A certificate confirming eligibility for specialist registration is awarded following a successful application under Article 14 of the General and Specialist Medical Practice order 2003 (Medical education, training and qualification). It is now processed by the GMC and it is a requirement for a doctor to be on the Specialist Register to be able to take up a substantive consultant appointment in the UK. Applicants will be measured against the standards of those who have successfully gained a certificate of completion of training (CCT). The test of knowledge required for a CCT is the Intercollegiate Fellowship Exam. All SASG (Specialty and Associated Specialty Grade) doctors working in the UK will be applying in the category of CESR Trauma and Orthopaedics where the applicant should have been awarded specialist qualification or 6 months of specialist training. Although fellowship exam is not mandatory, it is considered strong evidence of a current depth and breadth of orthopaedic knowledge and a valid reliable measure of good standard. It is extremely difficult otherwise to demonstrate this level of knowledge and skills.

The evaluation considers the training and/or qualifications, taking into account knowledge and experience. The evidence to be collected will be in the following domains: knowledge, skills and performance (75%), safety and quality (20%), communication, partnership and teamwork (5%) and maintaining trust (5%).

Anatomy of shoulder

The shoulder girdle is formed by the scapula, clavicle and proximal humerus. They form three synovial joints (glenohumeral, acromioclavicular and sternoclavicular) and two articulations (scapulothoracic and acromiohumeral).

The glenohumeral joint (GHJ), being the most mobile joint in the body, relies on static and dynamic stabilizers to remain centred. Static stabilizers are the glenoid labrum, the capsule/ligaments and negative pressure. The capsular ligaments tighten differentially according to the degree of elevation. In the midrange of motion (most activities of daily living) most capsules are lax and stability is contributed mainly by dynamic stabilizers. Anterior ligaments oppose anterior humeral translation in external rotation. Posterior ligaments oppose posterior humeral translation in internal rotation. The superior glenohumeral ligament opposes inferior translation in the adducted shoulder. The middle glenohumeral ligament opposes anteroinferior translation in the midrange of movement. The inferior glenohumeral ligament opposes anterior translation in higher degrees of abduction.

Introduction

There is a large recommended syllabus from the British Orthopaedic Foot and Ankle Society for the FRCS (Tr & Orth) examination. This syllabus is very detailed and comprehensive, and if you learned everything on it you would have no time to revise any other subject. Most candidates are not intending to become foot and ankle surgeons. It is difficult to know exactly how much detail is needed to pass the exam.

Whilst a candidate may not be expected to know all the details of every condition, he or she should at least be prepared to answer questions in general on most conditions and in particular on the more common foot and ankle disorders.

Hand surgery syllabus for the FRCS (Tr & Orth) examination

‘The hand’ covers the hand and forearm and the structures anatomically contained within. Knowledge of the structural anatomy and the biomechanics of joint and tendon function is required.

Pathology

A working knowledge of the acute conditions and trauma of the hand is required, i.e. injury to the bones, joints, tendons, nerves, skin and vessels of the hand and infective processes.

Introduction

This section is a brief overview of some of the more important paediatric topics that tend to appear regularly in the examination. It is not a comprehensive text but should point you towards the more important areas of the paediatric syllabus. Topics are included for two primary reasons:

1. They have been repeatedly asked in previous exams.

2. They are often the subject of confusion and textbooks are sometimes the source of it!

The paediatric oral can be tricky as the examiners expect you to have both a comprehensive range and depth of paediatric knowledge. Candidates may struggle unless they have had a reasonable working exposure to paediatrics, ideally 6 months as part of a higher surgical training rotation. Some topics are very predictable – in the oral candidates will invariably get one of the ‘big three’ (DDH, Perthes and SUFE), and not infrequently all three will come up.

Anatomy of the hip

The applied surgical anatomy of the hip joint is a subject with which you must be comfortable. Most examiners expect a trainee sitting the exit exam to know the anatomy and surgical approaches to the hip joint inside out. Two broad categories of question are asked:

• Surgical approaches to the hip joint

• Colour atlas photographs of hip joint anatomy (+/− bare labels).

Surgical approaches

It is odds-on that you will be asked about this during either the intermediate cases discussion or the basic science oral. It is not unusual to be asked in the adult elective orthopaedic or trauma oral.

The FRCS (Tr & Orth) is the major obstacle in higher surgical training. It is regarded as a fair but very probing examination. Passing depends on knowledge, performance on the day and a bit of luck. However, as with all exams, preparation is the key to success. That preparation should encompass not only reading to accumulate facts, but should include clinical experience, history-taking, clinical examination and, most of all, practice. This section acts as an introduction to the current format of the FRCS (Tr & Orth) and serves to provide prospective candidates with some helpful hints and top tips. This advice is based on our own personal experiences, those of our colleagues, our previous trainers and current trainees.

Examination format

The current FRCS (Tr & Orth) encompasses two sections: section 1 is the written exam and section 2 the clinical and oral exam.  For further details and to ensure no further changes have been made following this publication, we suggest all candidates carefully review the Intercollegiate Specialty Board (ISB) website (http://www.intercollegiate.org.uk).

Introduction

This can be a tedious and dry area of orthopaedics to learn but, for various reasons, examiners are being encouraged to ask candidates more questions on surgical approaches than ever before.

In real life it is a very important practical part of a practising orthopaedic surgeon's workload. The irony is that one would usually read up an unfamiliar or forgotten approach before undertaking the required surgery. It has been suggested that at least 10 minutes of the basic surgical oral should be spent discussing surgical approaches and anatomy with candidates.

Introduction

The one fact that links all trainees in an orthopaedic training programme is that we are all good at passing exams! It is self-selection of the highest order and none who present for this level of exam, 12 years or so after leaving school, would have achieved this level if this were not so.

The FRCS (Tr & Orth) is not a competitive examination in that a pass percentage rate is not set. It is a competency-based exam and so the pass rate will vary from examination to examination depending on the standard achieved. In recent years, the rate has varied from between 56% and 72%, with an average pass rate in 2009 of 65%.