FRCS Experience Chesterfield Feb 2015 – WC
Intermediate case lower limb
Downs syndrome with dislocated hip. Parents were also present.
History included multiple operations to left hip in past. No significant pain. Mild reduction in function. Examined, obvious shoe raise, LLD. Multiple scars. Stated obvious Downs syndrome. First case and nervous so forgot to do trendelenberg after gait assessment! Managed to sneak it in at the end. Offered to use blocks but examiners said move on. Thomas/Bryant triangle difficult/Galeazzi. No pain, full ROM. Obvious LLD Said I thought it was at the hip possibly dislocated. Examiners asked why if she had had multiple operations and what could she have had. Possible derotation osteotomies. No pelvic scars so unlikely pelvic osteotomy. Then showed x ray dislocated hip with false acetabulum and multiple metalwork in proximal femur. Asked what other orthopaedic manifestations of Downs and then what would I do with the patient now. Said patient pain free with good function so nothing. Pushed to give a surgical option if I had to. Briefly mentioned options for lax hip including fusion if painful and bell went!!!
Intermediate Upper limb
Young girl with MHE. Examiners more friendly (one of them I recognized from a course). History taken, multiple operations to remove lumps. Knew it was MHE so asked about family history. Asked to examine upper limb, specifically wrist. Swelling at wrist with mild pain no functional limitation. Some pins and needles over ulnar border. Asked what could cause ulnar nerve symptoms, said lesions affecting Guyon/Cubital tunnel and C8/T1. They asked me what could cause the C8/T1 and I said possibility of rib osteochondromas. How to differentiate Guyon (normal dorsal sensory branch). Shown x ray. OC distal ulna. Asked what I would do. MRI and if nerve symptoms worsen excise. Talked about genetics of MHE, EXT1/2/3, etc. Monitor especially pelvis.
Upper limb Shorts. Same 2 examiners take you to all 3 cases. 5 mins each.
- Child with contractures to elbows. Asked to target exam to elbows. Smooth skin with no skin wrinkles. 2 previous anterior surgical scars. 30 degree painfree range of movement. Quick history present since birth. Full pronation and supination, no obvious radial head dislocation. Said I thought it was arthrogryposis. Asked why and offered 2 joint contractures with no skin wrinkles since birth. Asked how many types of arthrogryposis there are. Asked about management as patient cannot do hygiene. Said that previous surgery did not work and is unlikely to work further. Said that he was painfree with relatively good function so would not do anything. Pushed for a surgical option and offered osteotomy as soft tissue unlikely to work (especially as previous soft tissue surgery not worked).
- Middle aged man with cuff tears. Obvious LHB. Asked to just examine cuff. Positive gerbers and speeds. Said it was LHB and subscap. Examiner asked why not distal biceps. Did hook test, supination etc. Brief chat about management.
- Asked to examine quickly. Described shortening of radial sided fingers. Also appeared to have had trapeziectomy on one side. Did a lot of describing , didn’t really know what they wanted so stuck to look, feel, move and quick functional assessment. Examined for either short or absent phalanges, difficult but decided they were short rather than absent. Asked what it was. Brachydactyly. Could I classify. I said no for brachydactyly but mentioned swansons classification. Asked what questions I would ask. Didn’t know too much about brachydactyly but said it was related to some syndromes. Couldn’t remember the syndromes under pressure so said I didn’t know. Thought as radial sided would rule out VACTERL/Holt oram/Fanconi anaemia despite knowing they were more syndromes for radial clubhand rather than Brachydactyly.
Lower limb shorts
- Teenager with HSMN and pes planus. Asked to examine feet. Described bilateral appearances of lower limb, pes planus, muscle definition etc. Said it looked like a form of muscular dystrophy. Lots of scars from previous surgery. Looked at footwear/gait etc. Double and single stance raise. Sensation and motor function. Jack test. Felt for pain. Tib post exam etc. Asked what I thought it was. Said as bilateral likely to be HSMN/CMT but usually more common for cavovarus. Asked what I thought about scars, said likely tendon transfers. Unlikely to have had fusion as flexible hindfoot. As we walked into the next clinic room with the examiner he was still asking about management. Think he was nice and trying to get me to score more points outside of the bell!!!
- Child with CP. Asked to observe gait. Described the usual gait pattern, footwear etc. Then got asked to assess tightening. Very little examination with this patient, maybe he was uncomfortable. Had a mini viva on CP instead, definition/classification/ principles of management etc.
- Another child! Not obvious pathology as I walked into the room. Asked to examine knees, instantly thought patella. Observed. Asked if any trauma. Mum said no. Asked child what to point to the problem and she pointed straight to both patellae. Knew it was instability. Commented on valgus nature/gait. Demonstrated J sign, examined extensor mechanism and then did rotational profile and quick beighton. Examiner asked what cause was, said it was not femoral anteversion/external tibial torsion from profile but beighton score 9. Would like imaging of PTFJ for alta and trochlear dysplasia. Discussed management principles and bell went.
Overall didn’t feel great about clinicals. Thought half went well and half went badly. Decided to just relax afterwards and took on advice of multiple pple. Forget and move on! Thought I needed to nail the vivas the next day to pass which made me more nervous. Watched the football with Bola in the bar afterwards. We all went to the hotel restaurant that night which was really nice. Night before vivas just did some drawings and went through cross sectional anatomy. In the words of Amresh “its not like you can revise the whole of orthopaedics in one night”!
It was in the same hotel. Only problem was having breakfast next to the examiners!! They make you wait for nearly an hour before the grilling begins.
Then the most surreal experience. You are lined up like cattle and taken into a massive room which looks like a bingo hall. There are 24 tables in a 4×6 configuration with 2 examiners each on each table. Each “column if you like” was one of the 4 viva topics. 4x 30mins vivas back to back. No rest in between. Each 30 minute viva has 6 scenarios and 5 mins to talk about them. Time flew by.
- Picture of comminuted distal humerus in 70 year old fit and well lady. Describe xray, examination etc. Management ORIF or TER. Asked approach, said olecranon osteotomy etc
- Open book pelvis. Standard. Talked about principles, permissive hypotension/haemostatic rescuscitation and Damage control surgery. Talked about Tranexamic acid/CRASH 2 trial, role of interventional radiology. Vallier paper on early appropriate care
- Dislocated hip with posterior wall fracture and sciatic nerve. Management and approach to fixation
- Young neck of femur. Bit of a gift to be honest. Irreducible, Leadbetter maneouver and anterior approach to hip. Talked about placing wires in the proximal femur before reduction so can just fire in when reduced.
- Supracondylar fracture. Another gift. Usual. Talked about white pulseless, open reduction approach and fixation method. Said I normally do cross wires as biomechanically stronger but on this occasion with vascular compromise I would do 2 divergent lateral 2mm k wires (as recommended by AO) as quicker and to personalize the situation a bit more. Examiners seemed happy
- Hawkins 2. Had been grilled about this at Oswestry course previously so had a well prepared answer. Talked about blood supply to talus, AVN rates, Hawkins sign, approaches to fixation and reduction
Hands and Paeds
- Clinical picture of pelvic obliquity corrected with blocks. LLD. Talked about causes of LLD. Eventually got to Menelaus and Paley. Principles of management
- Described clinical picture. Asked about Pirani classification. Talked about ponsetti etc then showed picture of correction with rocker bottom foot.
- Salter harris 1 distal femur fracture. Reduction and cross k wires etc
- Swelling dorsum of hand. Asked about differential. Usual differential. Asked what was in a ganglion, mucin etc. Swelling too large for ganglion so could be synovitis. Management
- Flexor tendon sheath infection little finger. Kanavels. Drainage. Communication with ulnar bursa. Stupidly mentioned deep palm space infection. Asked how would drain etc. Bruner, but not sure if it was right. Examiner was stonefaced throughout
- Management, surgical approach to radius. Talked about DRUJ and components. Asked to draw TFCC. Managed to draw meniscus homologue, UT/UL ligament and ECU sheath.
- Picture of resected proximal tibia from TKR. Asked if ACL was intact. Anteromedial wear so yes. Options for isolated wear. HTO vs UKR. Principles of HTO. Fujisawa line etc. Papers from Basingstoke on Tomofix. Indications for UKR. Usual list. Also mentioned papers from Oxford saying it can be done after ACL reconstruction and from Norwich! saying PTFJ OA does not affect outcome.
- Compartment syndrome. Label cross section of tibia. Usual draw the cross section of compartments and show how to decompress. Compartment pressure monitoring indications etc. 2 incision, preserve neurovascular structures. Soleal bridge etc. Indications for one incision technique. Said would always do 2 as per BOA/BAPRAS.
- Asked to draw different types and label. Standard stuff. Pullout strength etc. Difference between titanium and stainless steel screws. Draw youngs modulus graph of different materials
- Picture of foot prosection. Asked to label all anatomy. Pointed out approx. 10 structures. Approaches to foot and ankle, AM/AL/PL. Portals for arthroscopy. Nerve roots to DPN.
- What is your favoured knee replacement and biomechanically why? (ie do not mention NJR). Said Gen 2 as built in 3 degrees of ER. Asked what it was made of. CoCr/Poly/Titanium plate to reduce stress riser on tibia as youngs modulus closer to bone. Asked what the youngs modulus values of each were.
- What is wear? Gave definition then went into the 4 modes of wear and types of wear (adhesive/abrasive/fatigue/linear/volumetric). Asked about biomaterials and why we use CoCr and ceramic. Talked about asperities/scratch profile of metal and ceramic, fluid film and boundary lubrication, lambda ratio etc, before drawing the theta angle in wettability.
- Clinical picture of child foot with cellulitis. Asked about thoughts. Cellulitis/OM/Septic arthritis. Asked how would investigate. Usual bloods etc then said MRI. Asked if any other simpler test. Said USS, looking for joint effusion compared to normal side and collections. Then given picture of MRI. High signal in metaphysis and extending up extraosseous. Asked about management, needs drainage etc. Approach. Said like for fasciotomy on medial side. How long would you go? Said realized there was a cosmetic issue however eradication of infection most important so will have chat with parents and extend incision as long as required.
- Clinical scenario of 30 year old back pain and stiffness for a few months. GP referral. Said to rule out CE/Infection/Tumour however sounded like Ankylosisng spondylitis. Definition given based on new york criteria. Asked to draw what x ray would look like, so drew syndesmophytes. Asked difference between osteophytes in spine and drew. Why do osteophytes form? Explained it was wolffs law and excess bone formation to increase surface area and reduce stress.
- Clinical history of 70 year old fall onto elbow 18 months ago. Now sudden wrist drop. Why? Explained traumatic injury. Likely radial head fracture with possible malunion and HO. Asked to describe course of radial nerve and how to differentiate between PIN and radial nerve. Gift of a question really. Showed x ray of HO with nonunion radial head. Asked management, said with nerve involvement and now mature HO so surgical excision. Approach to radial head.
- Xray of shoulder with bone lesion in metaphysis. Described narrow zone of transition etc, calcification so chondrogenic lesion, with benign appearance so likely to be enchondroma. What would you do. Discus with MSK radiologist to confirm. Told if radiologist unsure what to do. Discuss with Tumour centre MDT. Showed MRI. Clear enchondroma. Well defined etc. Asked about biopsy principles and gave usual list
- 86 year old post cemented THR post op confusion. Discussed causes. Then shown picture of brain with multiple fat emboli infarcts. Discussed management.
- Young girl with brain tumour on steroids pain in shoulder and hips. Classic AVN question. Talked about Xrays/MRI and Ficat. Prognosis with kerboul angle etc. Management, medical core decompression and if OA THR etc. Asked if any other then bell went but carried on talking as they couldn’t ask anymore questions so mentioned trapdoor procedures as an option.
Good Luck and don’t hesitate to ask if you need viva practice when the time comes.