Preface to second edition

One of the aims of the first edition was to cover the whole FRCS (Tr & Orth) syllabus in one book, which had never previously been attempted. As such there were always going to be areas that could have read better. In addition, the exam format keeps changing with the long case format now dropped in favour of the intermediate cases. There was a feeling of unfinished business and a need for a second edition.

Whilst ‘Examination corner’ has proved extremely popular with candidates it has been criticized in some quarters. Rather than providing a list of topics asked in the orals we wanted to give a more detailed account of the interaction between candidate and examiner but without going into minutiae. Examination corner does not magically allow candidates to pass the exam but rather guides them better; it is not a substitute for the hard work and slog needed to get through the exam successfully.

Menisci

Menisci are crescent-shaped fibrocartilaginous structures that are triangular in cross-section. The lateral meniscus is more circular and covers 70% of the lateral tibial plateau, and the medial meniscus is C-shaped and covers 50% of the medial tibial plateau.

The menisci are composed primarily of type I collagen. The fibres are arranged radially and longitudinally (circumferential). Longitudinal fibres help to dissipate hoop stresses in the meniscus. The hoop tension is lost when a single radial cut or tear extends to the capsular margin. The extracellular matrix consists of proteoglycans, glycoproteins and elastin.

Introduction

The shoulder and elbow clinical cases in the exam consist of patients with good signs for you to demonstrate and are usually pain-free. However, as a subspecialty candidates are often nervous about the content. Stick to the principles of history and examination, and most diagnoses will become apparent.

Many of the cases illustrated in this chapter are from the previous long case examination. The cases themselves are equally applicable to the intermediate cases, but obviously require a more focused approach in the new format.

The possession of the FRCS (Tr & Orth) indicates clinical competency and the ability to practise independently, but also an appreciation of personal limitations and when to ask for advice.

Introduction

With the drastic reduction in the teaching of basic medical sciences and the subsequent perceived decline in the anatomical knowledge of medical students, there is a concern about how much anatomy practising surgeons actually know.

Introduction

The aims of the FRCS exam are to see if you have enough knowledge to become a consultant orthopaedic surgeon and be able to practise safely; not to test you as a paediatric orthopaedic consultant. Examiners appreciate that not all candidates have done paediatric training; nevertheless, they expect them to have a sensible approach to tackle the common paediatric orthopaedic problems that can face any orthopaedic surgeon in their daily practice. Candidates who have had training in paediatric surgery found the paediatric orthopaedic section relatively easy; however, those who did not found it extremely stressful and some actually failed it. We strongly advise candidates who did not have the opportunity to do a paediatric orthopaedic job to attend a few paediatric orthopaedic clinics in their institute or a nearby centre to become familiar with common scenarios and their assessment and management. In this section, there is a series of clinical cases that have appeared in the FRCS (Tr & Orth) exams over the past 5 years with comments on candidates' experience. This section should be read in conjunction with the paediatric core knowledge chapter and these should cover most of paediatric section syllabus.

Klippel–Feil syndrome

This can present in adult or child. There is a short webbed neck or no neck appearance with low hairline.

Foreword

Success with the examination is about technique as much as knowledge. This book will be as good as others from the knowledge point of view but adds huge insight into technique. All examinations, whether it be your driving test or the FRCS (Tr & Orth), demand a disciplined technique. This book gives many pointers as to where a good technique helps to overcome the stress of the examination. Knowledge is a must but in itself is not enough. I would advocate this book to all orthopaedic year 1 trainees. That is when you need to start preparation – not year 4. Use this book to guide preparation for the examination. If I can add my own advice, then it is to practise every day. Pester your consultants to viva you every day for 10 minutes. Understand the principles of everything you do in the course of your orthopaedic practice.

General examination experiences and advice

It is important to remember that you do require a huge amount of knowledge to pass the FRCS (Tr & Orth) and this takes preparation. However, the examiners are looking for candidates who have a solid grounding in the principles of orthopaedic and trauma surgery, and you are expected to convey to them that you are safe, sensible and logical. Keep this in mind when studying to keep things in perspective. You can't and won't be expected to know everything.

Introduction

The following pages give guidance on how to approach the trauma viva section of the FRCS (Tr & Orth) examination. The chapter is not exhaustive and the management principles provided should be used with discretion according to the scenario provided. The first few sentences that you say in each topic should be non-controversial and clear. The aim of the candidate should be to show that he or she will be a confident, safe and sound first year consultant in a district general hospital. There is no need to argue with the examiners – there is a fine line between being confident and arrogant. The aim is to secure as high marks as possible to compensate for areas where the candidate has not performed well. However, to get a 7 or even an 8, the candidate has to get 6 first. So, do not jump to quoting papers before talking about management principles.

Hence, the aim of answering in the trauma oral should be a practical approach with first line management and cannot be fobbed off as ‘needs specialist care’. For example, when faced with a cervical spine bifacetal dislocation at 2 am, if the candidate's answer is ‘will need spinal surgeon's care’, then he or she is digging a deep hole from which it becomes difficult to dig themselves out.

Introduction

Spine questions and cases are fair game in the exam. Although it is not expected that you will manage complex spinal problems as a day-1 consultant, the emergency management of spinal trauma is part and parcel of the initial management of the critically injured patient, especially in a district general setting. Also, many patients with spine problems present with brachialgia, leg pain or limitation of walking distance and may be referred to your general orthopaedic clinic. Congenital spine anomalies may initially be referred to the orthopaedic service, as may acute neurological dysfunction, or the initial assessment of patients presenting with tumours affecting the spine.

A few years ago it was entirely possible to get through the whole examination without being asked a single question on spinal surgery. This is no longer the case. The examination is now seen as a driver to improve the care of patients presenting with spinal problems, and their assessment, at least in an emergency setting, is seen as part of the trauma and orthopaedic curriculum. Thus, it is almost certain that, where possible, there will be at least one question on each viva table, and at least one short case in the upper limb section and possibly also in the lower limb section. It is not uncommon for patients with concurrent general orthopaedic problems to have degenerative stable spine conditions and these could easily form the focus of an intermediate case.