MSK Y2 MCQs

Question 1: A 35-year-old cyclist presents with shoulder weakness and inability to abduct the arm beyond 15°. Examination reveals a flattened deltoid contour. Which nerve is most likely injured?

A) Radial nerve
B) Axillary nerve
C) Musculocutaneous nerve
D) Median nerve
E) Long thoracic nerve

Question 2: A patient falls onto the shoulder and develops a “waiter’s tip” posture of the arm: adducted, medially rotated, and extended at the elbow. What part of the brachial plexus is most likely affected?

A) Upper trunk
B) Lower trunk
C) Lateral cord
D) Posterior cord
E) Medial cord

Question 3: A lesion of the posterior cord of the brachial plexus would most likely result in which of the following?

A) Winging of the scapula
B) Claw hand
C) Loss of thumb opposition
D) Inability to flex the elbow
E) Wrist drop

Question 4: A fracture of the supracondylar humerus is most likely to damage which nerve?

A) Ulnar nerve
B) Radial nerve
C) Median nerve
D) Musculocutaneous nerve
E) Axillary nerve

Question 5: A patient with a penetrating neck wound loses shoulder abduction from 0–15° and lateral shoulder rotation. Which nerve is injured?

A) Axillary nerve
B) Long thoracic nerve
C) Suprascapular nerve
D) Thoracodorsal nerve
E) Radial nerve

Question 6: Which of the following muscles is correctly matched to its nerve supply?

A) Pronator teres – Radial nerve
B) Flexor carpi ulnaris – Median nerve
C) Infraspinatus – Axillary nerve
D) Brachioradialis – Radial nerve
E) Subscapularis – Suprascapular nerve

Question 7: A 50-year-old man presents with loss of extension at the wrist and fingers following a humeral fracture. Which part of the humerus is most likely fractured?

A) Surgical neck
B) Medial epicondyle
C) Midshaft
D) Lateral epicondyle
E) Supracondylar region

Question 8: A patient with pelvic fracture presents with a positive Trendelenburg sign. Which nerve is most likely injured?

A) Inferior gluteal
B) Obturator
C) Sciatic
D) Superior gluteal
E) Femoral

Question 9: Which deformity is characterized by hyperextension at the metatarsophalangeal (MTP) joint and flexion at the proximal and distal interphalangeal joints (PIP and DIP)?

A) Hammer toe
B) Club foot
C) Hallux valgus
D) Claw toe
E) Trendelenburg gait

Question 10: A patient has an Injury Severity Score (ISS) calculated as 24 after a motorbike crash. Which of the following statements about ISS is correct?

A) An ISS of 6 in one region results in a total of 12
B) ISS is calculated by adding the 3 lowest AIS scores
C) ISS ≥12–15 usually defines major trauma
D) ISS is measured on a scale from 1 to 50
E) ISS includes pre-hospital observations

Question 11: Which trauma patient would benefit most from tranexamic acid (TXA)?

A) 2 hours post-injury with active bleeding
B) 5 hours post-injury, minor abrasions
C) 12 hours post-injury, stable haemodynamic
D) 3 hours post-injury, GCS 15
E) No trauma, elective surgery

Question 12: A patient has tenderness over the medial calcaneus and pain with the first steps of the morning. What is the most likely diagnosis?

A) Achilles tendinopathy
B) Plantar fasciitis
C) Tarsal tunnel syndrome
D) Calcaneal fracture
E) Posterior tibial tendonitis

Question 13: A 45-year-old office worker presents with lateral elbow pain aggravated by gripping and wrist extension. There is tenderness over the lateral epicondyle. What is the most likely diagnosis?

A) Golfer’s elbow
B) Olecranon bursitis
C) Tennis elbow
D) Radial tunnel syndrome
E) Cubital tunnel syndrome

Question 14: Which of the following features would most support a diagnosis of granulomatosis with polyangiitis (GPA)?

A) High eosinophil count and asthma
B) Recurrent mouth and genital ulcers
C) Isolated AKI with red cell casts
D) Palpable purpura on buttocks and legs in a child
E) Positive PR3-ANCA with nasal crusting

Question 15: Which of the following correctly matches a vasculitis type with its mechanism?

A) Eosinophilic granulomatosis with polyangiitis (EGPA) – T cell-mediated granulomas
B) Giant cell arteritis (GCA) – Immune complex-mediated
C) Granulomatosis with polyangiitis (GPA) – Immune complex-mediated
D) IgA vasculitis – Immune complex-mediated
E) Microscopic polyangiitis (MPA) – T-cell mediated

Question 16: A 62-year-old woman presents with new-onset headache, scalp tenderness, jaw claudication, and blurred vision in her right eye. ESR is 88 mm/hr. What is the most appropriate next step?

A) Order temporal artery biopsy before treatment
B) Initiate high-dose oral prednisolone immediately
C) Prescribe low does-aspirin
D) Refer to rheumatology as an outpatient
E) Request brain MRI

Question 17: Which of the following is a recognised feature of Takayasu arteritis?

A) Most often affects the aortic arch and its branches
B) Caused by IgA immune complex deposition
C) Associated with PR3-ANCA
D) Usually affects males over 60
E) Presents with lower limb purpura and arthritis

Question 18: A 23-year-old man presents with lower back pain and stiffness worse in the mornings, improving with exercise. He also reports episodes of eye pain and redness. What is the most likely diagnosis?

A) Cauda equina syndrome
B) Mechanical back pain
C) Ankylosing spondylitis
D) Spinal cord tumour
E) Osteoarthritis

Question 19: A 6-year-old boy presents with progressive muscle weakness, difficulty rising from the floor, and calf hypertrophy. What is the most likely diagnosis?

A) Becker muscular dystrophy
B) Duchenne muscular dystrophy
C) Spinal muscular atrophy
D) Charcot-Marie-Tooth disease
E) Cerebral palsy

Question 20: A 34-year-old woman with relapsing-remitting multiple sclerosis presents with acute left eye pain and progressive visual loss. Examination reveals decreased visual acuity and a relative afferent pupillary defect (RAPD). What is the most likely diagnosis?

A) Central retinal artery occlusion
B) Temporal arteritis
C) Optic neuritis 
D) Retinal detachment
E) Diabetic retinopathy

Question 21: A 28-year-old man has difficulty relaxing his grip after shaking hands. He also has frontal balding, ptosis, and a long face. What is the most likely diagnosis?

A) Myasthenia gravis
B) Multiple sclerosis
C) Becker muscular dystrophy
D) Myotonic dystrophy
E) Guillain-Barré syndrome

Question 22: A 70-year-old male presents with pain, swelling, and warmth in his knee joint. He has a history of diabetes and recent knee replacement surgery. Joint aspirate is turbid with >50,000 WBCs/µL. What is the most likely diagnosis?

A) Gout
B) Prosthetic joint infection
C) Pseudogout
D) Rheumatoid arthritis
E) Osteoarthritis

Question 23: A 10-year-old boy presents with a swollen, painful femur. X-ray shows a lesion in the diaphysis with an onion-skin periosteal reaction. What is the most likely diagnosis?

A) Ewing’s sarcoma
B) Osteosarcoma
C) Giant cell tumour
D) Fibrous dysplasia
E) Osteomyelitis

Question 24: A 6-year-old boy presents with fever, limp, and raised ESR. Hip ultrasound shows effusion. Kocher criteria are used. Which factor is not part of Kocher’s criteria?

A) Non–weight bearing
B) ESR >40
C) Temperature >38.5°C
D) WBC >12,000
E) CRP >50

Question 25: A 65-year-old man presents with sudden onset of severe pain, redness, and swelling in his right great toe. He drinks 3 pints of beer daily and has chronic kidney disease. Joint aspiration shows negatively birefringent, needle-shaped crystals. What is the most likely diagnosis?

A) Septic arthritis
B) Rheumatoid arthritis
C) Gout
D) Pseudogout
E) Osteoarthritis

Question 26: A 23-year-old woman presents with malar rash, photosensitivity, and joint pain. Her ANA is positive, and anti-dsDNA is elevated. What is the most likely diagnosis?

A) Rheumatoid arthritis
B) Systemic lupus erythematosus (SLE)
C) Dermatomyositis
D) Systemic sclerosis
E) Sjögren’s syndrome

Question 27: A 35-year-old woman has Raynaud’s phenomenon, tight facial skin, lung fibrosis and difficulty swallowing. What is the most likely antibody?

A) Anti-centromere
B) Anti-dsDNA
C) Anti-RNP
D) Anti-Scl-70 (anti-topoisomerase I)
E) Rheumatoid factor

Question 28: A patient with dry eyes, dry mouth, and recurrent parotid gland swelling is most likely to test positive for which antibody?

A) Anti-Ro (SSA)
B) Anti-centromere
C) Anti-Scl-70
D) Anti-dsDNA
E) Anti-Jo-1

Question 29: A 24-year-old footballer presents with an ankle sprain. MRI shows partial disruption of the anterior talofibular ligament. What grade of sprain is this?

A) Grade 0
B) Grade 1
C) Grade 2
D) Grade 3
E) Grade 4

Question 30: Which embryonic structure gives rise to the nucleus pulposus of the intervertebral disc?

A) Neural crest
B) Somite
C) Mesonephros
D) Neural tube
E) Notochord

Question 31: Which type of collagen is first laid down during tendon healing?

A) Type I
B) Type II
C) Type III
D) Type IV
E) Type V

Question 32: Which genetic mutation is associated with achondroplasia?

A) COL2A1
B) FGFR3
C) EXT1
D) PHEX
E) SLC26A2

Question 33: A patient presents with elbow trauma. The anterior fat pad is elevated, and the posterior fat pad is visible. What does this imply, and what is the likely diagnosis?

A) Normal finding, no fracture
B) Joint effusion — radial head fracture
C) Dislocation of the olecranon
D) Tendon rupture
E) Dislocation of the radial head

Question 34: Which of the following is a radiographic hallmark of osteoarthritis?

A) Periarticular osteopenia
B) Joint space widening
C) Osteophyte formation
D) Erosions
E) Subchondral cysts only

Question 35: A 34-year-old woman presents with bilateral wrist and MCP joint pain and morning stiffness >1 hour. Which of the following is the most specific antibody for rheumatoid arthritis?

A) ANA
B) Anti-dsDNA
C) Rheumatoid Factor
D) Anti-CCP
E) Anti-Ro

Question 36: Which radiographic feature is typical of RA?

A) Subchondral sclerosis
B) Marginal erosions
C) Osteophyte formation
D) Joint space widening
E) Bamboo spine

Question 37: Which joint deformity is due to PIP flexion and DIP hyperextension?

A) Boutonnière
B) Swan neck
C) Z-deformity
D) Claw hand
E) Ulnar drift

Question 38: A 25-year-old male with a history of IBD presents with back pain and stiffness. Which spondyloarthropathy is most likely?

A) Psoriatic arthritis
B) Enteropathic arthritis
C) Reactive arthritis
D) Osteoarthritis
E) Rheumatoid arthritis

Question 39: A baby presents with fusion of the second and third digits and craniosynostosis. Which syndrome is likely?

A) Holt-Oram
B) VACTERL
C) Apert syndrome
D) DiGeorge syndrome
E) Ellis-van Creveld syndrome

Question 40: A 29-year-old construction worker presents with medial scapular winging and difficulty pushing heavy objects forward after sustaining a deep laceration along the mid-axillary line from falling onto rebar. Neurologic examination reveals intact shoulder abduction and external rotation, but marked weakness with protraction of the scapula. Based on the clinical findings and suspected nerve injury, which of the following best describes the origin of the affected nerve within the brachial plexus?

A. Arises from the upper trunk
B. Arises from the posterior cord
C. Arises directly from the C5–C7 nerve roots
D. Arises from the lateral cord
E. Arises from the terminal branch of the musculocutaneous nerve

Question 41: A 32-year-old male is brought to the emergency department after a motorcycle accident. He was thrown from the bike and landed on his right shoulder, with a significant increase in the angle between his neck and shoulder. On examination, his right upper limb is held in adduction, internal rotation at the shoulder, with an extended and pronated forearm, and flexed wrist. He is unable to abduct his shoulder or flex his elbow, but finger movements are intact. Which part of the brachial plexus is most likely affected?

A. Lateral cord
B. Posterior cord
C. Lower trunk
D. Upper trunk
E. C8 and T1 nerve roots

Question 42: A 30-year-old cyclist presents after falling directly onto the superior aspect of his shoulder. He reports localized pain and swelling at the top of the shoulder. On physical exam, there is a visible step-off deformity between the clavicle and the acromion, and the shoulder appears to droop inferiorly when gentle downward pressure is applied. Arm strength and neurologic exam are normal. Which of the following best describes the nature of this injury?

A. Anterior dislocation of the glenohumeral joint
B. Posterior dislocation of the glenohumeral joint
C. Inferior dislocation of the glenohumeral joint
D. Dislocation of the acromioclavicular joint
E. Partial dislocation (subluxation) of the glenohumeral joint

Question 43: A 46-year-old man presents with weakness in hand grip and difficulty extending his fingers. He denies trauma but reports leaning with his arm over the back of a hard chair for several hours after drinking heavily. On exam, he has wrist drop, loss of extension at the metacarpophalangeal joints, and numbness over the dorsum of the hand. Elbow extension is preserved. Which of the following best explains the site of nerve injury?

A. Radial nerve injury in the axilla
B. Radial nerve compression at the spiral groove of the humerus
C. Posterior interosseous nerve syndrome in the forearm
D. Median nerve compression at the cubital fossa
E. Ulnar nerve compression at the ulnar tunnel

Question 44: A 35-year-old man sustains a displaced intra-articular distal femur fracture after a motorcycle accident. The orthopaedic team decides to proceed with open reduction and internal fixation using compression plates to achieve absolute stability. Three months later, imaging shows bone continuity without visible callus formation. Which of the following best explains the rationale for this treatment strategy?

A. To allow formation of a periosteal callus without compromising joint function
B. To convert the fracture into a low-strain environment suitable for endochondral ossification
C. To prevent callus formation in a high-strain region near a joint and promote primary bone healing
D. To allow soft callus to form and bridge the fracture gap before remodelling begins
E. To enhance cytokine release from neutrophils and fibroblasts to accelerate ossification

Question 45: A 65-year-old woman with osteoporosis undergoes open reduction and internal fixation (ORIF) of a non-displaced femoral neck fracture using compression plating. Follow-up imaging 3 months later reveals good cortical continuity without visible callus formation. Which of the following best explains the underlying mechanism of healing in this case?

A. Fracture site healing by endochondral ossification with a bridging soft callus
B. Healing via inflammatory cytokine-driven fibrocartilaginous matrix deposition
C. Bone healing through cutting cone remodelling led by osteoclasts and osteoblasts
D. Osteogenesis through granulation tissue formation and soft callus mineralisation
E. Woven bone formation followed by transformation into fibrocartilage

Question 46: A 72-year-old woman presents after a fall on her outstretched hand. She complains of wrist pain and swelling. X-rays reveal a fracture of the scaphoid bone. Which of the following best explains the concern regarding vascularisation and potential complications in this fracture?

A. The scaphoid has a rich periosteal blood supply from centrifugal vessels, promoting rapid healing
B. The scaphoid blood supply from the radial artery is superficial and easily compromised, risking avascular necrosis
C. The scaphoid receives blood from both anterior and posterior retinacular arteries, minimising necrosis risk
D. The scaphoid has a centripetal blood supply like adults’ long bones, ensuring good healing potential
E. The scaphoid’s vascular supply is primarily from medullary vessels protected within the bone marrow cavity

Question 47: A 28-year-old male is brought to the emergency department following a motorcycle collision. His injuries include: a moderate head injury (AIS 3), multiple rib fractures (AIS 3), a fractured femur (AIS 4), a fractured radius (AIS 2), and a superficial facial laceration (AIS 1). What is the Injury Severity Score (ISS), and how should the trauma be classified?

A. ISS = 25; moderate trauma
B. ISS = 34; major trauma
C. ISS = 41; major trauma
D. ISS = 50; critical trauma
E. ISS = 75; unsurvivable trauma

Question 48: A 25-year-old male is brought in after a high-speed collision. He is hypotensive, tachycardic, pale, and has a core temperature of 34°C. Arterial blood gas reveals a pH of 7.12 and elevated lactate. The trauma team suspects ongoing intra-abdominal bleeding. What is the most appropriate initial management strategy to address the underlying pathophysiology in this patient?

A. Begin high-volume isotonic saline resuscitation
B. Administer warming blankets and IV fluids to maintain normothermia
C. Delay oxygenation until blood loss is corrected
D. Aggressively cool the patient to reduce metabolic demand
E. Give only crystalloid fluids to avoid transfusion reactions

Question 49: A 46-year-old woman presents with progressive tightness and thickening of the skin over her hands and forearms. She describes her fingers turning white and painful when exposed to cold, and she has recently developed difficulty swallowing and heartburn. On examination, her fingers are tapered with reduced mobility, and dilated capillaries are noted at the nailfolds. Which of the following additional findings is most characteristic of her likely diagnosis?

A. Rapid onset of renal crisis with malignant hypertension
B. Widespread interstitial lung disease with early fibrosis
C. Pulmonary artery hypertension with signs of right heart failure
D. Erythematous malar rash sparing the nasolabial folds
E. Anti-dsDNA antibody positivity and low complement levels

Question 50: A 67-year-old man presents with sudden onset of a red, hot, and painful right knee. He is currently an inpatient for management of community-acquired pneumonia and has a past medical history of chronic kidney disease and hypertension. Joint aspiration of the knee reveals rhomboid-shaped crystals with positive birefringence under polarised light microscopy. Which of the following is the most likely diagnosis?

A. Septic arthritis
B. Gout
C. Osteoarthritis with crystal deposition
D. Pseudogout
E. Rheumatoid arthritis

Question 51: A 10-year-old boy presents with persistent left knee pain after a minor fall during football practice. X-rays show a Salter-Harris type II fracture involving the distal femur. The orthopaedic team is concerned about future growth disturbances due to the involvement of the growth plate. Which of the following best describes the zone of the growth plate that is primarily responsible for longitudinal bone growth and is most susceptible to injury?

A. Resting zone
B. Proliferative zone
C. Hypertrophic zone
D. Grooves of Ranvier
E. Perichondral ring of Lacroix

Question 52: A newborn is evaluated for upper limb abnormalities noted at birth. Examination reveals absence of the radius and thumb on the right side, with otherwise normal limb development. Radiographs confirm radial agenesis. Disruption in which of the following embryologic structures is most likely responsible for this anomaly?

A. Apical ectodermal ridge
B. Surface ectoderm
C. Zone of polarizing activity
D. Perichondral ring of Lacroix
E. Wnt signalling pathway

Question 53: A 2-year-old girl is brought to the paediatric orthopaedic clinic due to a visibly shortened left leg and difficulty walking. Examination reveals limb length discrepancy, a hypoplastic lateral femoral condyle, and a valgus deformity at the knee. Imaging confirms congenital absence of the fibula. Which of the following best describes the underlying limb deformity classification in this patient?

A. Failure of segmentation
B. Failure of formation (radial-ulnar axis)
C. Failure of formation (longitudinal axis)
D. Overgrowth
E. Other – constrictive defect

Question 54: A 58-year-old man with a history of treated lung adenocarcinoma presents with severe left thigh pain and inability to bear weight following minimal trauma. Imaging reveals a large lytic lesion in the proximal femur with cortical destruction and a soft tissue mass. Labs show hypercalcemia and elevated alkaline phosphatase.

Which of the following statements is MOST accurate regarding this patient’s bone lesion?

A. The lesion’s radiographic appearance and patient age suggest a primary bone tumour rather than metastasis
B. The presence of hypercalcemia indicates osteoblastic metastases are causing excessive bone formation
C. The proximal femur is a common site for sclerotic lesions due to metastatic prostate cancer
D. The lytic lesion’s location and pattern increase the risk of pathological fracture requiring surgical stabilisation
E. Secondary bone tumours predominantly affect patients under 30 years old and tend to be sclerotic in nature

Question 55: A 16-year-old adolescent presents with persistent, localised pain in the proximal femur, worse at night, which is completely relieved by aspirin. Radiographs reveal a small, well-demarcated, radiolucent lesion with a central nidus surrounded by reactive sclerosis. Bone scintigraphy shows increased uptake at the lesion site.

Which of the following is the most likely diagnosis?

A. Simple (Unicameral) Bone Cyst
B. Aneurysmal Bone Cyst
C. Giant Cell Tumour
D. Osteoid Osteoma
E. Osteosarcoma

Question 56: Which of the following bone tumours is epiphyseal in location, typically occurs in adolescents (10–20 years), and is benign but may expand into the metaphysis?

A) Osteochondroma
B) Enchondroma
C) Chondroblastoma
D) Chondrosarcoma
E) Fibrous Dysplasia

Question 57: A 35-year-old patient presents with a painful, cartilaginous-capped bony mass around the knee joint that has gradually limited mobility. The lesion is benign but has a small risk of malignant transformation. It developed during adolescence and is located near a bone undergoing endochondral ossification.

Which of the following is the most likely diagnosis?

A) Enchondroma
B) Osteochondroma
C) Chondroblastoma
D) Chondrosarcoma
E) Giant Cell Tumour

Question 58: A 14-year-old boy presents with localized bone pain and swelling in the diaphysis of his femur. He has had intermittent fever and weight loss over the past month. Plain radiographs reveal a permeative lesion with an “onion-skin” periosteal reaction. A biopsy reveals small round blue cells of neuroectodermal origin. Which of the following is the most likely diagnosis?

A) Osteosarcoma
B) Ewing’s Sarcoma
C) Chondrosarcoma
D) Osteomyelitis
E) Giant Cell Tumour

Question 59: A football player sustains a non-contact knee injury while twisting during a sprint. On examination, there is joint instability but no significant muscle weakness. Imaging reveals a torn structure connecting femur to tibia with mixed collagen and elastic fibre content. Which of the following structures is most likely injured?

A) Energy-storing tendon
B) Positional tendon
C) Ligament
D) Aponeurosis
E) Muscle belly

Question 60: A 30-year-old man sustains a partial tear to his Achilles tendon. The orthopaedic team plans a rehabilitation programme to optimise healing. Which of the following statements best explains the rationale for early controlled mobilisation?

A) It promotes healing by granulation tissue from the endotenon
B) It reduces collagen synthesis and fibril alignment
C) It promotes intrinsic healing and improves collagen alignment
D) It increases adhesions through endotenon-driven repair
E) It is superior for most types of tendon healing, including tendon-to-bone insertions

Question 61: A 68-year-old woman presents with chronic right knee pain, stiffness in the morning lasting less than 30 minutes, and reduced mobility. On examination, crepitus and reduced range of motion are noted. X-ray shows joint space narrowing, subchondral sclerosis, and osteophyte formation. Which of the following best describes the primary pathological process in this condition?

A) Autoimmune synovial inflammation
B) Deposition of monosodium urate crystals
C) Degeneration of articular cartilage and subchondral bone
D) Infective destruction of joint tissues
E) Fibrosis of the joint capsule

Question 62: A 70-year-old patient undergoes a total hip replacement. The implant used is coated with hydroxyapatite, and no bone cement is used for fixation. Which of the following best describes the fixation method and associated biological response?

A) Cemented fixation with bone-cement interface
B) Mechanical interlock with polymethylmethacrylate
C) Bone ingrowth into porous coating for biological fixation
D) Direct chemical bonding between implant and bone
E) Adhesion of bone to polyethylene interface

Question 63: A 68-year-old woman presents with new-onset temporal headache, jaw claudication, and transient vision loss. Blood tests show raised inflammatory markers. A temporal artery biopsy reveals granulomatous inflammation with multinucleated giant cells. Which of the following is the most likely diagnosis?

A) Granulomatosis with Polyangiitis
B) Takayasu Arteritis
C) Behçet’s Disease
D) Giant Cell Arteritis
E) Polyarteritis Nodosa

Question 64: A 22-year-old female presents with recurrent episodes of lateral patellar dislocation during physical activity. Examination reveals increased Q-angle and valgus deformity of the knee. Which of the following best explains the biomechanical reason for her patellar instability?

A) Decreased Q-angle causing medial patellar pull
B) Increased Q-angle causing lateral patellar pull
C) Patella positioned medially within the quadriceps tendon
D) Strengthening of vastus lateralis preventing patellar displacement
E) Varus deformity decreasing lateral patellar displacement

Question 65: A 45-year-old woman presents with pain and swelling over the medial side of her right foot at the base of the big toe. On examination, there is lateral deviation and subluxation of the first metatarsophalangeal joint, with lateral displacement of the sesamoid bones. She reports frequently wearing high-heeled shoes. Which of the following is the most likely diagnosis?

A) Hammer Toe
B) Claw Toe
C) Hallux Valgus
D) Congenital Clubfoot
E) Metatarsalgia

Question 66: A 40-year-old woman presents with chronic, widespread musculoskeletal pain, fatigue, and sleep disturbances. There are no objective inflammatory signs on examination or laboratory tests. She reports a history of significant psychological stress. Which of the following is the main pharmacological treatment recommended for her condition?

A) Long-term opioid analgesics
B) Non-steroidal anti-inflammatory drugs (NSAIDs)
C) Tricyclic antidepressants (e.g., amitriptyline)
D) Systemic corticosteroids
E) Disease-modifying anti-rheumatic drugs (DMARDs)

Question 67: A 68-year-old postmenopausal woman is diagnosed with osteoporosis after a fragility fracture. She has a T-score of -2.8 on her DXA scan. Which of the following is the most appropriate initial pharmacological treatment to reduce her fracture risk?

A) Teriparatide
B) Bisphosphonates
C) Romosozumab
D) Denosumab
E) Calcium and Vitamin D supplementation only

Question 68: A 70-year-old man presents with bone pain and deformity of the tibia. His X-rays show a “blade of grass” appearance with areas of both osteolysis and sclerosis. His alkaline phosphatase is elevated but calcium and phosphate are normal. What is the most likely diagnosis?

A) Osteoporosis
B) Paget’s Disease of Bone
C) Osteomalacia
D) Metastatic bone disease
E) Multiple myeloma

Question 69: A 55-year-old woman presents with diffuse bone pain and muscle weakness. Blood tests reveal low-normal calcium, low phosphate, raised alkaline phosphatase, and elevated parathyroid hormone. X-rays show Looser’s zones. What is the most likely diagnosis?

A) Osteoporosis
B) Paget’s Disease of Bone
C) Osteomalacia
D) Rheumatoid arthritis
E) Fibromyalgia

Question 70: A patient presents with radicular leg pain and MRI shows herniated disc material extending beyond the annulus fibrosus but still attached to the disc. Which term best describes this condition?

A) Disc protrusion (bulging)
B) Nuclear extrusion
C) Sequestered nucleus
D) Annular tear without herniation
E) Spinal stenosis

Question 71: A 45-year-old patient presents with bilateral leg pain, numbness in the perianal area, and difficulty initiating urination over the past 36 hours. MRI confirms compression of nerve roots distal to L1. Which of the following best describes the type of Cauda Equina Syndrome and the recommended management?

A) Early CES (CESE); monitor symptoms and perform MRI
B) Incomplete CES (CESI); emergency decompression within 48 hours
C) Retention CES (CESR); urgent decompression without delay
D) Spinal cord infarction; supportive care only
E) Peripheral neuropathy; physical therapy and observation

Question 72: A 4-year-old boy presents with acute left hip pain, a high-grade fever of 39.2°C, and inability to bear weight. Examination shows a flexed, painful hip with restricted movement. Bloods show WBC of 14 x10⁹/L and ESR of 62 mm/hr. What is the most likely diagnosis, and what is the gold standard investigation?

A) Juvenile idiopathic arthritis; MRI scan
B) Osteomyelitis; blood cultures
C) Septic arthritis; synovial fluid aspiration
D) Transient synovitis; ultrasound
E) Crystal arthropathy; polarising microscopy

Question 73: A 67-year-old man with a recent total knee replacement presents with increasing joint pain, swelling, and erythema around the surgical site 2 weeks post-operatively. He has a history of poorly controlled type 2 diabetes and obesity. What is the most likely pathogen, and what is the most important factor complicating treatment?

A) Streptococcus; deep venous thrombosis
B) Pseudomonas; haematogenous spread
C) Staphylococcus; biofilm formation
D) Enterobacter; immune complex deposition
E) E. coli; antibiotic resistance

Question 74: A 32-year-old man presents with chronic lower back pain and stiffness that is worse in the morning and improves with activity. He has a history of anterior uveitis and recently developed difficulty taking deep breaths. Imaging reveals bilateral sacroiliitis and early syndesmophyte formation. He tests positive for HLA-B27. Despite NSAID use, his symptoms progress, and DEXA scan shows reduced bone density. What is the most likely underlying mechanism contributing to both his axial symptoms and vertebral fracture risk?

A) Autoantibody-mediated synovitis and joint destruction
B) TNF-alpha-driven erosion of cortical bone via RANKL activation
C) Enthesitis with subsequent bone marrow oedema, fat metaplasia, and aberrant osteogenesis
D) Immune complex deposition at fibrocartilaginous joints
E) T-cell mediated granulomatous inflammation of the sacroiliac joints

Question 75: A 29-year-old man presents with a 9-month history of insidious lower back pain that is worst in the early morning and improves with activity. He also reports recent episodes of blurred vision and photophobia. Examination reveals reduced chest expansion and limited forward lumbar flexion. MRI shows bilateral sacroiliitis. ECG reveals first-degree AV block. Which of the following features most strongly supports the diagnosis of ankylosing spondylitis in this patient?

A) Positive HLA-B27
B) Inflammatory back pain and anterior uveitis
C) Limited chest expansion and lumbar flexion
D) Bilateral sacroiliitis on imaging
E) Family history of psoriasis and IBD

Question 76: A 35-year-old male athlete presents with persistent knee pain following a twisting injury. MRI reveals a focal chondral defect on the medial femoral condyle that is entirely above the tidemark. After conservative treatment fails, which of the following is the most appropriate next step to promote healing?

A) High tibial osteotomy to redistribute load
B) Total knee arthroplasty
C) Autologous chondrocyte implantation
D) Observation and physiotherapy
E) Microfracture technique to induce bleeding

Question 77: A 39-year-old man with a history of renal transplant presents with groin pain exacerbated by weight-bearing. Examination reveals pain-limited hip rotation but no limb shortening. Plain radiograph shows a crescent sign without joint space narrowing or acetabular involvement. MRI confirms a subchondral fracture with preserved articular cartilage. What is the Ficat stage and the most appropriate management strategy?

A) Stage 2; start bisphosphonates and monitor progression
B) Stage 1; initiate physiotherapy and analgesia
C) Stage 3; core decompression or osteotomy
D) Stage 4; total hip arthroplasty
E) Stage 2; hip resurfacing as joint-preserving option