Blackburn April 2015

FRCS Experience Blackburn April 2015 – NO

Clinicals: – As noted before I have labeled these with diagnoses but you need to prepare for the clinicals with diagnoses and differentials in mind but have a framework for dealing with cases where this is not clear, as you are not always certain at the time.

Upper limb intermediate

  • Calcific tendinopathy
    • Multiple comorbidities including Diabetes/IHD
    • Examination – fairly non-specific
    • Discussion – x-rays/USS/management options
    • The discussion tested confidence in diagnosis/differentials and led onto how I would actually perform the procedures I had suggested.

Lower limb intermediate

  • Spina Bifida pt with hip and knee pain
    • Poor historian
    • History of multiple unilateral lengthening procedures of femur and CTEV surgery
    • Limited mobility, could mobilise a few steps, frame for longer distances, catheterized
    • Examination – I found this difficult as was just told to examine the patient and given the fact patient was in a wheelchair and history focused on problems with hip and knee it felt like a far from ideal situation. Ultimately I when back to basics, assessed footwear/inserts, leg length, gait then tried to examine hip and knees on the couch. This ran over 5 minutes and left me short on time for discussion and although I could discuss radiographs reasonably I did not come up with the additional diagnosis of previous Polio

Upper limb shorts

  • Ulnar ulnar nerve:
    • Asked to examine ulnar nerve
    • Explain Froments test
    • Sites of ulnar nerve compression
    • Nerve conduction tests – which muscles do you test? What findings do you look for?
    • How will you manage this pt with cubital tunnel syndrome? Would you transpose nerve or not?
  • Rheumatoid pt with one wrist fused, other wrist Caput Ulna
    • Described findings, concentrated on fused wrist first but soon moved onto other wrist which had caput ulna and evidence of CMCJ OA
    • Asked to comment on x-rays. How would I manage the unfused wrist? How would I critique the fused wrist?
      • I thought it was a little flexed and started discussing the angles of fusion but as I felt this wasn’t going down all that well I asked the patient what she thought… She thought it was great and therefore revised my answer to what the patient had said.
    • Congenital dislocation of radial head/Post-axial deficiency
      • Asked to examine one elbow – commented on bilateral congenital abnormalities and couldn’t feel radial head, checked the other side – similar
      • Questions revolved around what I would do if ED referred the patient after a fall – What advice would I give etc.

Lower limb shorts

  • Polio/ankle fusion/Post polio syndrome
    • Asked to examine limb
      • After missing Polio earlier offered this fairly quickly with a globally hypotrophic limb. Then assessed further to find ankle fusion etc
    • Discussed ankle x-rays
      • Asked to comment on x-rays show? What could cause her foot/leg pain? How could it be treated?
    • Post TKR pt – lost to follow-up… Likely a short notice fill-in pt
      • Asked to examine knee
      • Asked to comment on knee x-rays, indications for revision, follow-up arrangements
    • Introduced as a patient with a congenital problem requiring foot and ankle surgery ~ 50 years previously
      • Asked to examine limb, differential diagnoses
      • After giving Spina Bifida as a differential, prompted to examine elsewhere on pt for additional information – lower back scar noted
      • Didn’t really get onto x-rays etc

Take home messages

  • You get interrupted lots and rarely do a full examination from start to finish so need to be able to focus on the most clinically relevant aspects and also tailor your examination to the scenario
  • You will get weird and wonderful stuff… Need to just stick to basics and build up from there
  • Try and practice reviewing at least one new patient a week with this exam structure in mind without having seen the referral letter(5mins hx, 5mins ex, 5mins quizzing on mx options from the boss)

Vivas

Adult Pathology

  • Charcot ankle
    • 60 year old patient ankle pain
      • Asked to comment on xrays and what relevant history I would ask for? I think xrays showed mild OA.
      • How would you manage this patient? Options discussed
      • Returns in 3/12 post steroid injection and significant progression on xrays – further management… Long discussion on infection vs charcot – how to differentiate between the two clinically and what investigations might help?
      • Discussion on treatment options – nonoperative/operative
    • Fat embolism post THR
      • Introduced with confused pt post-op THR – How would you manage the patient? Tests? Differentials
      • Cross section of cerebrum with petechial hemorrhages 1 week later at post mortem
      • Mechanism of fat embolism
      • Operative steps to reduce risk
    • Pagets of the tibia
      • Introduced as elderly patient with knee pain
      • Xrays showed arthritic knee with Sabre Tibia
      • Asked regarding xray findings and diagnosis
      • What is Pagets/Pathology of Pagets/Complications
      • What tests would you do and why?
      • Management – medical/surgical – would you operate?
    • Shoulder pain/cuff tear/enchondroma
      • 60 year old GP referral with shoulder pain – Comment on xrays/How would you manage the patient
      • What relevant questions would you ask?
    • Lumbar disc herniation
      • Axial + sagittal images with multiple slices through the foramina
      • What questions would you ask? What clinical findings would you expect?
      • How would you manage the patient – discussion on medications/NRB/theatre set-up
      • Others asked on surgical approaches
    • ASR pt with contralateral hybrid with eccentric wear
      • Although introduced as a patient in an ASR clinic after commenting on ASR hip asked to focus on contralateral hip – radiological findings/expected sx/indications for revision

Trauma – This was the best place to quote papers

  • TA rupture
  • Gartland 3 supracondylar fracture
  • Holstein Lewis fracture
  • Spinal fracture mx
  • Talar neck fracture
  • Spinal cord injury

Paeds/Hands

  • Perthes/Gait analysis
    • Image of 10 year of with coxa magna and an arthrogram next to it
    • Started off with discussion of images, relevance, started offloading all I could regarding Perthes but quickly changed to the role of abduction and degrees necessary in the gait cycle… Under pressure this did not go smoothly, eventually came back round to Perthes management for the patient – non-operative/operative
  • Lateral condyle fracture
    • Discussion of images – Salter harris etc
    • Management/complications – specifically asked regarding technique and screw position
  • Rotational profile/Limb deformity
    • Image to introduce case
    • Differentials/limb alignment/rotational profile assessment
    • Management
  • Flexor sheath infection
    • Diagnosis/Karnavels signs/Management/Complications/What to do if recurs/Additional incisions
  • Scaphoid nonunion/SNAC
    • 50 year old with wrist pain after recent injury – comment on findings
      • New or old injury?
      • Additional xray findings that substantiate assumption that it is old?
      • Management?
      • What would you do if returns in 6/52 with ongoing sx – relevant imaging and surgical options
    • Penetrating injury to hand with median nerve laceration
      • Assessment of nerves
      • Incisions
      • Nerve repair technique – including suture size

Basic Science – many of these questions started off with a clinical orientation

  • Imaging – MRI/CT/USS/X-ray/Bone scan
    • Essentially asked to explain how each of these modalities worked, indications/advantages/disadvantages etc
  • Thromboembolic prophylaxis
    • Discuss guidelines/evidence – The question was introduced as… You are a new consultant in a department and have been giving the task of reviewing thromboembolic prophylaxis. How would you go about this? Are you aware of any sources of information that might guide your recommendations to your colleagues?
    • Modes of action of various agents/clotting cascade
    • Management of complications
  • Antibiotics/MRSA
    • Modes of action of different abx
    • MRSA mechanism of resistance/alternative agents
    • ? Discussion on risk factors for infection/reducing risk of antibiotic resistance
  • Osteoporosis
    • Explain this test (DEXA results) – what is it? What does DEXA stand for? What do the different parameters mean?
    • How would you explain the findings to the patient?
    • Define Osteoporosis/Osteopaenia
    • What are the risk factors – how to manage these?
    • What would you treat this patient with?
    • How do these medications work? What are their complications?
  • Nerves
    • Started with a Holstein Lewis fracture image – asked to comment then subsequently led on to management of nerve injuries
    • Draw structure of nerve – question of the various components
    • Nerve injury classification
    • Explain how NCS studies work
  • Bone healing
    • Tell me all you know about bone healing?
      • Primary/Secondary/Cutting cones
    • What factors affect bone healing?
    • Nonunion discussion