# PLAB 1 Orthopaedics Questions: 10 Free Practice MCQs

> 10 free PLAB 1 orthopaedics questions with answers and explanations, from a bank of 14 orthopaedics questions. Try them now, no sign up.

Canonical: https://medhub.one/practice/plab-1/orthopaedics
Last updated: 2026-10-29

Ten PLAB 1-style orthopaedics questions with the answer and the reasoning behind it. They come from the UK.med bank, which has 14 orthopaedics questions and many more across every topic.

1. 1 / 10  
An 82-year-old female falls and sustains an intracapsular displaced neck of femur fracture.  
According to NICE guidelines, which surgical option is most appropriate given she is mobile outdoors with one stick?  
Show answer

**Answer: B.** Total Hip Replacement

**Why:** NICE recommends Total Hip Replacement for displaced intracapsular fractures if the patient was able to walk independently out of doors with no more than the use of a stick and is cognitively intact.

  * **A.** Used for extracapsular fractures.
  * **C.** Used for undisplaced intracapsular fractures.
  * **D.** Usually for less active/frail patients or those with cognitive impairment.  
Sources: NICE CG124
2. 2 / 10  
An 82-year-old man is admitted with a left-sided intracapsular hip fracture. He is in severe pain. His past medical history includes severe COPD and chronic kidney disease stage 4.  
What is the recommended method of administering analgesia in the emergency department to minimize systemic side effects according to NICE guidelines?  
Show answer

**Answer: A.** Offer a fascia iliaca compartment block (FICB) or femoral nerve block

**Why:** NICE guideline CG124 emphasizes early, effective analgesia for hip fractures. Fascia iliaca compartment blocks (FICB) should be offered in the ED. They work by placing local anesthetic (e.g. Levobupivacaine) under the fascia iliaca, blocking the femoral, lateral femoral cutaneous, and obturator nerves. This provides excellent pain relief for femoral fractures and reduces opioid-related complications (delirium, respiratory depression, constipation).

  * **B.** Intramuscular injections are painful and absorption is unpredictable. High-dose opioids also carry a high risk of respiratory depression (dangerous in COPD) and acute confusion/delirium in the elderly.
  * **C.** NSAIDs are contraindicated in patients with severe renal impairment (CKD stage 4) due to risk of precipitating acute-on-chronic kidney injury.
  * **D.** Fentanyl patches take 12-24 hours to reach therapeutic levels and are not suitable for acute, severe pain management in the ED.  
Sources: NICE CG124
3. 3 / 10  
A 22-year-old male falls onto an outstretched hand (FOOSH) during a football match. On examination, he has localized tenderness in the anatomical snuffbox of his right wrist. Initial radiographs of the wrist are normal.  
What anatomical feature of the scaphoid predisposes it to avascular necrosis following a fracture?  
Show answer

**Answer: A.** Retrograde blood supply from the radial artery entering at the distal pole

**Why:** The scaphoid is the most commonly fractured carpal bone. Its blood supply is retrograde, with 70-80% of arterial supply entering at the ridge of the distal tubercle and coursing to the proximal pole. A fracture through the scaphoid waist can disrupt this blood supply, predisposing the proximal segment to ischemia, avascular necrosis (AVN), and non-union.

  * **B.** If the supply were anterograde entering proximally, distal fractures would cause necrosis, which is not the case.
  * **C.** The scaphoid is largely covered by articular cartilage, which limits periosteal healing, but the primary cause of avascular necrosis is the retrograde blood supply.
  * **D.** EPL tendon lies in the Snuffbox but does not cause avascular necrosis of the bone.  
Sources: BOA Blue Book; Gray's Anatomy
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5. 4 / 10  
A 58-year-old man presents with a 24-hour history of an excruciatingly painful, hot, swollen right knee. He is unable to bear weight. On examination, the knee is erythematous, warm, and has a large effusion with severely restricted range of motion. His temperature is 38.6°C.  
What is the recommended sequence of management?  
Show answer

**Answer: C.** Perform emergency needle aspiration of the joint fluid for gram staining and culture, then immediately start intravenous antibiotics

**Why:** Septic arthritis causes rapid, irreversible chondrolysis (cartilage destruction) within 24-48 hours. BSR guidelines recommend: (1) Immediate joint aspiration under sterile conditions (fluid sent for gram stain, MCS, and crystal analysis to rule out gout). (2) Start empiric IV antibiotics (e.g. Flucloxacillin 2g QDS, or Clindamycin/Vancomycin if penicillin-allergic). (3) Surgical review for emergency joint washout (arthroscopy or arthrotomy) to remove bacterial toxins.

  * **A.** Starting antibiotics prior to joint aspiration significantly reduces the culture yield, making pathogen-directed therapy difficult. Aspiration must be done first.
  * **B.** MRI is not required for diagnosis of septic arthritis. Joint aspiration is diagnostic and therapeutic, and should not be delayed for advanced imaging.
  * **D.** Antibiotics must not be delayed for culture results. Once the fluid is aspirated, empiric broad-spectrum IV antibiotics must be started immediately to prevent rapid cartilage destruction.  
Sources: British Society for Rheumatology (BSR) Guidelines on Septic Arthritis
6. 5 / 10  
A 78-year-old woman is admitted to the emergency department after falling at home. She is unable to bear weight and has a shortened, externally rotated right leg. An X-ray confirms a displaced intracapsular fracture of the right femoral neck. She has no cognitive impairment and was fully active beforehand.  
What is the recommended definitive surgical treatment according to NICE guidelines?  
Show answer

**Answer: D.** Total hip replacement (THR)

**Why:** NICE guideline CG124 details hip fracture management. Surgical choice depends on location: (1) Intracapsular displaced: arthroplasty (THR if fit, active, and cognitively intact; otherwise hemiarthroplasty). (2) Intracapsular non-displaced: internal fixation (cannulated screws). (3) Extracapsular (trochanteric): internal fixation with a Dynamic Hip Screw (DHS). (4) Extracapsular (subtrochanteric): intramedullary nail.

  * **A.** Hemiarthroplasty is reserved for patients who do not meet all three NICE criteria for a THR (e.g., those with cognitive impairment, pre-existing mobility limitations, or who are frail).
  * **B.** Displaced intracapsular fractures in elderly patients have a high risk of avascular necrosis and non-union if fixed with screws; arthroplasty (THR/hemiarthroplasty) is preferred. Screws are used for non-displaced fractures or young patients.
  * **C.** A DHS is the treatment of choice for extracapsular hip fractures (trochanteric fractures), not displaced intracapsular fractures.  
Sources: NICE CG124
7. 6 / 10  
A 68-year-old female presents with a 24-hour history of a hot, swollen, and excruciatingly painful right knee. She is unable to bear weight. On examination, the knee is erythematous, warm, and has a large effusion. Her temperature is 38.2°C.  
What is the most appropriate immediate management?  
Show answer

**Answer: A.** Perform joint aspiration for culture and gram staining, then start intravenous antibiotics

**Why:** Septic arthritis is a medical emergency with a high risk of rapid cartilage destruction and systemic sepsis. Under BSR guidelines, management requires joint aspiration (synovial fluid analysis for cells, gram stain, polarising microscopy, and culture) prior to initiating empiric IV antibiotics (typically Flucloxacillin or Cefuroxime). Following aspiration, orthopaedics should be consulted for urgent joint washout (arthroscopy).

  * **B.** Starting antibiotics before aspiration is a critical error. MRI is not needed for diagnosing acute septic arthritis.
  * **C.** Septic arthritis requires emergency hospital admission and IV antibiotics; oral treatment is insufficient and will lead to rapid joint destruction.
  * **D.** Intra-articular steroids are strictly contraindicated in an actively infected joint, as they will worsen the infection.  
Sources: British Society for Rheumatology (BSR) Guidelines
8. 7 / 10  
A 45-year-old man presents with a 2-day history of severe lower back pain and bilateral sciatica. Today, he noticed difficulty passing urine and numbness around his buttocks when wiping after a bowel movement. On examination, he has reduced sensation in the saddle area and reduced anal sphincter tone.  
What is the most appropriate next step in investigation?  
Show answer

**Answer: B.** Arrange an emergency MRI scan of the lumbar spine

**Why:** Cauda Equina Syndrome (CES) is caused by compression of the lumbosacral nerve roots within the central spinal canal, most commonly due to a massive central disc protrusion. Symptoms include bilateral sciatica, saddle anaesthesia, bladder dysfunction (retention or overflow incontinence), bowel incontinence, and sexual dysfunction. British Orthopaedic Association (BOA) standards mandate immediate referral for emergency MRI if CES is suspected. If confirmed, emergency surgical decompression (laminectomy) is performed.

  * **A.** While a bladder scan is useful to confirm retention, it must not delay the definitive investigation (MRI). Cauda equina is a neurological compression, not a primary urological issue.
  * **C.** Plain X-rays only show bony anatomy and cannot visualize soft tissue disc herniations or cauda equina compression, making them useless for this diagnosis.
  * **D.** Cauda equina syndrome requires emergency decompression (usually within 24-48 hours of symptom onset) to prevent permanent paraplegia and bowel/bladder incontinence. Outpatient imaging causes unacceptable delays.  
Sources: British Orthopaedic Association (BOA) Standards for Cauda Equina Syndrome
9. 8 / 10  
A 24-year-old male is admitted following a crush injury to his right lower leg. He has undergone plaster splinting for a closed tibial fracture. Two hours later, he complains of severe, constant, throbbing pain in his calf that is not relieved by intravenous Morphine. On examination, passive stretching of his toes causes excruciating pain. The calf is swollen and tense.  
What is the most urgent next step in management?  
Show answer

**Answer: C.** Split the plaster cast and dressings down to the skin; if pain persists, perform emergency surgical fasciotomy

**Why:** Acute compartment syndrome occurs when increased pressure within a closed osteofascial compartment compromises tissue perfusion. It is an orthopaedic emergency. Cardinal features: pain out of proportion to injury, pain on passive stretch (most sensitive), swollen/tense compartment, paresthesia, and paralysis. Pulselessness is a late sign indicating irreversible damage. Management requires splitting casts/dressings down to the skin immediately. If pressures remain high, emergency surgical fasciotomy (incision of the fascial compartments to relieve pressure) must be performed within 4-6 hours.

  * **A.** Elevating the limb is contraindicated in compartment syndrome, as it reduces perfusion pressure and worsens tissue ischemia. Increasing opioids masks symptoms of ongoing necrosis.
  * **B.** Compartment syndrome is a clinical diagnosis. Distal pulses (and duplex ultrasound) are often normal because systolic BP is higher than the compartment pressure, so waiting for imaging causes dangerous delays.
  * **D.** While compartment pressure monitoring can assist in unconscious patients, diagnosis in alert patients is clinical. Decompressing the limb (splitting cast/fasciotomy) must not be delayed for pressure measurements.  
Sources: BOA standards for trauma; Oxford Handbook of Clinical Surgery
10. 9 / 10  
A 28-year-old male presents to the emergency department after falling from a ladder. He has sustained a displaced mid-shaft fracture of the right tibia, with a 2 cm skin wound directly over the fracture site from which bone was briefly visible. The wound is actively oozing blood.  
What is the most appropriate initial management of the wound and fracture according to BOAST guidelines?  
Show answer

**Answer: C.** Photograph the wound, cover it with saline-soaked gauze, administer IV antibiotics, and temporarily splint the limb

**Why:** BOAST (British Orthopaedic Association Standards for Trauma) guidelines dictate that open fractures require immediate assessment and management to prevent osteomyelitis. In the ED, the wound should be photographed (to prevent repeated dressing changes), dressed with a saline-soaked sterile dressing, and splinted. Intravenous antibiotics (e.g. Co-amoxiclav 1.2g IV, or Clindamycin if penicillin-allergic) must be given as soon as possible (ideally within 3 hours of injury).

  * **A.** Open fracture wounds should not be closed or washed out in the emergency department. Formal debridement and washout must take place in the operating theatre.
  * **B.** Open fractures are orthopaedic emergencies requiring immediate IV antibiotics and urgent admission for surgical stabilization; oral antibiotics and outpatient referral are unsafe.
  * **D.** A full cast should not be applied to an open fracture in the ED due to risk of compartment syndrome and inability to monitor the wound.  
Sources: BOAST Guidelines for Open Fractures
11. 10 / 10  
A 45-year-old man has a radiographically confirmed displaced distal radius fracture after a fall onto his outstretched hand. He can flex and extend his fingers, but no formal sensory, perfusion or tendon examination has yet been documented.  
What can be concluded from his ability to move the wrist and fingers?  
Show answer

**Answer: A.** Movement is reassuring for some motor function but does not determine fracture alignment or exclude nerve, tendon or vascular injury.

**Why:** Preserved wrist and finger movement suggests that some motor function is intact, but it cannot establish fracture stability, exclude comminution or rule out sensory or vascular injury. Document neurovascular status and use radiographs to assess displacement and articular involvement. Management then depends on the fracture pattern and reduction.

  * **B.** Comminution and the need for surgery are determined by imaging, fracture pattern and reduction, not movement alone.
  * **C.** A displaced fracture needs radiographic assessment; preserved movement does not establish stability.
  * **D.** Motor function does not rule out sensory or vascular injury; examine and document these separately.  
Sources: NICE NG38: Fractures (non-complex), assessment and management

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