unable to do a single stance heel raise. X-rays reveal the
planovalgus deformity but no arthritis of the subtalar or ankle joint. The optimal
treatment should be:
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A. A steroid injection into the tibialis posterior sheath.
B. A supportive insole.
C. Subtalar fusion.
D. Transfer of flexor digitorum longus (FDL) tendon to the
navicular and calcaneal osteotomy.
E. Ankle and subtalar fusion.
Sorry, you have selected the wrong answer.
The correct answer is D. The patient has stage 2 tibialis posterior insufficency.
The tib. post. tendon is not functioning as she is unable to single stance heel
raise. This is longstanding because the arch has collapsed and the heel is in
valgus. There is no arthritis in the subtalar joint though, which means that the tib.
post. can be reconstructed using an FDL tendon transfer and calcaneal
osteotomy. If there was arthritis a fusion would be indicated.
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107. A 70-year-old lady attends the clinic complaining of mid-thoracic back pain,
which is so severe that she cannot sleep. The pain has been present for 8 weeks
and is getting worse. She has tried many different painkillers to no avail. She has
no history of trauma. She is generally well, but 8 years ago had a mastectomy for
breast cancer. She has unintentionally lost two stone over the last 8 weeks.
Neurological examination is normal. X-rays reveal wedge fractures of T8 and
T11. There are areas of patchy osteopenia in T4 and T5. Initial treatment should
consist of:
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A. Reassurance that these are simple osteoporotic wedge
fractures.
B. Oral analgesia, provision of a corset brace and referral to
physiotherapy.
C. An urgent bone scan.
D. Oral calcium and vitamin D supplements.
E. Referral to the osteoporosis clinic for consideration of
bisphosphonate therapy.
Sorry, you have selected the wrong answer.
The correct answer is C. This lady has several red flag symptoms suggestive of
spinal metastases. Although these may be simple osteoporotic wedge fractures,
bony mets from previous breast cancer are a distinct possibility. She needs an
urgent whole body bone scan, as well as further imaging of the spine.
Involvement of the oncologists is imperative. The red flags are:
· •
Thoracic pain
· · •
Fever
· · •
Unexpected weight loss
· · •
History of cancer
· · •
Age of onset <20 years >55years
· · •
Pain worse at night
· · •
Neurological deficit – e.g. foot drop or paraesthesia
· · •
Saddle anaesthesia or loss of bladder or bowel control
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108. At 10 pm, a 33-year-old IT engineer attends A&E complaining of severe low
back pain. He is well known to the spinal team, having had sciatica for over 6
months. He had an MRI a month ago that showed a moderate sized L4-L5 right
paracentral disc prolapse. He is on the waiting list for an elective discectomy.
Four hours ago the pain got suddenly worse when he sneezed. He is now
complaining of weakness in both legs and is unable to stand unaided. He had an
episode of faecal incontinence whilst trying to get up the stairs to bed. Whilst
cleaning himself up he noticed he was unable to feel his perineum. He has not
passed urine since he arrived at the hospital 2 hours ago. Examination reveals
grade 2 weakness in ankle plantarflexion, hallux dorsiflexion, and ankle
dorsiflexion. Ankle jerks are absent bilaterally. He has reduced sensation in L4-5
and S1 dermatomes and anal tone is reduced. The next step in his treatment
should be:
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A. Analgesia, urgent re-referral to the spinal clinic so that his
discectomy date can be brought forwards.
B. Referral to physiotherapy for core stability and strengthening
exercises.
C. Repeat MRI within the next week.
D. Admission, MRI in the morning.
E. Immediate admission, catheterisation, urgent MRI that night
and referral to a spinal surgeon.
Well done, you have selected the right answer.
The correct answer is E. This man has cauda equina syndrome, probably due to
a massive disc proplapse. This is an emergency. He needs an urgent MRI so that
he can be taken to theatre for a decompression as soon as possible. If the
hospital he has attended does not have MRI facilities out of hours, he needs to
be transferred to the regional spinal unit ASAP. Failure to recognise and treat
cauda equina is negligent and has very serious implications for the patient's
neurological recovery.
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109. Which of the following tumours metastasise to the spine?
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A. Lung
B. Breast
C. Prostate
D. Thyroid
E. Kidney
F. All of the above
Well done, you have selected the right answer.
The correct answer is F. All of these may metastasise to the spine. Multiple
myeloma also occurs in the spine.
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