Master Orthopaedics & Rheumatology
for PLAB 1
Access 50+ high-yield questions tailored for the 2026 syllabus. Includes AI-powered explanations and performance tracking.
Core Concepts
Orthopaedics deals with musculoskeletal system disorders (bones, joints, ligaments, tendons, muscles). Key areas include trauma (fractures), degenerative conditions (osteoarthritis), infections (osteomyelitis, septic arthritis), and congenital deformities. Rheumatology focuses on systemic inflammatory and autoimmune diseases affecting joints, muscles, and soft tissues, often with multi-system involvement (e.g., Rheumatoid Arthritis, SLE, vasculitis).
Differentiate between:
- Mechanical pain: Worsens with activity, improves with rest (e.g., osteoarthritis, tendinitis).
- Inflammatory pain: Worsens with rest, improves with activity, prominent morning stiffness (>30 mins) (e.g., rheumatoid arthritis, ankylosing spondylitis).
Clinical Presentation
- Pain: Localised, radiating, joint-specific, or widespread. Characterise as inflammatory or mechanical.
- Stiffness: Morning stiffness duration is key (inflammatory >30min, mechanical <30min).
- Swelling: Joint effusion (warm, tender, boggy) or soft tissue oedema.
- Deformity: Joint malalignment, subluxation, contractures.
- Reduced range of motion: Active and passive, painful or restricted.
- Weakness: Muscle wasting or neurological deficit.
- Systemic symptoms: Fever, fatigue, weight loss (suggests inflammatory/infectious cause).
- Specific signs: Crepitus (OA), erythema migrans (Lyme), tophi (Gout), butterfly rash (SLE).
Diagnosis (Gold Standard)
A thorough history and clinical examination are paramount for initial diagnosis.
- Fractures: X-ray (initial imaging), CT (complex fractures, joint involvement), MRI (soft tissue injury, occult fractures).
- Osteoarthritis: Clinical findings + X-ray (joint space narrowing, osteophytes, subchondral sclerosis/cysts).
- Rheumatoid Arthritis: Clinical criteria (joint involvement, serology, acute phase reactants, symptom duration) + X-ray (erosions, joint space narrowing). Bloods: ESR, CRP, RF, anti-CCP.
- Gout/Pseudogout: Arthrocentesis (joint fluid aspiration) for microscopy:
- Gout: Negatively birefringent needle-shaped urate crystals.
- Pseudogout: Positively birefringent rhomboid-shaped calcium pyrophosphate crystals.
- Septic Arthritis: Arthrocentesis with Gram stain & culture (Gold Standard). Bloods: CRP, ESR, WCC.
- Osteoporosis: DEXA scan (dual-energy X-ray absorptiometry) measuring bone mineral density (T-score).
- Ankylosing Spondylitis: Clinical features (sacroiliitis) + X-ray/MRI of SI joints. HLA-B27 is supportive but not diagnostic.
Management (First Line)
- Fractures:
- RICE (Rest, Ice, Compression, Elevation) for minor soft tissue injuries.
- Immobilisation (casts, splints) for stable fractures.
- Analgesia (Paracetamol, NSAIDs, Opioids).
- Surgical fixation (ORIF - Open Reduction Internal Fixation) for unstable, displaced, or intra-articular fractures.
- Osteoarthritis:
- Lifestyle modification (weight loss, exercise, physiotherapy).
- Analgesia (Paracetamol, topical/oral NSAIDs).
- Intra-articular steroid injections.
- Surgery (arthroplasty/joint replacement) for severe cases.
- Rheumatoid Arthritis:
- Disease-Modifying Anti-Rheumatic Drugs (DMARDs) - e.g., Methotrexate (first-line), Sulfasalazine, Hydroxychloroquine, Leflunomide.
- NSAIDs for symptomatic relief.
- Short-course oral corticosteroids or intra-articular injections for flares.
- Biologics for unresponsive cases.
- Gout:
- Acute attack: NSAIDs (e.g., Naproxen, Indomethacin), Colchicine (if NSAIDs contraindicated/ineffective), oral corticosteroids.
- Prophylaxis (after acute attack resolves): Allopurinol (xanthine oxidase inhibitor) or Febuxostat to lower uric acid.
- Septic Arthritis:
- Urgent joint aspiration & IV antibiotics (empiric broad-spectrum, then guided by culture).
- Surgical washout/drainage if aspiration inadequate.
- Osteoporosis:
- Calcium & Vitamin D supplementation.
- Bisphosphonates (e.g., Alendronate) are first-line pharmacotherapy.
Exam Red Flags
- Cauda Equina Syndrome: Saddle anaesthesia, bilateral sciatica, bowel/bladder dysfunction, reduced anal tone. Emergency MRI and neurosurgical referral.
- Compartment Syndrome: Severe pain disproportionate to injury, pain on passive stretch, paraesthesia, pallor, pulselessness (late sign). Emergency fasciotomy.
- Open Fractures: Bone breaks through skin. High infection risk. Urgent surgical debridement and IV antibiotics.
- Septic Arthritis: Hot, swollen, exquisitely painful joint, fever, malaise, unable to weight bear. Urgent joint aspiration and IV antibiotics.
- Giant Cell Arteritis (GCA): New onset temporal headache, jaw claudication, scalp tenderness, visual disturbance (amaurosis fugax, permanent vision loss). Urgent high-dose corticosteroids to prevent blindness.
- Malignancy (Bone/Spine): Unexplained persistent bone pain, night sweats, weight loss, pathological fracture.
- Spinal Cord Compression: Rapidly progressive neurological deficit, back pain, weakness, sensory loss, bladder/bowel changes. Emergency imaging and specialist review.
Sample Practice Questions
A 62-year-old male presents with chronic right knee pain, which is worse with activity and improves with rest. He reports morning stiffness lasting about 15 minutes. On examination, there is crepitus on movement and mild tenderness along the joint line. X-rays show narrowing of the joint space and osteophyte formation. What is the most appropriate initial pharmacological management for this patient?
A 38-year-old male presents with a 3-week history of severe lower back pain radiating down the posterior aspect of his left leg to his foot, accompanied by numbness in the left great toe and weakness when trying to dorsiflex his ankle. He reports the pain worsens with coughing and sitting. On examination, straight leg raise test is positive at 40 degrees on the left. Dorsiflexion of the left ankle is graded 3/5. Which of the following is the most likely diagnosis?
A 24-year-old male presents to the emergency department after twisting his knee while playing football. He describes hearing a 'pop' and experienced immediate swelling and severe pain in his left knee. He now feels his knee is unstable and he cannot bear weight properly. On examination, there is a large effusion, and he demonstrates a positive anterior drawer test and Lachman test. Which of the following is the most likely injury?
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