As the doctor running the osteoporosis clinic at a CHC, you start weekly oral alendronate 70 mg for a retired nurse whose DXA T-score at the lumbar spine is -2.9. Her serum calcium, 25-hydroxyvitamin D and creatinine are normal, and she has no difficulty swallowing. Which instruction best reduces the commonest serious side effect of this drug?

Take it fasting with plain water, then stay upright

Take it with tea and lie down for an hour

Take it at bedtime with the calcium tablet

Take it after breakfast with a glass of milk

On the second day after a below-knee amputation for diabetic gangrene, the physiotherapist finds the patient lying with a pillow under his knee because it eases the stump pain. She removes it and explains why. Which complication is this position most likely to cause?

Fixed flexion contracture of the knee

Bony overgrowth at the stump end

Four weeks after starting vitamin D and calcium for nutritional rickets, a toddler's wrist X-ray is repeated at the paediatric OPD of a district hospital to check the response. The ALP has started to fall and the child is more active. Which radiological change is the earliest evidence that the rickets is healing?

A dense line of provisional calcification

Fusion of the distal radial physis

Straightening of the bowed tibiae

Metabolic bone disease, arthritis and amputations

29 NEET-PG practice questions on Metabolic bone disease, arthritis and amputations, part of Orthopaedics. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
At a menopause clinic, the FRAX tool is used to estimate a woman's 10-year probability of fracture before deciding on treatment. Which of these are entered into FRAX? 1. Lumbar spine bone mineral density 2. Age and sex 3. Current use of oral glucocorticoids 4. Femoral neck bone mineral density (optional)
1. A2, 3 and 4 only
2. B1, 2, 3 and 4
3. C1, 2 and 3 only
4. D2 and 3 only
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Answer: A · 2, 3 and 4 only
FRAX combines age, sex, weight and height, previous fragility fracture, parental hip fracture, smoking, glucocorticoid use, rheumatoid arthritis, secondary osteoporosis and alcohol intake, with femoral neck BMD as an optional input. It gives the 10-year probability of a hip fracture and of a major osteoporotic fracture, calibrated for each country. Lumbar spine BMD is not an input, which is one known limitation of the tool. Key point: FRAX gives 10-year hip and major fracture probability from clinical risk factors, with optional femoral neck (not spine) BMD.
- B: Statement 1 is wrong, so all four cannot be correct.
- C: Statement 1 is wrong: FRAX does not use lumbar spine BMD.
- D: This leaves out femoral neck BMD, which FRAX accepts as an optional input.
Question 2 · Medium
As the doctor running the osteoporosis clinic at a CHC, you start weekly oral alendronate 70 mg for a retired nurse whose DXA T-score at the lumbar spine is -2.9. Her serum calcium, 25-hydroxyvitamin D and creatinine are normal, and she has no difficulty swallowing. Which instruction best reduces the commonest serious side effect of this drug?
1. ATake it with tea and lie down for an hour
2. BTake it fasting with plain water, then stay upright
3. CTake it at bedtime with the calcium tablet
4. DTake it after breakfast with a glass of milk
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Answer: B · Take it fasting with plain water, then stay upright
Oral bisphosphonates can cause oesophagitis and oesophageal ulcers if the tablet lodges in the oesophagus, and they are very poorly absorbed (under 1%) when taken with food, milk, calcium or other drinks. So alendronate is taken on waking, on an empty stomach, with a full glass of plain water, and the patient stays upright and does not eat for at least 30 minutes. Calcium supplements are taken at a different time of day. Key point: Alendronate: fasting, plain water, stay upright 30 minutes, no food or calcium for 30 minutes, to prevent oesophagitis.
- A: Tea reduces absorption and lying down promotes oesophagitis.
- C: Calcium binds the drug, and lying down at night risks oesophageal injury.
- D: Food and milk block absorption almost completely.
Question 3 · Medium
On the second day after a below-knee amputation for diabetic gangrene, the physiotherapist finds the patient lying with a pillow under his knee because it eases the stump pain. She removes it and explains why. Which complication is this position most likely to cause?
1. ANeuroma of the tibial nerve
2. BBony overgrowth at the stump end
3. CFixed flexion contracture of the knee
4. DPhantom limb pain
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Answer: C · Fixed flexion contracture of the knee
After a transtibial amputation the knee tends to be held flexed for comfort, and a pillow under the knee quickly leads to a fixed flexion contracture, which makes fitting a prosthesis and walking very difficult. The stump is kept straight, the patient lies prone for periods, and early quadriceps and hip extensor exercises are started. Stump bandaging in a figure-of-eight pattern shapes the stump. Key point: Never put a pillow under the knee after a below-knee amputation: it causes a flexion contracture that ruins prosthetic fitting.
- A: Neuromas form at cut nerve ends regardless of position.
- B: Terminal overgrowth is a problem mainly in children's amputations.
- D: Phantom pain is not caused by stump position.
Question 4 · Hard
Creatinine clearance of 28 mL/min has been recorded for a woman of 74 with long-standing diabetic nephropathy who has just had a low-trauma vertebral compression fracture; her DXA T-score at the total hip is -3.1. She had a deep vein thrombosis of the left leg two years ago. Serum calcium and 25-hydroxyvitamin D are now normal after supplementation. Which drug is the most appropriate to start?
1. AZoledronic acid
2. BRaloxifene
3. COral alendronate
4. DDenosumab
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Answer: D · Denosumab
She needs treatment for osteoporosis with a fragility fracture, but bisphosphonates are renally excreted and are avoided when creatinine clearance falls below about 35 mL/min, because of the risk of further renal damage. Denosumab, a monoclonal antibody against RANKL, is not cleared by the kidney and reduces vertebral, hip and non-vertebral fractures. Calcium and vitamin D must be adequate first, because hypocalcaemia is more frequent in chronic kidney disease. Key point: Osteoporosis with creatinine clearance below 35 mL/min: avoid bisphosphonates; denosumab (with calcium and vitamin D) is preferred.
- A: Zoledronic acid is contraindicated below a creatinine clearance of 35 mL/min.
- B: Raloxifene raises the risk of venous thromboembolism and does not reduce hip fractures.
- C: Alendronate is also not recommended below a creatinine clearance of 35 mL/min.
Question 5 · Medium
Four weeks after starting vitamin D and calcium for nutritional rickets, a toddler's wrist X-ray is repeated at the paediatric OPD of a district hospital to check the response. The ALP has started to fall and the child is more active. Which radiological change is the earliest evidence that the rickets is healing?
1. AFusion of the distal radial physis
2. BA dense line of provisional calcification
3. CThickening of the shaft cortex
4. DStraightening of the bowed tibiae
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Answer: B · A dense line of provisional calcification
The first radiological sign of healing, seen within 2-4 weeks of treatment, is a dense white line of provisional calcification at the metaphysis, separated at first from the shaft by a lucent band of still uncalcified osteoid. The cupped, frayed metaphysis then fills in over the following months. Bowing corrects slowly, over months to years, and some needs surgery. Key point: Earliest X-ray sign of healing rickets: a new dense line of provisional calcification at the metaphysis within 2-4 weeks.
- A: Physeal fusion occurs only at skeletal maturity, not with healing.
- C: Cortical thickening is not the early marker of healing.
- D: Bowing corrects slowly over months and is a late sign.
Question 6 · Medium
On azathioprine 100 mg daily, tacrolimus and prednisolone after a renal transplant, a man develops recurrent gout with tophi, and the nephrologist plans to start allopurinol. What is the most important precaution?
1. AStop prednisolone first
2. BCut the azathioprine dose sharply
3. CGive allopurinol on alternate days
4. DDouble the dose of tacrolimus
Answer and explanation in LearnFree account
Question 7 · Hard
eGFR 22 mL/min/1.73 m2 (stage 4 chronic kidney disease) and a duodenal ulcer that bled last year are on record for a retired bus driver who now has an acutely hot, swollen left knee. Aspiration shows needle-shaped, negatively birefringent crystals with a negative Gram stain and no organisms on culture so far. He takes atorvastatin, and clarithromycin was started yesterday for a chest infection. No other joint is involved. Which treatment of the acute attack is most appropriate?
1. AIntra-articular corticosteroid injection
2. BIndomethacin 50 mg thrice daily
3. CColchicine at the full loading dose
4. DFebuxostat at full dose today
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Question 8 · Medium
Synovial fluid from a swollen knee: clear and pale yellow, high viscosity with a good string sign, white cells 800/mm3 with 25% neutrophils, no crystals under polarised light and a negative Gram stain. The patient is a retired cook of 70 with bony enlargement of the knee and coarse crepitus. How is this fluid best classified?
1. AHaemorrhagic, as in haemarthrosis
2. BNon-inflammatory, as in osteoarthritis
3. CInflammatory, as in rheumatoid arthritis
4. DSeptic, as in bacterial arthritis
Answer and explanation in LearnFree account
Question 9 · Hard
Creatinine 4.8 mg/dL, eGFR 14 mL/min/1.73 m2, serum calcium 7.9 mg/dL (8.8-10.8), phosphate 7.2 mg/dL (4.0-6.5), alkaline phosphatase raised and PTH 680 pg/mL (10-65): the results belong to a boy of 10 years who had posterior urethral valves operated in infancy. He now has knock knees and bone pain, and X-rays show rickets-like metaphyseal changes with subperiosteal erosions on the radial side of the middle phalanges. Alongside planning for dialysis, which treatment is most appropriate for his bone disease?
1. AOral phosphate supplements
2. BHigh-dose cholecalciferol (stoss)
3. CIntravenous bisphosphonate
4. DCalcitriol with a phosphate binder
Answer and explanation in LearnFree account
Question 10 · Hard
Ankle-brachial pressure index of 1.4 is recorded in both legs of a man with long-standing type 2 diabetes and wet gangrene of two toes of the right foot; plain X-ray shows heavily calcified tibial arteries and no gas. Once the infection is controlled, the vascular team must choose the most distal amputation level likely to heal. Which test is most useful for this decision?
1. ATranscutaneous oxygen tension (TcPO2)
2. BPlain X-ray of the foot and leg
3. CGlycated haemoglobin (HbA1c)
4. DRepeat ankle-brachial pressure index
Answer and explanation in LearnFree account
Question 11 · Medium
In the casualty at night, a labourer with diabetes has a foul-smelling, black, crepitant foot a week after a nail injury, with cellulitis spreading to mid-calf, temperature 39.5 °C, BP 86/50 mmHg after fluids and lactate 4.6 mmol/L. X-ray shows gas in the soft tissues of the foot and lower leg. After resuscitation and IV antibiotics, which operation is most appropriate?
1. AHyperbaric oxygen before any surgery
2. BPrimary closed below-knee amputation
3. COpen guillotine amputation, definitive later
4. DSyme's amputation with primary closure
Answer and explanation in LearnFree account
Question 12 · Easy
To look for rickets in a toddler, which single radiograph is most useful?
1. ALateral view of the spine
2. BPA view of the chest
3. CAP view of the wrist
4. DLateral view of the skull
Answer and explanation in LearnFree account
Question 13 · Medium
In the rheumatology clinic, patients with gout are reviewed. Under the ACR 2020 guideline, which of these have a strong indication to start urate-lowering therapy? 1. One or more subcutaneous tophi 2. A first flare, serum urate 7.8 mg/dL and normal kidneys 3. Two or more flares a year 4. Asymptomatic hyperuricaemia of 9.5 mg/dL with no flares
1. A1, 2, 3 and 4
2. B1, 2 and 3 only
3. C3 and 4 only
4. D1 and 3 only
Answer and explanation in LearnFree account
Question 14 · Medium
Serum calcium 9.4 mg/dL (8.5-10.5), phosphate 3.5 mg/dL (2.5-4.5), alkaline phosphatase 88 U/L (40-130), with normal PTH and 25-hydroxyvitamin D: these are the results of a retired clerk, aged 66, whose dorsolumbar X-ray, taken for sudden back pain after lifting a pressure cooker, shows an anterior wedge compression of D12 and generalised osteopenia. Serum protein electrophoresis is normal. What is the most likely diagnosis?
1. APrimary hyperparathyroidism
2. BPostmenopausal osteoporosis
3. COsteomalacia
4. DPaget disease of bone
Answer and explanation in LearnFree account
Question 15 · Medium
Six weeks after a transtibial amputation, a farmer is fitted with a patellar tendon bearing (PTB) prosthesis at the district rehabilitation centre. The prosthetist checks that the socket is loading the correct areas. In this socket, which structure carries the most body weight?
1. AIschial tuberosity
2. BPatellar tendon
3. CHead of the fibula
4. DDistal end of the stump
Answer and explanation in LearnFree account
Question 16 · Easy
In Syme's amputation, the foot is removed at which level?
1. ACalcaneus fused to the tibia
2. BMid-tarsal (Chopart) joint
3. CTarsometatarsal (Lisfranc) joint
4. DAnkle joint, heel pad preserved
Answer and explanation in LearnFree account
Question 17 · Medium
Serum calcium 8.2 mg/dL (8.8-10.8), phosphate 2.6 mg/dL (4.0-6.5), alkaline phosphatase 1,450 U/L (raised), PTH 210 pg/mL (10-65) and 25-hydroxyvitamin D 6 ng/mL (sufficient above 20): these are the results of an 18-month-old boy from an urban slum who is still exclusively breastfed by a mother who rarely goes outdoors. He has thickened wrists, bowed legs and delayed walking. What is the diagnosis?
1. AX-linked hypophosphataemic rickets
2. BVitamin D-dependent rickets type 1
3. CHypophosphatasia
4. DNutritional vitamin D deficiency rickets
Answer and explanation in LearnFree account
Question 18 · Medium
Knee radiographs of a retired farmer with years of activity-related knee pain are being reviewed in the orthopaedic OPD alongside those of a patient with long-standing seropositive arthritis. Which radiological finding most clearly marks the farmer's disease as osteoarthritis rather than rheumatoid arthritis?
1. AMarginal bony erosions
2. BUniform loss of joint space
3. CPeriarticular osteopenia
4. DOsteophytes with subchondral sclerosis
Answer and explanation in LearnFree account
Question 19 · Hard
Denosumab 60 mg every six months has been given for five years to a retired bank manager with postmenopausal osteoporosis. Her latest total hip T-score is -2.2, she has had no new fracture, and her renal function is normal. Because of the cost, she now wants to stop the injections altogether. What is the most appropriate advice?
1. AStop it; take calcium and vitamin D only
2. BContinue at half dose once a year
3. CStop it, but follow with zoledronic acid
4. DStop it and take a drug holiday
Answer and explanation in LearnFree account
Question 20 · Easy
Radiographs of the feet of a man with chronic tophaceous gout show punched-out juxta-articular erosions. Which feature of these erosions is typical of gout?
1. AMarginal erosions with periarticular osteopenia
2. BPencil-in-cup deformity
3. COverhanging edges with sclerotic margins
4. DChondrocalcinosis of cartilage
Answer and explanation in LearnFree account
Question 21 · Medium
Dry gangrene of the forefoot and heel has developed in a retired teacher with diabetes; the popliteal pulse is palpable and the skin of the upper calf is healthy and warm. The surgeon chooses a below-knee rather than an above-knee amputation and explains the reason to the family. What is the main functional benefit of keeping the knee?
1. ANo need for any prosthesis
2. BMuch lower energy cost of walking
3. CLess risk of phantom limb pain
4. DFaster healing of the stump wound
Answer and explanation in LearnFree account
Question 22 · Easy
Which is the most common fracture caused by osteoporosis?
1. AFemoral neck fracture
2. BDistal radius fracture
3. CVertebral compression fracture
4. DFracture of the proximal humerus
Answer and explanation in LearnFree account
Question 23 · Hard
Bowing of both legs since he began walking, short stature and recurrent dental abscesses without caries are the problems of a boy of 4 years, and his mother has similar bowing. Results: serum calcium 9.6 mg/dL (8.8-10.8), phosphate 2.1 mg/dL (4.0-6.5), alkaline phosphatase raised, PTH normal, 25-hydroxyvitamin D normal, 1,25-dihydroxyvitamin D inappropriately normal and tubular reabsorption of phosphate low. A stoss dose of vitamin D given last year made no difference. What is the underlying mechanism?
1. ADeficient dietary vitamin D intake
2. BLoss of renal 1-alpha-hydroxylase
3. CMutation of the vitamin D receptor
4. DPHEX mutation raising FGF23 levels
Answer and explanation in LearnFree account
Question 24 · Medium
Knee pain on climbing stairs for two years, a BMI of 32 kg/m2, crepitus and early medial joint space narrowing on X-ray: a homemaker from Thrissur asks what will help her most before injections or surgery are considered. Her blood sugar and renal function are normal. Which first-line measure has the best evidence?
1. AWeight loss with quadriceps strengthening
2. BArthroscopic lavage and debridement
3. CMonthly intra-articular steroid injections
4. DOral glucosamine with chondroitin
Answer and explanation in LearnFree account
Question 25 · Easy
Hard, bony, painless swellings at the distal interphalangeal joints of several fingers are seen in a woman with osteoarthritis of the hands. What are these swellings called?
1. ABouchard nodes
2. BGouty tophi
3. CHeberden nodes
4. DRheumatoid nodules
Answer and explanation in LearnFree account

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Metabolic bone disease, arthritis and amputations

On the second day after a below-knee amputation for diabetic gangrene, the physiotherapist finds the patient lying with a pillow under his knee because it eases the stump pain. She removes it and explains why. Which complication is this position most likely to cause?

On azathioprine 100 mg daily, tacrolimus and prednisolone after a renal transplant, a man develops recurrent gout with tophi, and the nephrologist plans to start allopurinol. What is the most important precaution?

To look for rickets in a toddler, which single radiograph is most useful?

Six weeks after a transtibial amputation, a farmer is fitted with a patellar tendon bearing (PTB) prosthesis at the district rehabilitation centre. The prosthetist checks that the socket is loading the correct areas. In this socket, which structure carries the most body weight?

In Syme's amputation, the foot is removed at which level?

Radiographs of the feet of a man with chronic tophaceous gout show punched-out juxta-articular erosions. Which feature of these erosions is typical of gout?

Which is the most common fracture caused by osteoporosis?

Hard, bony, painless swellings at the distal interphalangeal joints of several fingers are seen in a woman with osteoarthritis of the hands. What are these swellings called?