FRCS Experience Chesterfield Feb 2015 – LB
“You’ll be fine”
I don’t want to repeat what others have said, but preparation really is a personal thing. I would recommend a study group for the vivas/clinicals, even if only for the 3-4 weeks before. If you get easily stressed (like me!) then try to keep things in perspective – it is a horrible time, and friends and family will suffer, but it really isn’t the end of the world if you fail, it would just mean prolonging the misery for another few months…oh, and costing another £1300. Surprisingly, one of the most reassuring things that I was reminded was that if you fail you won’t be the first person to fail, and you certainly won’t be the last person, you will get there in the end, it’s just a matter of when. When you’re a consultant no one will care whether you passed the first time or the fourth… although it’s always nice to pass first time! You will have been through 4 or 5 years of a recognised training rotation before the exam, many of the other candidates will not have – and this really does make a difference. As someone kept reminding me, ‘the odds are in your favour’.
Even if it’s a long time since you properly revised for something, by this stage in life you should know what methods work best for you. Bola’s ‘long game/short game’ theory definitely holds true, and you’ll know which one you are! My ‘short game’ revision method will certainly not work for everyone, and although it got me through I shouldn’t really recommend starting revision in September for the November MCQs! Having said that, definitely choose your own tactics and ignore everyone who tells you that you have to have read Miller x number of times, and been through all the orthobullets questions at least once. I did neither of these (in the case of Miller, x was <1) and still managed to score very comfortably over the pass mark in the MCQs.
People will tell you ad nauseam that the clinicals and vivas are all about being safe and sensible and appearing like a day one consultant… you probably will not believe this until you go through the exam yourself, but it is true. Whilst I found the clinicals far from ‘a normal day in clinic’, the questioning and answers where really quite straightforward and the examiners were just looking for a sensible approach to things rather than knowledge of minutiae. Vivas really are about technique, you can pass or fail with what you say in the first few sentences of your answer, so stick to key principles and being safe, the examiners will then push you to try to get the higher marks, until eventually you may have to say “I don’t know”. Practising with people who have been through the exam, fellow examinees in a study group, and attending viva courses really does help by letting you see how others approach questions, and allows you to think about and prepare answers for common questions.
Now to relive my exam…
Lower Limb Intermediate
58yr old man with foot deformity following corrective surgery 1 year ago. Born with spina bifida but able to function well and work until about 10 years ago when diagnosed with diastematomyelia. Two spinal operations but residual weakness and deformity of both feet, right > left. Corrective surgery on right foot one year ago but now recurring cavovarus with lesser toe clawing. Examination – Asked to examine foot only. Looked at footwear, gait etc. mostly inspection of foot noting deformities, scars from previous surgery/tendon transfers etc. No blocks available for Coleman block test, but mentioned I would normally do it and why. No imaging available. Discussed conservative v operative management of deformity. Management if evidence of degenerative change in ankle, methods of fusion and success rates. Asked what tendon transfer I thought he’d had… bell rang.
Not an easy case, the patient was a poor historian, and checked with the examiners what he could and couldn’t tell me. It was difficult to work out how much history I should take of the spinal problems, or whether to focus solely on the foot & ankle. Also, there were only chairs available for the patient and his wife, I had to take the history standing in front of him (not ideal for communication skills marks!), and examination was in a very enclosed space with not much room for walking, and no couch! I didn’t think this was a great start, but as everyone advises, I put it to the back of my mind and moved on to the next one…
Upper Limb Intermediate
73yr old man with bilateral thumb CMCJ OA and previous wrist replacement on right. Reasonably straighforward history, paying particular attention to hand function and treatments so far (he managed to divulge that he was going to have surgery on his right thumb the following week to remove a bone!). Routine examination of hands and wrists, assessment of different types of grip (unable to test all but told examiners which ones I would like to test). Radiograph showing thumb CMCJ OA, DRUJ and radiocarpal OA. Discussed conservative management of thumb – splints, analgesia, injection, asked where would inject and whether would do it in clinic or under II in theatre – said my usual practice is to do it in clinic. Discussed operative management of DRUJ OA (Darrach’s, Sauve-Kapandji, ulnar head replacement) and then radiocarpal OA – PRC, fusion, wrist replacement.
I felt that this case was much better than the previous one. They were conditions I was more familiar with and had managed and discussed many times before in clinics. I think that the only part of this case in which I specifically had to use my exam revision was mentioning the problems with ulnar head replacement – all else came from my clinical experience over the past few years.
Lower Limb Short Cases
- 15yr old boy (same as Warwick’s 2nd case)– asked to look at his gait and comment (spastic gait with ankle equinus and flexed knee). Asked what thought diagnosis was (CP), and what type. Asked to examine for FFD of hip – demonstrated Thomas’ test but mentioned that if FFD of knee (as he had) will give false positive so would normally examine with leg off edge of bed (unable to do due to set up in examination room). Asked to do Silfverskiöld’s test and explain findings. Asked to comment on scars on right leg and what operations he may have had (femoral osteotomy).
- 9yr old girl (same as Warwick’s 3rd case) – asked to assess her walking/knees. Valgus and slight hyperextension. Asked her to get onto couch (fortunately she didn’t lie down but sat on the edge, keen to demonstrate her J sign – which thankfully helped me!). Demonstrated bilateral J sign. Supine demonstrated patellar tilt and M-L translation. Beighton score. Assess femoral neck anteversion. Discussed causes of patellofemoral maltracking and brief mention of sitting in ‘W’ position due to increased anteversion.
- 30yr old male examiners asked me to ask him some questions – pain in left hip (he pointed more towards AIIS), worse on playing sports. Differential diagnosis – rectus femoris strain/avulsion, labral tear, FAI. Examine for impingement (FAIR). Radiograph showing protrusio and asphericity of head/neck junction. Asked to show ilioischial and iliopectineal lines, anterior and posterior walls of acetabulum (cross-over). Asked what type of impingement I though he had (said mixed pincer and cam).
I felt that these three cases all went OK, and were much better than the lower limb intermediate. There really isn’t much time in each 5 minute slot so the examiners really directed what they wanted you to look for.
Upper Limb Short Cases
- 10yr old girl. Asked to examine upper limbs. Left cubitus valgus with scars medially and laterally over elbow. No functional or neurological deficit. Possible causes – lateral condyle or supracondylar fracture. XR showing malunited supracondylar. Possible complications of cubitus valgus – tardy ulnar nerve palsy – management options.
- 50yr old man (think this was the same as Warwick’s 2nd case, but there were a few similar ones around!). Examine upper limbs – abnormal biceps contour on right. Speeds test. Show why LHB and not distal biceps: Hook test. Management options – non-op. What if he demands surgery because it’s painful ?tenodesis. Where would you make incision.
- 70yr old woman. I can’t remember this one very clearly as I think I’ve blocked it out. Asked to examine upper limbs. Nothing obvious initially so went through look, feel, move. Eventually ascertained she’d had a proximal humeral fracture several months ago which had caused a high median nerve palsy which was gradually recovering.
These did not go as well as the previous short cases. I didn’t like the ‘examine this patient’s upper limbs’ – not particularly helpful when you’re stressed and know you only have a few minutes to find the problem. Having said that, the examiners did help out by asking more direct questions when I floundered with the third case!
- Picture of resected proximal tibia – same as Bola and Warwick and pretty much the same questions.
- Photograph of foot prosection – identify some structures so we know that you can orientate where you are. Peroneus longus – origin & insertion, retinaculae, problems if cut tendon.
- Cross-section of leg – label compartments and contents. What is compartment syndrome, where to make fasciotomy incisions and what is decompressed with each.
- Lag-screw – principles, how to do, which fractures would you use it in? Why do you countersink?
- Polyethylene acetabulum cup with wear – definition and modes of wear. Osteolysis and mechanism (cytokines, macrophages etc).
- What is a knee replacement made of? What is the role of the chromium? How is poyethylene made? Is it the same poly we were using 20 years ago (wasn’t sure but said it was now high molecular weight and may be highly cross-linked), how does it cross-link. Sterilisation of poly.
- Shoulder Xray with lesion in metaphysis also has impingement. Kept trying to distract me by asking what I was going to do about the impingement! Went through ‘bone lesion’ answer (Radiologist/MDT/tumour unit if not sure).
- 30yr old with back pain and neurological deficit. Rule out cauda equina – what to look for in particular. When would you decompress. Approach for decompression.
- XR of pelvis of 40yr old man. No abnormality on XR. Has pain, previously on steroids – ?AVN – MRI. Ficat. Causes of AVN. Management of patient at this stage. How to do core decompression. Management options if grade 3 – I would do THR, asked for other options: mentioned trapdoor, vascularised graft, osteotomy (with a lot of prompting) but preference would be for THR with ceramic on poly.
- Child’s foot/ankle with cellulitis – same as Warwick’s questions
- 70yr old following fall onto elbow months ago and now sudden wrist drop – same as Warwick’s but without describing the course of the radial nerve! Excision of HO and prophylaxis against recurrence – what would you use?
- Elderly woman post-op THR with confusion – initial management (ABC, bloods, ABG etc.) likely causes. Pathology section of brain – emboli. Causes – cementing/ fat embolism, thromboembolism. Management if has haemorrhagic stroke and a DVT – anticoagulation contraindicated, discuss with haematology and possibly insert an IVC filter.
- Supracondylar fracture (Gartland 3 as always!). Neurovascular structures at risk and how to assess. Management if patient comes in at 8pm – said would take to theatre ASAP. How to reduce and method of fixation. Patient reviewed 2 weeks post op and has numbness in ulnar nerve distribution – remove wire and observe. Most are neurapraxia. If not then refer to PNI unit.
- Talar neck fracture with subtalar dislocation and talus rotated in mortise therefore said it was a Hawkins 3. Immediate management. Complications. Method of fixation (went for double plating but think they wanted screws), medial malleolar osteotomy for approach, and why. Hawkins sign and its significance.
- Young displaced intracapsular NoF. What are you worried about? What’s your management. What are you going to do to reduce it? Approach if need to do open reduction – pretty much the same questions and answers as Warwick!
- Knee dislocation with no pulse – management. ATLS, contact vascular, priority to restore blood supply then stabilise knee, ex fix.
- Segmental ulna and radius fractures fixed elsewhere – non-union of ulna. Reasons for non-union. Management options for non-union: non-op (Ultrasound – asked if knew NICE guidance on this – I didn’t!), operative – revise +/- graft.
- Comminuted distal humerus fracture in 70yr old lady with rheumatoid arthritis. Management options – bag of bones, ORIF, elbow replacement. Went for non-op due to rheumatoid, and option to replace elbow later if symptomatic.
Hands & Paeds
- CTEV clinical photograph. What else would you examine newborn for. What is CTEV? Risk factors. Management – Ponsetti and rationale behind it, order of correction. How long in boots and bar after casting?
- XR of SUFE in 12yr old boy. Things to ask for on history. Classification – Loder paper and rates of AVN, asked if I believed evidence where they report 0% complications! Other classifications/grades – this is severe slip as >50%. Any angles? Southwick angle but only on lateral so cannot use in this case. Why not do lateral XR in this case? Management – severe unstable slip present >24hrs: discuss with paeds, traction 2-3weeks then neck osteotomy and screw fixation. Asked if knew different types of osteotomies and their function – mentioned different levels of osteotomy and risk of AVN with more proximal ones and aim to correct deformity.
- Forearm XR with short bowed ulna with exostosis. Told there is also a lump on the knee – likely MHE. Got confused with multiple enchondromas (D’Oh) and they asked me about Ollier’s and Mafucci’s – corrected my mistake, apologised and went back to MHE. Asked about risk of malignant change and how to monitor (size of cartilage cap on MRI)
- Transscaphoid perilunate dislocation. Disruption of Gilula’s lines, greater arc injury. Risk of acute carpal tunnel. Asked what I would tell my registrar to do in the middle of the night – reduce dislocation (asked to demonstrate method on examiner’s wrist!) and decompress carpal tunnel if median nerve symptoms. Approach for open reduction (said dorsal as easier, more familiar with, and can repair ligaments, even if making palmar incision for carpal tunnel).
- Small finger PIPJ fracture dislocation. Management – conservative with extension block splint. Operative – wanted an exhaustive list, eventually I said ex fix which was what he was waiting for! Likely longterm outcome.
- Trigger thumb in a 1yr old – when to release. Draw pulleys in fingers and thumb. How to release A1 pulley.
Overall I wasn’t very happy with any of the vivas at the time, although I tried to stay calm I think my stress levels were evident and I thought that I didn’t answer questions as well as I had in previous mock vivas (understandable I suppose!). I felt that I said ‘um’ more than anything else, and there were more than a few instances of ‘I don’t know’. However, with retrospect when I thought about the level of questioning I had got to in many of the vivas e.g. osteotomies for SUFE I thought that maybe I had just done enough to get through… fortunately I was right!!
Lynne Barr FRCS (Tr & Orth)