FRCS Experience Chesterfield Feb 2015 – BA

You’ll be getting a summary of all the cases that we got asked. However the focus of my write up would be a bit different. So here goes:

  1. You’ve been doing the job for the 5 years before your exam but there’s still an awful lot that you don’t know. But you will know them, just before the exam, and you will be astonished at how you’ve managed to amass so much information in such a short time duration; and also how quickly you start to forget!
  1. Having said the above, time spent as a registrar prior to the exam will stand you in good stead during those difficult scenarios.
  1. It is true that, in the main, your performance would not have been as bad as you thought. If it were as bad, most of us wouldn’t pass on our first attempt. Therefore, no matter how badly you thought you did, it is crucial that you forget about it as you move on to the next station. I thought I’d screwed up my intermediates and I made a mental note to smash the short cases – and I did (at least to my mind). Interestingly, days later, after the stress response of the exam had dissipated, I reflected on my intermediates again and I did not think that I did that badly at all. But at the time, I did! So if you’re the nervous type, now is the time to start to work on relaxation techniques to help you through what is a potentially stressful exam.
  1. Weekly teaching does not prepare you for the exam. This has been consistently noted by every generation of exam takers. So the question is – what would be the ideal weekly teaching session? Here’s my take – hot seat involving a clinical exam and viva style session; and all those other things that we get taught as well.
  1. I personally did not find Orth North of much use if I’m being honest. Mostly because the direction you’ll be led down varies hugely from one person to another. Perhaps its usefulness lies in making you aware of the width of knowledge you ought to possess. But you already knew that!
  1. While it is true that you can lead the examiners down a particular path, this isn’t always the case. I got asked about post-op confusion. Because of Sim’s experience last year, I’d prepared for SIADH. Trying to lead the examiner down that route, he wasn’t buying it and instead pushed me towards what he really wanted to hear – fat embolism!
  1. Speak like a 1st day consultant. Put yourself in the mind frame that you are a 1st day consultant. It will reflect in your answers, your tone, and your body language. It will make you believable! When I got asked about what I would do for a Gartland 3 supracondylar fracture with a palpable pulse who wouldn’t be fit for surgery until 2am, I maintained that I would take him/her to theatre anyway. I did add that as a new consultant, I would not be able to sleep at night, as it was a potentially limb threatening injury!
  1. Aim for 7’s because you might get some 5’ It’s a shame that candidates who pass don’t get feedback, otherwise we would have been able to advise you all better. Aim for 7’s but answer the question. Don’t confabulate. I’m not certain that quoting a paper would take you from a 5 to a 6, but it should take you from a 6 to a 7 (ceteris paribus – check that one out :-)). If you know the answer to a question, go to town on it. Smash it! Blow it apart! You might just score an 8.
  1. You must know your trauma! That’s the one area that we’re all exposed to. And it’s a relatively easy area to score top marks in! The tendency is to neglect trauma because you think that you know it so well. A week to the exams, just go through the trauma sections. Does anyone know what OOPWAC means? Exactly! That’s a trauma mnemonic for you right there!
  1. Most of the examiners are friendly, especially if you’re saying sensible stuff. And they’re trying to help. Listen to the cues. Don’t argue. I told my basic sciences examiner that peroneus longus was responsible for plantar flexion of the 1st ray. He clearly didn’t know that. So I stuck with eversion!
  1. When you are faced with a question that you do not know, do not go silent. Revert to 1st principles. Sometimes you might just need to blag your way through. For my fat embolism scenario for instance, I was given a photo of a brain specimen with microangiopathic emboli. I’d never seen it before but I just said what I thought it looked like. In my paeds section, when asked what the rate of AVN after osteotomy for chronic SCFE was, I just said 44%. The examiner said 24%. Big deal – I was doing well anyway! Don’t say anything stupid, but don’t go totally silent either. Blag a bit. Rely on your experience of having been a registrar for 5 years prior, meaning that you’ve picked up loads of random facts that lie hidden away in your subconscious. Plus when you say things confidently, sometimes they’ll believe you!

Now on to my questions:

Upper Limb Intermediate

Woman with bilateral painful wrists. Right was fused, left had wrist replacement. As I progressed in my history taking, it was obvious that it was the right that was the problem. Wrist fusion secondary to multiple fractures secondary to osteogenesis imperfecta. I wasn’t too happy with this station. I sort of muddled my way through and I thought that I’d done badly. Management revolved around causes of painful fusion (she’d had a secondary procedure – ulna head replacement as well, ruling out DRUJ OA), of which I couldn’t think of many. Examiner led me down to position of fusion which I didn’t actually actively check for. Just mentioned that when I checked her wrist movements, it looked like she was in neutral dorsiflexion, which isn’t ideal. Then we spoke a bit about OI. Bell rang.

This one worried me. It was my 1st case. I was the 1st candidate to see the lady. I thought I’d messed it up but I had to forget about it as I moved on to the next case. On reflection however, I realised that I’d gone through the motion anyway – history of pain/function/expectation; examination of movements/sensibility/hand function; some discussion. So even though I thought I messed up, I probably did just ok.

Lower Limb Intermediate

Middle aged man with injury to knee 7 years previously. Knee dislocation with vascular injury requiring grafting. Also had a skin graft to his lower leg. Had multi-ligament reconstruction as well. This was a real tricky one. The chap was asymptomatic and had returned to heavy duty work. My 1st question was “so how did this happen?” And he goes, “I dislocated my knee when I had an accident.” I assumed that it was an RTA. Imagine my horror when I was later asked during my examination of the knee which ligaments I would expect to have been damaged. So I said, “following an RTA, I would expect the PCL…” I got stopped. The examiner said, “I don’t think he’s had an RTA.” Candidate turned to me with a victorious smile, “no, I jumped off a wall.” Shit! When I asked him about his skin graft, he told me that he had sustained a compound injury. I took this to mean compound fracture and I checked with him, to which he said yes. Imagine my 2nd horror, when examiner asked me why I thought he had the graft. I was going down the open tibial fracture route when I was stopped. Examiner said, “hmm… he didn’t have a fracture. What else could it be?” So I said, possibly fasciotomy following arterial injury repair. Which it was.

Overall this candidate was a poor historian. Right from my 2nd question, he was asking the examiners what he was expected to answer. So I took charge of the station – asking a lot of closed questions, because I felt that otherwise, I wouldn’t get anywhere with this guy. I got asked a lot about what I would do in A&E, investigations, principles of dealing with the vascular injury (shunt, ex-fix, repair), etc. Despite my gaffes I actually was enjoying myself with this station, until my inaccurate history taking was pointed out of course, at which point I became quite dampened.

Upper Limb short cases

I got the same cases as Warwick, so won’t go over them. This one went really well. There was a lot of nodding, smiling, and 1 or 2 gasps of delight from the observer, who made a point of offering me an enthusiastic handshake at the end of it all!

Lower Limb short cases

This went really well. 1st case was a kid with a hypoplastic and subletting patella. For some reason I asked to look at his nail. Diagnosed nail patella syndrome (without prompting), and I saw the examiner smile – one of those rare moments when I come out with a piece of impressive knowledge. 2nd case was hallux valgus. Pretty straightforward. When asked about treatment, patient said she had no pain but could only wear trainers. Offered surgery with caution (she’d had the other side done and she was delighted with it). 3rd case was a young girl who’d had a deep peroneal nerve injury. Asked to test sensation for DPN; also asked to check power of Tib. Ant; patient had had a Tib. Post. transfer which I mentioned when asked about the scars. This led on to discussion about the principles of tendon transfer. Was asked about splinting and whether I would choose a soft or hard splint. Went with soft because of risk of pressure ulcers with an insensate skin. Examiner seemed pleased.

My short cases went really well. I thought I’d made up some 7’s here. They are more haphazard, and therefore should feel more comfortable. There’s no real need to be systematic. It’s often a spot diagnosis sort of thing. And for some reason, the 5 mins felt just about right.


Adult Path:

Almost the same as Warwick. Photo of child with erythema of foot/ankle – differentiate between septic arthritis and osteomyelitis; woman with HO after non union radial neck fracture; presenting with radial nerve palsy; post-op confusion – leading to discussion about fat embolism; AVN of the proximal humerus and femoral head, leading to discussion of pathophysiology, Ficat classification and treatment; Cauda equina syndrome; lesion in proximal humerus with shoulder impingement – lesion was enchondroma; in discussion of impingement I was asked to describe the Hawkin’s test.

Viva went well. I was happy.


40 year old with displaced, intracapsular NOF; knee dislocation; elderly rheumatoid patient with unreconstructable distal humerus fracture (discussed bag of bones treatment / elbow replacement); off ended supracondylar fracture; talar neck fracture with subtalar dislocation; forearm segmental ulna and proximal radius fractures – discussed initial ex-fix – was asked for location of pins which led me to mention that no definite safe area in humerus; and then definitive management – rigid fixation.

Viva went well. I was happy.

Paeds and Hands:

Clubfoot deformity; Chronic SCFE; Xray of ulna – shortened, bowed, sloping physis, exostosis; told he had another similar swollen on the knee; discussed MHE.

Hands – transscaphoid perilunate dislocation; trigger thumb in a 1 year old (asked to draw the pulleys in the thumb); PIPJ fracture dislocation (got showed photo of suzuki frame; said I knew what it was but had never seen it used).

Viva went well. I was happy.

Basic Sciences:

Photo of antero-medial knee OA; Definition of OA; what happens at the molecular level? Clinical deformity; which ligaments affected? 2nd question – polyethylene cup with polar and edge wear; discussed types of wear; asked about osteolysis; 3rd question – components of TKR; what’s femoral component made of? Discuss machining of cobalt chrome (forge casting, annealing, polishing, sterilisation); what’s tibial component made of (titanium)? How is its machining different from that of cobalt chrome (did not know)… led examiner to discussing polyethylene production and sterilisation which I knew.

This half of the basic sciences didn’t go too well. The examiner was being very poker faced, sometimes a bit snappy and I felt that the answers were being dragged out of me a little bit. I must have looked flustered because the 2nd examiner asked me to take a moment before he started to ask me his own questions.

2nd half – photo of foot and ankle; picked on peroneus longus; origin, insertion, retinaculi, actions, injury to, etc; 2nd question – lag screw, easy!; 3rd question – cross section of tibia leading to discussion about compartment syndrome; wanted to know why sensation goes before paralysis – explained because fibres carrying sensation were more sensitive to increased pressure.

This half went well. I was happy.

So there you have it. All the best.