2016 – RW

RW – 2016 – FRCS Tr & Orth Experience

Intermediate Cases

2 x 15 minute stations. A different pair of examiners for each. A short break after each patient. This was held in the outpatient department on a Sunday. The fact that it was in this setting was very settling and made if feel like you were just seeing another patient in clinic. That is certainly the approach I would advise taking in all of the clinical stations – think of them as a new patient assessment in clinic.

Upper Limb Intermediate Case

History: 68yr gentleman. 3 months post fall landing heavily on his right shoulder. All problems stemmed from that event. Sustained a proximal humeral fracture dislocation and wrist drop(!). Since then had been having problems with the shoulder – pain and stiffness – and the wrist drop. Single thing he wanted dealing with was the wrist drop as this was debilitating. Otherwise reasonably fit and well. Retired engineer.  7 or 8

Examination: This was very challenging and I did not do it well. Was given very little prompting from the examiners. With the wrist drop and proximal humeral fracture (something I had never come across before) I felt I had to examine his shoulder function first to then enable me to examine his plexus to try and work out where the level of the lesion was. Then I could focus on the peripheral nurse. Suffice to say that I found it difficult to get all of this in in 5 minutes. I did not look slick. I was able to work out that he had clearly had a massive cuff tear and also had a distal posterior cord lesion (effectively just a very high radial nerve palsy). ?5

Discussion: Did not have a lot of time left for this but some had been done during the examination. Clarified my diagnosis and the reasoning behind it. Discussed the management of the radial nerve palsy. Principles of tendon transfer. Final question was which movements one should aim to restore and which tendon transfers to do. 

Overall: History went well. During the examination, I think I was able to elicit all of the relevant signs and broadly work out what was going on but I really did not feel as though it had gone well. There was just too much to do. The discussion was pretty brief and superficial and I was able to talk reasonably sensibly about tendon transfers. Maybe scraped a 6 overall? Maybe a 5…

Lower Limb Intermediate Case

History: 27yr lady from West Africa. Longstanding problems with her right hip since she was 10years old. Probable TB of the hip treated medically in Africa (drug which made her urine go orange). Previous had a (now healed) sinus over right buttock. 2-3 years of increasing pain in the right hip and difficulty walking due to pain and limp. 7 or 8. Don’t think I missed anything in this one.

Examination: Started with Gait. Lots to comment on. Leg clearly very short. Foot in plantigrade ++ to compensate with hip and knee flexion on contralateral side and vaulting get to allow other leg to come through. Commented on healed sinus. Supine was able to show large LLD (offered to formally measure but they moved me very quickly on). Did Galleazi test and demonstrated Bryant’s triangle to conclude that it was a predominately supra-trochanteric LLD. Thomas test – fixed flexion ++. Again 7 or 8 – pretty much nailed it.

Discussion: Which investigations to do. Started simply and worked up. Talked a bit about how to look for TB. CXR etc. Heaf/Mantoux testing. Then got onto imaging. Was relieved when the plain radiographs (very poor, printed on paper) showed exactly what I had concluded from the examination. Got on to additional imaging to assess bony anatomy with CT and then quite a full discussion of some of the operative challenges with this case – structured it as patient-related, soft tissues, bony. Probably a 7  but did not know any relevant literature (although did not really get asked to use any to support my discussion). This just felt like an adult discussion between 2 colleagues, such as one might have in the coffee room in theatres.

Overall: I felt at the time like I had nailed this one. Who knows! Hopefully I got some 7s for this. Don’t know how to get an 8 for history but I really was confident I had left no stone unturned and had a good rapport from the off.

Short Cases

These were in blocks of 3 x upper limb cases, one after the next. Then a short break and quick move and 3 x lower limb cases. Each one is 5 minutes only. You have NO TIME to faff about. It is very rapid fire and you will get cut off the moment the bell rings (although the lower limb question asked me one final question in each as we moved to the next patient). There are 2 examiners for each block and you have the same 2 for all upper limb and a different 2 for all lower limb.  Just one of them took me through all of the cases in lower limb but they alternated in the upper limb (I think it is up to them how they do it).

Upper Limb Short Cases

  1. 27yr chap with stiff elbow. “Examine this man’s elbow”. Lots of scars – lateral Kocher type incision extended proximally and every arthroscopy portal in the book. Stiff elbow with ROM from 15-80deg. Asked to try and work out from that what had happened. Got lucky and guessed capitellum fracture quite early in my differential and said it was most likely. Got it right. Went through X-rays. Asked for the classification (forgot it) and complications. Talked about AVN and blood supply and was shown current x-ray with evidence of AVN. That was it. Covered a lot of ground. 6 or 7
  2. Mid 40s chap. “Examine this man’s shoulder”. Barn door rotator cuff tear. Clear signs. Reasonably slick and focussed examination. Only one test for each muscle. Told them what I thought. Asked to see US or MRI. Got shown some terrible US images. Told them I did not have a clue what I was looking at so they showed me a coronal MRI slice showing a supraspinatus full thickness tear. Got onto discussion about management options. Could have gone deeper and had a couple of papers ready to quote but no time. 6 or 7
  3. Gentleman in his late 60s. “Examine his left hand”. Generalised OA with small joint deformity and nodes. Also had chronic dislocation of the PIPJ of the left little finger. Described all of the findings. Then asked specifically about the little finger. Asked to see the Xrays. Discussed the management. Talked about optimal positions of fusion. Comfortable 6 or 7.

Overall, I was struck by how simple the second and third cases were. The first case could have been more complicated but I hit the nail on the head first time and got lucky. I could have wasted a lot of time going round a differential that did not include capitellum fracture. I overheard a couple of other candidates moaning about that case. This made me feel better and that I had done relatively well in this case.

Lower Limb Short Cases

  1. Late 40s woman. “Examine this lady’s feet”. Got a bit mislead on this. Because of that specific instruction I went straight for her bunions. She also had flat feet and tib post dysfunction bilaterally (stage 2). They let me talk about her bunions but got me to examine her tib post. Meant that I lost a bit of flow. Straightforward discussion about tib post and management of different stages. Solid and uninspiring 6.
  2. Late 50s gentleman. In wheelchair. “Look at his feet. Do you know the spot diagnosis?”. I said “I think so but can I ask a couple of questions and tell you in 20 seconds? They said “fine”. Then I asked about family history and commented on his handshake and said HSMN. Got asked about HSMN, genetics and classification. He had very deformed feet which were not your typical cavo-varus feet but they asked me to describe what the feet would typically be like and the problems which can develop. Demonstrated Coleman block test on examiner and explained it. I also noticed his calloused knees and scar on the front of knee. They asked what I thought was going on and I correctly surmised that he “walked” on his knees and might have had a chronic bursa excised. Got it right (patient was nodding along and smiling). Clear 6.
  3. Mid to late 40s chap. “You have one minute ONLY to take a history”. Got it pretty quickly. Delayed presentation of Achilles rupture. Missed diagnosis by GP. Presented at 3 months to orthopaedics. Needed less than a minute. Before they prompted me I started examining him prone and was able to demonstrate Simmonds test and obvious gap in tendon. High level discussion with Examiner over management options. Examiner then asked me to explain it all to patient and see which he wanted and check understanding of rehab etc… Strongly wanted operative management which is the option I had gone for in my discussion. Also able to quote a lot of papers (having ruptured my own TA I feel as know this subject well – came up again in trauma viva!). Nailed this one. Patient, examiners and me all smiling at the end. 7 (?or 8?).

All feet! Really glad I had had a good foot firm and felt confident with them. Also glad I remembered something about basic sciences for HSMN. Examiner was very nice. Again, all pretty straightforward and stuff that you could see in a foot or fracture clinic.

Summary of clinicals

Overall, I enjoyed the clinicals. I felt like I was seeing people in clinic and the short cases were good fun and like a “who-dunnit” of mostly spot diagnoses. I kept everything very simple and listened very closely to prompts from the examiners and just did what they said. There is such little time that if you are going off-piste then I felt like you would be dragged back on track pretty quickly.

I felt very down after the upper limb inter case as this had been very complex and I felt that I had not nailed the examination. In retrospect, discussing it with the others, I got to the diagnosis and was able to make some sensible suggestions. Everyone says it but it is really important to move on when you have had a bad station and just forget about it!