Introduction

The FRCS Orth examination will definitely test you on aspects of basic science – in the past there has commonly been a surgical approach question in the written paper, and although the format is changing it is highly likely that the emphasis and content of questions will not. Critical appraisal of a journal article will remain a part of the revised examination and will require a working knowledge of statistics.

The Basic Science Oral is often feared by candidates, but having established that there is no avoiding it, the key to understanding basic science in orthopaedics and to making it stick in your head is to keep it clinically relevant and to concentrate on understanding concepts rather than learning lists of esoteric facts.

The Basic Science section of the syllabus includes the following headings:

• Anatomy

• Tissues

• Physiology, biochemistry and genetics

• Biomechanics and bioengineering

• Bone and joint diseases

• Osteoarthritis

• Osteoporosis

• Metabolic bone diseases

• Rheumatoid arthritis and other arthropathies (inflammatory, crystal, etc.)

• Haemophilia

• Inherited musculoskeletal disorders

• Neuromuscular disorders – inherited and acquired

• Osteonecrosis

• Osteochrondritides

• Heterotopic ossification

• Bone and soft-tissue sarcomas

• Metastases

• Orthopaedic oncology

• Investigations

• Operative topics

• Infection, thromboembolism and pain

• Prosthetics and orthotics

• Research and audit

• Medical ethics

This section of the guide will take you through areas that are commonly tested from the above list. The content cannot be comprehensive; you should check through the above list after reading this chapter and identify areas of weakness in your knowledge that remain.

Anatomy will not be covered here as it is a topic well dealt with in other revision texts.

Not an exhaustive list but big enough to stir up uncomfortable feelings of hard work ahead. Try to imagine the typical scenario of each case, the likely positive clinical findings and possible questions the examiners will ask afterwards.

Shoulder

• Acromioclavicular joint (ACJ) dislocation

• ACJ pain

• Brachial plexus muscle power testing

• Clavicular non-union

• Erb's palsy

• Frozen shoulder

• Impingement tests

• Instability of the shoulder post trauma

• Instability testing – unidirectional and multidirectional

• Klippel–Feil syndrome

• Long head of biceps rupture

• Osteoarthritis of the shoulder

• Pseudoarthrosis of the clavicle

• Pseudoparalysis of the shoulder (septic arthritis) – destruction of the humeral head as an infant

• Rotator cuff pathology and testing of muscle strength

• Voluntary posterior dislocation of the shoulder

Elbow

• Bilateral congenital radial head dislocation

• Unilateral congenital dislocation of the radial head

• Congenital absence of forearm

• Cubitus valgus

• Cubitus varus

• Madelung's deformity plus multiple osteochondromas

• Osteoarthritis of the elbow post trauma

• Radioulnar synostosis

• Rheumatoid elbow

• Rheumatoid nodules

• Tennis elbow – demonstration of tests

Wrist and hand

• Any congenital abnormality – cleft hand, syndactyly, polydactyly, etc.

• Bilateral Dupuytren's

• Bilateral Dupuytren's plus peripheral neuropathy

• Carpometacarpal osteoarthritis

• Combined nerve lesions

• Deformed hands due to Ollier's disease

• Demonstration of Allen's test

• EPL rupture

• Ganglion right middle finger

• Kienböck's disease

• Madelung's disease

• Non-union of radius and ulna

• Quadriga effect

• Rheumatoid hand

• RSD post ulnar fracture

• Severe carpal tunnel syndrome

• SLAC and SNAC wrist

• Spaghetti wrists

• Ulnar claw hand

• Wrist drop

Hip

• Osteoarthritis of the hip secondary to AVN post ORIF acetabular fracture

• Perthes with secondary osteoarthritic changes

• Untreated developmental dysplasia of the hip

• Osteoarthritis of the hip

Cerebral palsy

May come up as a long case; it is unlikely as a short case. If unlucky, you will be shown a video of the gait of a cerebral palsy patient near the end of the paediatric oral and asked to describe it.

Try to minimize moving backwards and forwards from the couch to reduce distress to the patient and look as though you have a system:

• General

• Standing

• Walking

• Supine on couch

• Lateral position on couch

• Prone on couch

General

Comment on the presence of wheelchairs, walking aids, gastrostomies, nappies, braces and orthotics, e.g. KAFOs, AFOs, spinal braces.

Look at pattern of involvement

• Monoplegic

• Hemiplegic

• Diplegic (lower limbs affected more than upper)

• Paraplegic (arms not affected)

• Quadriplegic

• Total body

Cerebral palsy can also be classified according to type:

• Spastic (60%)

• Athetoid (20%)

• Ataxic

• Hemiballismic

• Hypotonic

• Combination

Standing

• Ask whether the patient is able to stand first

• Look from behind, from the side and from the front for obvious deformities, e.g. obvious joint contractures, adduction of the hip, shortened leg, equinus and varus or valgus feet

• Note stability when the child is gently pushed forwards, backwards and from side to side (predicts the need for support when walking)

• Spine: is there a fixed scoliosis? Adams' test (bending over)

• Pelvic obliquity: if there seems to be a limb length discrepancy, use blocks to even up the pelvis and look from behind

Walking

• Look and describe walking in three planes

1. Sagittal: from the side

2. Transverse: from the front

3. Coronal: imagine looking from above