Past FRCS Exam Experience
Reflections from the FRCS (Tr & Orth) – Glasgow, February 2005
Sitting the FRCS Orthopaedics examination in Glasgow was a defining moment in my career. It was not just an exam—it was a true assessment of how one thinks, reacts, and prioritises as a surgeon. The day was a whirlwind of clinical reasoning, anatomy, surgical approaches, and communication. What follows is my recollection and reflection of the experience, shared in the hope it helps others preparing for their own FRCS journey.
Written Papers
The written paper was designed to test broad clinical reasoning rather than obscure facts.
One scenario involved a rear-seat passenger with a lap belt injury and severe low back pain after an RTA. The questions moved logically through imaging interpretation—what to look for on a cervical spine X-ray, what to check on a chest X-ray, and what immediate investigations to prioritise and why.
Another question described a 50-year-old man with an acutely swollen knee two weeks after dental work. The focus was on differential diagnosis (with septic arthritis at the top of the list), recognising its classic presentation, and outlining both immediate and subsequent management steps—including what to do if the knee failed to respond to treatment.
A question on thromboprophylaxis in orthopaedics explored not only clinical reasoning but also organisational and policy-based understanding—how one would implement a departmental protocol safely and consistently.
A practical scenario described a 25-year-old butcher with a flexor tendon injury—unable to flex both interphalangeal joints but with intact neurovascular status. This required an outline of initial wound management, surgical repair technique, and postoperative rehabilitation strategy.
Finally, an essay on minimally invasive hip approaches tested knowledge of anatomical landmarks, intermuscular planes, and the associated neurovascular risks for both anterior and anterolateral approaches.
A JBJS 2000 paper on femoral-neck–preserving hip replacement featured in the paper analysis. The questions focused on critical appraisal—interpretation of life-table analysis and recognising methodological limitations in short-term follow-up studies.
Clinicals
The long case was a memorable one: a 31-year-old ex-joiner, eight months post–motorcycle accident, with open fractures of the femur and tibia and a flail upper limb from a brachial plexus injury. Despite the intimidating setting, the format was fair—ten minutes for history, ten for examination, and time for discussion.
The patient’s main difficulty was functional use of the limb rather than pain. I took a detailed history, but during examination I missed a posterior shoulder dislocation—a valuable lesson in systematic assessment. The discussion evolved into principles of tendon transfer for elbow flexion, the use of nerve conduction studies and EMG, and clinical signs of supraclavicular lesions such as Horner’s syndrome.
The key takeaway? Don’t mention a topic unless you can confidently discuss it. The examiners will take you at your word.
Short Cases
he short cases were rapid, fair, and clinically rich:
Dupuytren’s contracture – classification, complications, and patient counselling.
Ulnar nerve palsy – demonstration of hand signs; this one unexpectedly led to a finding of a subclavian artery aneurysm!
Kienböck’s disease – classic young wrist pain with local tenderness and limited range of motion.
Rotator cuff arthropathy – assessment and discussion of reverse total shoulder replacement.
Valgus knee in a 40-year-old woman – discussion of lateral joint pain and instability, compared with varus OA and the role of distal femoral osteotomy.
Bilateral forefoot arthropathy – severe hallux valgus and lesser toe clawing; surgical and conservative management options.
Painful flat feet in a young man – tarsal coalition spot diagnosis.
The advice I’d give anyone: say what you see, and explain what you’re doing as you do it. The examiners will generally let you proceed unless you appear lost.
Viva Stations
Adult Pathology & General Orthopaedics
Topics included:
Hallux valgus – quantifying deformity and treatment options.
Moth-eaten humerus in an 8-year-old – differentials, investigations, and the features of Ewing’s sarcoma.
Dislocated total hip replacement – discussing risk factors, surgeon and patient contributions, and high-risk groups.
Metastatic disease in the femur – investigations, staging, and management of pathological fractures.
Patellofemoral OA on skyline views – full spectrum of treatment options.
Cavus foot – causes, pathology, and staged surgical management (soft tissue versus bony procedures).
Trauma
A fast-paced and practical section covering:
Unstable intertrochanteric fractures fixed with DHS – predicting and explaining failure.
Posterior shoulder dislocation with head-split fracture – recognising on imaging and describing the surgical approach.
Capitellum fracture – fixation techniques and approach rationale.
Paediatric elbow dislocation with incarcerated medial epicondyle – management and fixation principles.
Throughout, the examiners emphasised surgical exposure, fixation method, and reasoning rather than rote recall.
Paediatrics & Hands
Subtle SUFE – radiological recognition (Trethowan’s sign), risk factors, classification, and prophylactic pinning indications.
Clubfoot – examination, Ponseti regime, and counselling parents on prognosis.
Varus knees in children – differentiating physiological from pathological, with an age–valgus curve sketch.
Bennett’s fracture – management rationale.
Carpal tunnel decompression – full operative detail including local anaesthetic dose.
Thumb CMC arthritis – classification and staged management options.
Basic Science
This section tested depth of understanding across anatomy, biomechanics, histology, and infection control:
Anatomy of the foot and ankle – coronal section labelling of tendons and vessels.
Biomechanics of femoral nails – reaming, working length, and the purpose of a hollow design.
Histology of bone – identifying cancellous bone structures, Haversian canals, osteocytes, and canaliculi function.
Osteoclasts – cellular origin, hormonal control, and the Rank–RankL pathway (mentioning it earned a smile!).
WHO and BOA criteria for osteoporosis – interpretation of T- and Z-scores with real BMD data.
Meniscus structure and function – proteoglycan composition, hoop stresses, and mechanical integrity.
Bone grafting principles – osteoconduction vs osteoinduction, sterilisation, and disease screening.
Laminar flow systems – HEPA filters, particle counts, and referencing the landmark “Lidwell 1982” study.
Final Reflections
The Glasgow FRCS was a fair but thorough assessment. It covered a vast spectrum, testing how wide and how deep you could go under pressure. The examiners were probing but not cruel—they wanted to know what you knew, not what you didn’t.
The biggest lesson was this: you don’t need to know everything, but you need to show you can think like a consultant.
If you don’t know an answer, say so, and they’ll move on. But if you hesitate or bluff, the silence becomes uncomfortable.
Key Takeaways for Future Candidates
Practise structured, aloud reasoning – it’s half the battle.
Revise surgical approaches as thoroughly as fixation principles.
Don’t introduce topics you can’t expand on.
Be observant, systematic, and calm – the exam rewards clarity and logic.
Remember, this exam mirrors real orthopaedic life: time pressure, uncertainty, and decision-making with limited data.
My FRCS (T&O) Exam Experience: Reflections, Questions, and Final Thoughts
As the FRCS examination approached, I reminded myself—and others going through the same journey—to stay calm, focused, and grounded. By 5 or 6pm the night before, I made a conscious decision to stop revising, clear my mind, and allow myself to rest properly.
On the day, the biggest lesson was simple:
Look confident but stay safe. Listen carefully. Keep your answers structured. Attention to detail matters more than complexity.
You cannot run before you walk, and in this exam, safe steady steps are valued more than speed.
Most importantly, I kept visualising success—standing on the RCS stage, receiving the FRCS diploma, with family smiling proudly in the audience. If someone has done it before, then so can you.
Below is an overview of the topics and scenarios I faced. Although every station felt intense and layered, this list may help others understand the breadth and depth of the exam.
VIVA EXPERIENCE
Basic Science Viva
This station was, without doubt, the most challenging part for me. The discussion was deep, fast, and at times felt intentionally disruptive to stress-test clarity of thought.
Topics included:
Exeter Stem – design philosophy, creep, stress relaxation, and comparisons with metal-on-poly wear.
Osteomyelitis – microbiology, staging, imaging, management.
Deltopectoral approach – anatomy, planes, danger zones, cadaveric identification.
Bone cement syndrome – physiology, risk factors, prevention.
Gait cycle – the three rockers and pathological deviations.
Humerus tumour – radiology and biopsy principles.
Osteogenesis imperfecta, collagen structure and formation, and why OI leads to blue sclerae.
Anatomy of the distal humerus, including neural relationships.
Kaplan–Meier survival analysis, stress–strain curves, tibial plateau wear patterns.
Polyethylene wear – comparing new vs worn inserts.
Bone healing, bone grafts, tourniquet principles, metastatic bone disease.
This station required clarity, drawings, biomechanical understanding, and safe reasoning.
Trauma Viva
This was fast-paced, practical, and clinically oriented. Themes included:
3-part proximal humerus fracture – fixation options, reduction principles.
AC joint dislocation (Type V) – biomechanics and surgical indications.
Capitellum fracture – classification, fixation strategies.
Knee dislocation – vascular assessment, emergency priorities.
Osteoporotic vertebral fracture – differentiating wedge vs burst patterns.
Posterior shoulder dislocation – missed injuries, reverse Hill-Sachs implications.
Talus fracture with pilon injury – skin risk, staging, Hawkins classification.
Femur shaft + proximal femur fractures – ipsilateral injuries.
L1 burst fracture with canal compromise – TLICS, neurology, operative decision-making.
Old patient with intracapsular fracture after previous nailing – goals of care in a 98-year-old.
Polytrauma scenarios requiring discussion around airway, shock, haemorrhage, and damage-control orthopaedics.
Massive transfusion protocol – initiation, pack 1 vs pack 2, physiology.
Paediatric and Hand Viva
Topics were wide-ranging:
Septic hip – Kocher criteria, urgent management.
NAI (non-accidental injury) – safeguarding responsibilities.
Cerebral palsy hip dislocations – migration percentage and management.
CTEV / Clubfoot – Ponseti timing and indications; one scenario included contralateral polydactyly.
Anterolateral bowing – including differential such as NF1 pseudoarthrosis.
Giant cell tumour of the thumb, lunate/perilunate dislocation, SNAC wrist.
Jersey finger – differentiating FDP vs FDS, retraction patterns, repair techniques.
Extensor compartments – EPL rupture pathways, De Quervain’s.
Flexor tendon repair zones – especially Zone II techniques.
Bony mallet – Ishiguro method.
Adult Pathology Viva
Key themes I faced:
Periprosthetic fractures (hip and knee) – classifications and management.
Hip impingement, groin pain assessment.
Liposarcoma, osteosarcoma (including histology, staging, management).
TA rupture – neglected cases and reconstruction options.
Cervical myelopathy – red flags and surgical principles.
Spinal metastasis – cord compression management pathways.
Ankylosing spondylitis hip involvement.
Severe OA patterns in knee and elbow.
Solitary distal humerus metastasis from breast cancer.
Failure of Bankart repair and glenoid bone loss.
Neglected posterior shoulder dislocation, young patient.
OA hip in AS, and degenerative lumbar scoliosis.
Pathology viva questions were clinically rich and often required integrating imaging with surgical principles.
THE ETHICS / PROFESSIONALISM SCENARIO
One scenario stood out:
A child in A&E required urgent orthopaedic review. When I called the on-call consultant, it became apparent that he had been drinking alcohol.
I stated clearly:
My primary duty is to the patient.
I must escalate the concern by informing the clinical lead.
I would ensure the consultant was spoken to safely, explore the reasons behind the behaviour, and arrange for him to be sent home, ensuring no risk to patients.
It was a difficult scenario, designed to test leadership, insight, boundaries, and patient safety.
CLINICALS
Short Upper Limb
Rotator cuff tear with wasting
Rheumatoid hand deformities
Parsonage-Turner syndrome
Short Lower Limb
Bilateral fasciotomy scars; foot drop on one side
Insertional Achilles tendinopathy
Tarsal coalition
A particularly puzzling case involved an elderly patient with bilateral foot drop for 40 years, intact sensation, and no metabolic, neurological, or traumatic history. Possible differentials included motor neuron disease, but the short time limited detailed exploration.
Intermediate Upper Limb
Rotator cuff arthropathy
Elbow arthritis with extension deficit
Ulnar nerve symptoms
Bilateral TKR with one symptomatic pending revision
Intermediate Lower Limb
Failed PCL repair
Medial femoral condyle AVN
Ilizarov frame in place
Persistent pain in a 46-year-old
Additional intermediate cases from colleagues included shoulder seronegative OA and bilateral lateral-compartment OA with inflammatory features.
Reflections
Across all stations, there were no simple questions. Every topic evolved into deeper layers, requiring diagnostic reasoning, anatomy, surgical decision-making, and evidence-based justification.
Many candidates agreed that:
Basic Science was the hardest,
Trauma and Pathology were manageable with structured thinking,
Clinicals required calm observation and pattern recognition,
The examiners sometimes pushed, interrupted, or dragged the discussion intentionally to test stability under pressure.
But in the end, the breadth and difficulty were exactly what the exam was designed to deliver.
Final Words to Future Candidates
Stay calm.
Stay safe.
Stay structured.
Visualise success. You belong on that ceremony stage more than you know.
My FRCS (T&O) Exam Experience: A Candid Reflection on the Cases, Questions, and Learning Points
Sitting the FRCS Trauma & Orthopaedics examination had always felt like the final summit after years of training, and when the day finally arrived, it was every bit as intense, wide-ranging, and intellectually demanding as I had imagined. I wanted to share my own experience — not as a checklist of answers, but as an honest reflection on the structure, depth, and style of questioning I faced.
What struck me most was not the obscurity of the topics, but the examiners’ relentless focus on safe practice, sound reasoning, and an ability to think clearly under pressure.
INTERMEDIATE CASE
The intermediate case opened with a 22-year-old rugby player who had sustained a left shoulder dislocation three months earlier. Although the shoulder had been reduced, he continued to experience burning dysaesthesia in the little finger, raising suspicion for a preganglionic brachial plexus injury.
I was asked what I expected to see on MRI. The examiners focused on classical features such as the empty nerve root sleeve / empty foramen sign. They pushed further on management — specifically nerve repair versus grafting, and why results are often limited due to the distance between the injury and the motor end plates in the hand.
This naturally led into tendon transfer options, nerve roots associated with Horner syndrome, and signs suggestive of root avulsion.
It was a strong reminder: the intermediate case is about demonstrating depth, logic, and safe surgical judgment.
SHORT CASES
1. Acute Black Discolouration of the Finger Pulp
A young man presented with sudden blackish discolouration of the fingertip, without trauma. I was asked for differentials such as subcutaneous abscess or pyogenic flexor tenosynovitis.
This led into the Kanavel signs, surgical incision placement (A1 and A5 pulleys), and splinting positions for the MCPJ and PIPJ with justification based on preserving function.
2. Teenage Boy With External Rotation of the Leg (SUFE)
A 14-year-old boy with progressive out-toeing months after a fall. I was asked to outline examination, expected gait findings, affected movements, and the classic radiological features of SUFE on AP and lateral views.
I was also asked to draw and measure the Southwick angle.
3. Middle-Aged Woman With Wrist Deformity (Madelung)
A clinical photograph and radiograph pointed to Madelung deformity. I had to describe the pathology, additional examination focus (especially forearm and DRUJ), and management options.
4. Child With Unilateral Bowing of the Leg (Blount Disease)
A 14-year-old girl with unilateral leg bowing. The exam focused on describing the deformity, measuring the Drennan angle, defining metaphyseal beaking, and outlining appropriate treatment.
TRAUMA VIVA
1. Femoral Neck Fracture in a Young Patient
I was asked how I would fix it, to describe the surgical technique, and explain the role of an additional derotation screw. I had to discuss reduction assessment, and define the tip-apex distance.
2. Young Lady With Back Pain After a Fall
The examiners emphasised trauma assessment, particularly neurological examination in the context of spinal and neurogenic shock.
They pushed me to differentiate burst vs compression fractures, when to fix, and to apply the TLICS system correctly.
3. Hip Dislocation With Associated Femoral Neck Fracture
This scenario tested urgency of reduction, risk of AVN, and whether it should be done immediately — even at night.
4. Crush Injury to Tibia
I was asked to explain crush syndrome, mechanisms of myonecrosis, risks such as renal failure and metabolic derangement, and critique external fixation placement when pins breach the fracture zone. The examiners then probed alternative constructs and factors affecting frame rigidity.
5. Calcaneal Fracture in a Labourer (BMI 30)
Assessment steps, need for CT (coronal view), Sanders classification, drawing Bohler and Gissane angles, operability, and evidence-based reasoning were key.
Assessment including Beighton score, reduction steps, surgical options, MPFL anatomy, graft choice (gracilis), intraoperative identification, and reconstruction technique.
Final Thoughts
The FRCS examination tested not only knowledge, but clarity, safety, and clinical maturity. The stations rewarded structured thinking, calm decision-making, and understanding the “why” behind every step.
While the breadth was enormous, the underlying theme was constant: safe, evidence-based orthopaedic practice.
I hope this reflection helps future candidates appreciate the style and depth of the exam — and perhaps approach it with a little more confidence than I did walking in.
Walking into the FRCS (Tr & Orth) – A Journey from the Hot Seat
The FRCS (Tr & Orth) exam was everything I’d been warned about – intense, unpredictable, and relentless. But it was also an opportunity to prove that years of training, endless evenings of viva practice, and thousands of patients had shaped me into a surgeon ready to take the next step.
The morning I walked into the exam hall, I carried two things with me: a sharpened mind and the determination not to let any stumble define my performance.
Paediatrics & Hands – Baptism of Fire
The first station eased in with a case of Perthes disease – classification, prognostic factors, and how to separate it from infection. Familiar ground, and a chance to set the tone.
That comfort didn’t last long. The next case was a femur fracture in a 9-month-old. No X-ray, just the knowledge that this was likely a non-accidental injury. The discussion ran deep into safeguarding protocols and the medico-legal responsibilities that come with being the doctor in that room.
A case of left thoracic scoliosis followed. I knew the drill – history, examination, differentials – but the MRI image quality was so poor I couldn’t confidently make a call. I described what I saw, clinically and objectively, until the bell cut me off.
Then came the rheumatoid hand. The questions were vague, the examiner’s expression unreadable. Every answer was met with another question, not a nod or hint of agreement. It was like shadowboxing – I could only keep swinging.
A young patient with central wrist pain came next. The X-ray later revealed Kienböck’s stage II. I mentioned ulnar variance – apparently a mistake – and it felt like I’d opened the wrong door in a maze. Time slipped away before I could offer a complete management plan.
The last was a proximal phalanx fracture with severe dorsal angulation. My mention of nil by mouth prompted a rapid-fire interrogation: urgency of surgery, sedation choice, local anaesthetic dose, technique, fixation options. It was a volley of questions with no breathing room, ending only when the bell finally rang.
Basic Science – From Curves to Cartilage
The stress–strain curve for bone was first. I drew it out, explained why “necking” doesn’t occur in bone, and then, mid-flow, was asked to sketch the curves for osteomalacia and osteoporosis. A shaky start – I briefly confused the two – but recovered in time.
A hip X-ray with osteolysis and linear wear shifted us into an in-depth discussion on bearing surfaces and lubrication. Then, a cadaveric hand dissection opened up a deep dive into anatomy – muscles, compartments, vascular arches, surgical approaches.
NAI returned for the second time, this time linked to Gillick competency and paediatric consent law.
Theatre design came next – laminar flow, ventilation, pros and cons of systems, and what makes an arthroplasty theatre safe.
The final image was an arthroscopic view of a cartilage defect. I drew the cartilage microstructure, then outlined treatment strategies by defect size and stage.
Trauma – Split-Second Thinking
An elderly patient with a neck of femur fracture opened the trauma section. We discussed total hip replacement, bearing choices, approaches – then the age dropped to 37 and the conversation pivoted to open reduction techniques.
A shoulder dislocation in ED with suspicious X-rays led me to suspect instability. Spotting a bony Bankart, I outlined acute and definitive management.
A Gustilo–Anderson IIIA open tibial fracture demanded BOAST-compliant planning, from initial stabilisation to timing of fixation.
A floating knee with a cold, pulseless limb tested my vascular injury protocols – on-table angiography, external fixation, timing with vascular repair.
An ankle fracture–dislocation became a discussion about surgical approaches and rehab, and an olecranon fracture in a 93-year-old turned into a lesson on balancing fixation principles with frailty.
Adult Pathology – The Curveball Moments
The most humbling case came early – a foot ulcer. I launched into differentials, only to have the examiner ask, “Can you count the toes?” One was missing, and I hadn’t noticed. Recovering quickly, I scored the ulcer using the SINBAD system and laid out a management plan.
From there:
Medial knee osteoarthritis – exploring the role of high tibial osteotomy.
Shoulder AVN post-trauma with intact cuff – suitability for total shoulder arthroplasty.
Primary elbow osteoarthritis in a builder – fusion versus replacement.
Hip prosthesis loosening four years post-THR – ruling out infection, planning revision.
Subtrochanteric pathological fracture in a post-nephrectomy RCC patient – staging, biopsy, and the place of PET scans.
Lessons from the Hot Seat
The FRCS exam isn’t just about getting the right answers – it’s about getting to the answer fast, staying calm when the examiner doesn’t blink, and keeping your surgical priorities clear even when the patient’s presentation is bizarre or the questioning is deliberately distracting.
Some examiners encourage, others push, a few test your resilience more than your orthopaedic knowledge. The key is not to flinch – to keep working through the problem, even if it feels like you’re walking uphill against the wind.
By the end, I was mentally drained but strangely energised. The exam had tested not just what I knew, but how I thought under pressure – exactly what it means to be a consultant.
Inside the FRCS (Tr & Orth): A Candid Reflection from the Exam Room
The FRCS (Tr & Orth) is an exam that tests far more than factual recall. It challenges judgment, composure, and clinical fluency under pressure. My sitting was no exception — a fast-paced test of breadth, reasoning, and calm communication. Below is my reflection on the short and intermediate cases, viva questions, and key lessons learned from the experience.
Short Cases
Upper Limb
The first case was a shoulder swelling demonstrating Geyer’s sign. I was asked how to assess the swelling, what else I would examine around the shoulder, and how to interpret my findings. The focus was on systematic assessment — inspection, palpation, movement, and correlation with potential underlying pathologies such as AC joint cysts or cuff tears.
Next came juvenile idiopathic scoliosis, where the examiners wanted clarity on X-ray measurements: Cobb angle, Risser grading, sagittal balance, and vertebral rotation assessment. They expected me to outline how these guide management thresholds.
The final upper limb short case was Dupuytren’s contracture — a familiar classic. I discussed functional assessment, staging, indications for surgery, and postoperative rehabilitation, emphasising that communication and expectation-setting are key.
Lower Limb
The first lower limb case was truly memorable — a child with tibial hemimelia, limb-length discrepancy (LLD), and a striking “lobster foot” deformity. I was asked to comment on gait, measure LLD clinically, and identify the best assessment method when both limbs are deformed. The Galeazzi test was the expected answer, along with understanding compensatory pelvic tilt.
Then came a patient with achondroplasia. I was asked to list the characteristic features — rhizomelic limb shortening, lumbar lordosis, genu varum — and predict changes with growth. The genetic discussion explored how normal parents may have an affected child due to a de novo mutation in FGFR3.
Finally, a malunited tibial fracture with multiple scars appeared. I was asked to interpret the deformity, comment on union, and outline how to correct it. The emphasis was on identifying the plane of deformity, planning the osteotomy, and discussing whether the malalignment was due to bone or soft tissue imbalance.
Intermediate Cases
Upper Limb
The upper limb case involved a 64-year-old man with rotator cuff arthropathy. I was asked to demonstrate all the clinical signs for each rotator cuff muscle, then to interpret X-ray, MRI, and CT findings. The examiners moved the discussion toward biomechanics of the reverse shoulder replacement — particularly how medialising and lowering the centre of rotation recruits the deltoid for elevation when the cuff is deficient.
Lower Limb
A 44-year-old woman with bilateral valgus knees, diabetes, obesity, and a smoking history formed the second intermediate case. The X-ray suggested spontaneous osteonecrosis of the knee (SONK). Discussion revolved around the challenges of valgus TKR, infection risk in obese diabetic patients, and the role of the multidisciplinary team in optimisation — smoking cessation, weight loss, and metabolic control. I also had to explain the Whiteside line and alignment principles for valgus correction.
Viva Stations
Adult Pathology
This section tested reasoning through diverse clinical scenarios:
Septic vs reactive arthritis of the knee — differentiating features and early management.
PIN palsy in an alcoholic patient — differential diagnosis and prognosis.
Valgus knee in a young patient, possibly following discoid meniscus excision.
Metastatic spinal lesions — classification, staging, and red flag symptoms.
Metastatic femoral lesions — discussion of fixation versus prosthetic replacement.
Infected MTPJ fusion — debridement, implant management, and staged reconstruction.
Each case required clear prioritisation: stabilise, investigate, and plan within safe surgical principles.
Trauma
The trauma viva was fast-paced and practical:
L1 superior endplate fracture – classification, stability, and spinal precautions.
Floating shoulder – double disruption of the superior shoulder suspensory complex.
Monteggia variant fracture-dislocation in an adult – mechanism, surgical exposure, and fixation strategy.
Open tibial fracture with >24-hour bone exposure – debridement stages and timing of coverage.
Infected humeral non-union – BOA guidelines, Cierny–Mader classification, and reconstruction ladder.
Comminuted distal femur fixed with a short retrograde nail and rotated butterfly fragment – biomechanical critique and revision planning.
Hand and Paediatric
This mixed station was a blend of emergencies and congenital conditions:
Fight bite – urgent washout and antibiotic protocol.
Flexor pollicis longus (FPL) injury – repair and rehabilitation.
Rheumatoid hand – pattern recognition, deformity sequence, and surgical prioritisation.
Congenital knee dislocation – classification and management options.
SUFE – radiographic signs, risk factors, and bilateral fixation indications.
CTEV – Ponseti principles, relapse management, and parental counselling.
The key was demonstrating confident clinical reasoning while keeping safety at the forefront.
Basic Science
Basic science questions tested both understanding and application:
Complex regional pain syndrome (CRPS) – pathophysiology and Budapest criteria.
Cartilage – structure, zones, and regeneration principles.
Bone grafting – osteoconduction vs osteoinduction and incorporation.
DISI deformity – mechanism, imaging, and clinical relevance.
Gout – crystal chemistry and surgical implications.
Haemophilia – perioperative planning, inhibitor management, and safe surgical technique.
Reflections
The FRCS exam is not a test of memory — it’s a test of judgment, structure, and calm reasoning.
Every station rewards clarity, safe practice, and professionalism under pressure.
What I learned:
Speak with purpose — structure your answer before you speak.
Be methodical; examiners value organisation over speed.
Don’t bluff; if unsure, reason logically and stay safe.
Stay human — composure, empathy, and teamwork matter.
The FRCS is more than an exam. It’s a reflection of what it means to think, act, and lead like a consultant.
FRCS (Tr & Orth) – Reflections from the Exam Room
Sitting the FRCS (Tr & Orth) exam was a defining experience — one that tested not only what I knew, but how I thought, structured, and communicated under pressure. The cases spanned every subspecialty of orthopaedics, and the pace was relentless.
Here’s a reflection on some of the short cases, intermediate cases, and viva topics that I faced — and what I took away from the process
Short Cases
Upper Limb
The first short case was a shoulder swelling demonstrating Geyer’s sign. The examiners asked how I would assess the swelling, what further shoulder structures I would examine, and which systemic or local causes I would consider. The key, I learned, was to stay calm and methodical — describe what I see, what I feel, and what I would do next. They wanted a structured, stepwise approach rather than a rushed list of differentials.
The second was juvenile idiopathic scoliosis. I was asked what measurements I would make on the X-ray: Cobb angle, Risser grade, sagittal balance, and vertebral rotation. The discussion expanded into management thresholds and the role of growth remaining — a reminder that even simple questions can open into broader reasoning if you show understanding.
The final upper limb short case was Dupuytren’s contracture, the “classic” of many FRCS exams. The focus was on a clear, confident examination, functional assessment, and explaining indications for surgery, complications, and rehabilitation. The lesson here — concise structure and confidence go a long way.
Lower Limb
The lower limb short cases were more challenging.
The first showed a child with tibial hemimelia, limb-length discrepancy, and a lobster foot deformity. I was asked to comment on gait and describe how I would assess the limb-length difference, especially given deformity in both limbs. The Galeazzi test was the key clinical point. It reinforced the importance of mentioning compensatory mechanisms and the limitations of simple block tests in complex deformity.
Next was achondroplasia, with questions on its characteristic features — rhizomelic limb shortening, frontal bossing, genu varum — and what to expect with growth. The examiners also asked why the parents were normal despite the child being affected, which tested understanding of autosomal dominant mutations and de novo variants of FGFR3.
The third case showed a malunited tibial fracture with multiple scars. I was asked to describe the deformity, determine whether it was united, and explain how I would correct it. The key learning point was to focus on deformity analysis — coronal, sagittal, rotational, and length components — and to outline correction principles using osteotomy or circular fixation.
Intermediate Cases
Upper Limb
The first intermediate case was a 64-year-old man with rotator cuff arthropathy. I was asked to demonstrate signs of cuff integrity, interpret X-rays, and discuss MRI and CT findings. This naturally led to reverse shoulder arthroplasty biomechanics — how medialising and lowering the centre of rotation recruits the deltoid as the prime elevator when the cuff is deficient. The discussion also covered surgical indications, complications, and functional expectations postoperatively.
Lower Limb
The second case involved a 44-year-old woman with bilateral valgus knees, diabetes, obesity, and smoking history — X-rays suggested spontaneous osteonecrosis of the knee (SONK). I was asked to comment on radiographs, surgical challenges, and infection risks in obese diabetic patients.
A lively debate followed regarding infection risk in TKR among obese patients. I discussed MDT optimisation — weight reduction, smoking cessation, and diabetic control — and alignment principles such as Whiteside’s line. It reinforced that management is often as much about patient preparation and risk reduction as surgical skill.
Viva Stations
Adult Pathology
The pathology viva covered a wide spread of topics:
Septic versus reactive arthritis of the knee – recognising systemic features and joint aspiration findings.
Posterior interosseous nerve (PIN) palsy in an alcoholic patient – causes and prognosis.
Valgus knee deformity in a young patient post–discoid meniscus excision.
Metastatic spine and femoral lesions – staging, stability, and palliative fixation principles.
Infected MTPJ fusion – management and revision strategy.
Each case tested my ability to reason safely and communicate a clear management plan.
Trauma
The trauma section was an unrelenting sequence of real-world decision-making:
L1 superior endplate fracture – classification, stability, and management.
Floating shoulder – double disruption of the superior shoulder suspensory complex.
Monteggia variant in an adult elbow – reduction and fixation strategy.
Open tibial fracture with bone exposed for >24 hours – staged management and timing of coverage.
Infected non-union of the humerus – principles of debridement, fixation, and reconstruction.
Comminuted distal femur fracture fixed with a short retrograde nail – assessing construct stability and planning revision.
It felt like a test not just of knowledge, but of calmness under fire.
Hand and Paediatrics
This table mixed acute and congenital topics:
Fight bite – emergency management to prevent septic arthritis.
Flexor pollicis longus (FPL) injury – repair technique and rehabilitation.
Rheumatoid hand – deformity sequence and surgical staging.
Congenital knee dislocation – classification and treatment strategy.
SUFE – diagnosis, classification, and indications for prophylactic fixation.
CTEV – Ponseti regime, relapse management, and long-term follow-up.
These stations required calm, structured answers and constant demonstration of safe clinical reasoning.
Basic Sciences
The basic science component was concept-heavy but fair:
Complex regional pain syndrome (CRPS) – pathophysiology and management hierarchy.
Cartilage biology – histological zones and regenerative potential.
Bone grafting – osteoconduction, osteoinduction, and integration.
DISI deformity – biomechanics and imaging findings.
Gout – crystal structure and implications for surgery.
Haemophilia – perioperative management, inhibitors, and surgical safety.
This section reminded me that the science underpinning orthopaedics is inseparable from its practice.
Reflections
The FRCS (Tr & Orth) is not a test of memory — it’s a test of judgment, composure, and clarity under pressure.
Every case rewards a structured, safe, and professional approach more than encyclopaedic recall.
I learned three key lessons:
Structure beats speed — pause, plan, and speak logically.
Stay safe — the right answer is the safe answer.
Think like a consultant — prioritise, reason, and communicate clearly.
Ultimately, the FRCS is more than an exam. It’s a reflection of how we think, lead, and respond under scrutiny — not just as surgeons, but as professionals.
Sitting the FRCS (Tr & Orth) examination was one of the most demanding and eye-opening experiences of my career. It tested not just knowledge, but composure, communication, and the ability to think like a consultant under pressure. What follows is a personal reflection on the stations I encountered in November 2021 – a mixture of expected topics, curveballs, and the ever-present ticking of the bell.
Paediatrics & Hands
The exam opened with a case of Perthes disease. The examiners wanted the essentials: classification, prognostic factors, key points in history and examination, and differentials, with a strong emphasis on excluding infection.
Next was a femur fracture in a 9-month-old, presented without imaging. The discussion immediately centred on non-accidental injury – safeguarding, red flags, and the importance of multidisciplinary involvement.
A left thoracic scoliosis followed. I ran through history, examination, differentials, investigations, and management. Unfortunately, the MRI quality was poor, so I described what I could see objectively until the bell interrupted.
The rheumatoid hand case was more challenging. Questions were vague – “What do you expect to find? What do you expect the patient to have?” – while the examiner responded only with further questions. It felt less like a structured discussion and more like an endurance test in maintaining focus.
For a young patient with central wrist pain, the X-ray later revealed Kienböck’s stage II. Mentioning ulnar variance seemed to irritate the examiner and cost valuable time. My suggested management of retrograde drilling was also poorly received, and the bell cut off further discussion.
The last case in this section was a proximal phalanx fracture with severe dorsal angulation. After outlining basic steps – including nil by mouth status – I was pressed hard: “Is this urgent?” “What sedation would you use?” “Which local anaesthetic, dose, and technique?” The rapid-fire questioning continued into fixation choices until the bell finally ended the exchange.
Basic Science
The station began with the stress–strain curve of bone. I drew the classic curve, explained why “necking” does not occur in bone, and was then asked to reproduce curves for osteomalacia and osteoporosis. Initially, I confused the two, but corrected myself in time.
An X-ray of hip osteolysis and linear wear led to a discussion about bearing surfaces, wear mechanisms, and lubrication.
A cadaveric image of the dorsal hand prompted a detailed anatomy review – carpals, interossei, hand compartments, vascular arches, and surgical approaches to release.
Non-accidental injury reappeared, this time shifting into a discussion of consent in children and Gillick competency.
Another station moved into theatre design – ventilation types, laminar flow pros and cons, and prerequisites for an arthroplasty theatre.
Finally, an arthroscopic image of a cartilage defect tested knowledge of cartilage microstructure and treatment options depending on defect size and stage.
Trauma
The trauma cases came thick and fast:
Neck of femur fracture in a 73-year-old, initially about THR type, bearings, NJR data, and approaches. The scenario then shifted to a 37-year-old, requiring open reduction techniques and complications.
Neck of femur fracture in a 73-year-old, initially about THR type, bearings, NJR data, and approaches. The scenario then shifted to a 37-year-old, requiring open reduction techniques and complications.
Shoulder dislocation with inconsistent APs – reduced, then apparently dislocated, then back in place – highlighting instability. A bony Bankart was identified, and we discussed management.
Open tibia fracture (GA IIIA) required BOAST-compliant management, external fixation, timing, and definitive fixation strategy.Floating knee with a cold, pulseless limb brought vascular compromise to the forefront – on-table angiography, ex-fix timing, and combined repair strategies.
Trimalleolar ankle fracture–dislocation tested management principles, surgical approaches in detail, and rehabilitation planning.
Finally, a 93-year-old with an olecranon fracture – a reminder that age and comorbidities must shape surgical decision-making.
Adult Pathology
This section was full of clinical nuance:
A foot ulcer case caught me out – I initially missed a toe amputation, only for the examiner to ask, “Can you count the toes?” I recovered with SINBAD scoring, differential diagnosis, and a structured management plan.
Medial knee OA led to a discussion of indications for high tibial osteotomy.
Post-traumatic AVN of the shoulder with an intact cuff on MRI opened discussion on total shoulder arthroplasty.
Primary elbow osteoarthritis in a manual worker required weighing fusion against total elbow replacement.
Hip prosthesis loosening four years post-THR tested approaches and differential diagnosis.
A subtrochanteric pathological fracture in a patient with prior nephrectomy for RCC focused on staging, biopsy, bone scans, and PET imaging – and on tailoring management for solitary versus multiple lesions.
Reflections
The FRCS exam demanded more than just textbook knowledge. It tested clarity of thought under pressure, resilience in the face of difficult examiners, and the ability to reach safe, consultant-level decisions quickly.
Some lessons stood out:
Always start with observation – even something as simple as counting toes.
Stay composed under silence or challenge – examiner style is part of the test.
Think like a consultant – prioritise, plan, and communicate clearly, even if you don’t reach the “perfect” answer.
The FRCS (Orthopaedics) examination stands as a formidable milestone in every orthopedic trainee’s career. It demands a breadth of clinical knowledge, clarity in decision-making, and the ability to perform under pressure. This blog is a comprehensive reflection on my own experience with the FRCS (Tr & Orth) exam in April 2021 — from the actual questions I was asked to how I approached them in real-time, with lessons learned along the way.
Viva Section
Trauma
Talar Fracture – Hawkins Type II
I was presented with a scenario of a talar neck fracture and asked to classify it. I described the Hawkins classification, focused on the vascular risk to the talus, and highlighted that Hawkins II involves subtalar joint subluxation. I was asked about the risk of avascular necrosis and how to reduce that risk surgically.
Biceps Tendon Rupture
A patient presented with a “Popeye” deformity and reduced supination strength. I explained the differences between proximal and distal ruptures, clinical tests like Hook test, and discussed surgical repair techniques and indications.
Non-Union of Humerus
The case involved a delayed union of a humeral shaft fracture. I was asked how to assess a non-union—clinical signs, radiographic features, and the role of infection. The discussion progressed into surgical approaches, particularly posterior and anterolateral approaches, and the considerations in revision surgery.
Polytrauma Scenario
Although the question initially focused on the ATLS approach, the examiner wanted a deeper discussion on physiological responses to trauma. I was probed on the components of the lethal triad—hypothermia, acidosis, and coagulopathy—and the principles of damage control resuscitation versus early total care.
Basic Science
Kaplan-Meier Curves
I was shown a survival curve and asked how to interpret it. The discussion shifted toward understanding variability—explaining the difference between common cause and special cause variation.
Funnel Plots
A graphical representation was shown, and I was asked how to use funnel plots to detect outliers in clinical performance or complication rates. I described how they help monitor consistency across institutions.
Tendon Healing
The stages of tendon healing were discussed—hemostasis, inflammation, proliferation, and remodeling. I was asked about specific inflammatory mediators released during the early phase.
Bone Healing
Using an image of a distal radius fracture treated with a spanning plate, I was asked to describe secondary bone healing. I discussed callus formation and the importance of micromotion and biological environment.
Muscle Length-Tension Relationship
I was asked to explain how muscle length affects force generation, and how this impacts function in conditions like tendon transfers or contractures.
Paediatrics
Fibular Hemimelia
I was asked to describe the clinical presentation and classification. The examiner wanted to discuss the implications for limb-length discrepancy and reconstructive strategies.
Cerebral Palsy
The focus was on the GMFCS classification and how it helps guide treatment. I was presented with a case of bilateral hip subluxation and asked about surveillance, conservative management, and surgical options.
Paediatric Neck of Femur Fracture
A scenario was given involving a child presenting late at night with a neck of femur fracture. I was asked if I would operate out-of-hours and why. The discussion included fracture classification (Delbet), risk of AVN, and fixation options.
Hands
Ollier’s Disease
A case with multiple lucent lesions in the hand prompted a differential diagnosis. I explained the distinction between Ollier’s and Maffucci’s syndrome, the risk of malignant transformation, and long-term monitoring.
Flexor Tenosynovitis
I was given a clinical image and asked to identify Kanavel’s signs. I discussed urgent surgical management and empirical antibiotic therapy.
Rheumatoid Hand
The examiner presented a classic RA deformity and asked about joint involvement, tendon ruptures, and the rationale behind common surgical interventions like synovectomy and tendon transfer.
Adult Pathology
Heterotopic Ossification Post-Hip Resurfacing
The question focused on identifying the condition on imaging and discussing preventive strategies (indomethacin, radiotherapy) and treatment options.
Cauda Equina Syndrome
I was asked to describe the clinical red flags, when to perform an MRI, and the timeframe for decompression. The discussion extended into medico-legal implications of delayed diagnosis.
Early Elbow Arthritis
I was introduced to the concept of the Outerbridge-Kashiwagi (OK) procedure, including indications and expected outcomes.
Meniscal Cyst
An MRI scan was shown, and I was asked about diagnosis, association with meniscal tears, and arthroscopic management strategies.
Protrusio Acetabuli
I was asked about the challenges it presents during hip arthroplasty and how to choose an appropriate implant. The discussion covered techniques to restore hip biomechanics.
Intermediate Cases
Radial Club Hand (Upper Limb):
I examined a patient and discussed classification, associated syndromes (e.g., Holt-Oram), and staged reconstructive options including soft-tissue releases and centralization procedures.
Valgus Knee in a 52-Year-Old Male (Lower Limb):
I examined the patient and was led into a discussion on high tibial osteotomy. I was asked about indications, alignment correction principles, and outcomes compared to total knee replacement.
Short Cases
Set 1:
Adolescent Idiopathic Scoliosis:
I was asked to assess the posture, perform Adams forward bend test, and interpret radiographs using Cobb angle. Management included bracing versus surgical intervention based on curve severity.
Congenital Pseudoarthrosis of Tibia:
A child presented with a bowed tibia and non-union. I discussed the association with neurofibromatosis and surgical strategies like intramedullary nailing or vascularized fibular graft.
Physiological Flatfoot in a Teenager:
I was reassured by the presence of a normal arch on tiptoe. I discussed how to differentiate it from pathological causes, and reassured the examiner that no treatment was needed.
Set 2:
Pectoralis Major Rupture:
The scenario involved a weightlifter with anterior shoulder bruising. I discussed mechanism of injury, clinical signs, and MRI confirmation, followed by surgical repair techniques.
Sagittal Band Rupture in the Hand:
The patient could not extend the middle finger properly. I explained the diagnosis, mechanism, and repair options.
Spinal Assessment in a 6-Year-Old:
I was asked to examine posture, gait, and perform neurological assessment. The discussion focused on early detection of scoliosis and red flags such as back pain and neurological deficit.
Final Reflections:
This exam tested far more than textbook knowledge. It assessed clinical judgment, surgical planning, communication skills, and emotional resilience. There were moments of doubt, some tricky stations, and challenging examiners. But what carried me through was preparation, consistency, and learning from each case discussed with peers and mentors.
My Advice to Future Candidates:
Prepare Broadly and Deeply: Ensure wide coverage of the syllabus, particularly basics and principles.
Practice Clinical Exams Religiously: Use clinics as mock exams, and hone your presentation under time pressure.
Viva Practice is Key: The more you speak out loud, the more confident and structured you become.
Stay Focused in the Exam: If one station goes poorly, reset your mindset for the next.
The FRCS is not just an exam; it’s a culmination of your training and a gateway to becoming an independent orthopaedic surgeon. Trust your preparation, stay calm under pressure, and go in knowing that you’ve done everything to earn the title. Good luck!
VIVA:
Pediatrics and Hands
- Perthes Disease
- Question: Discuss the classification, prognostic factors, important points in history and examination, differential diagnosis (DD), and how to exclude infection.
- My Answer: I described the Catterall and Herring classifications for Perthes disease. Prognostic factors included age at onset and extent of femoral head involvement. Important points in history involved the onset of limp and hip pain, while examination focused on limited hip abduction and internal rotation. To exclude infection, I mentioned blood tests and imaging, including MRI to assess joint effusion.
- Femur Fracture in a 9-Month-Old
- Question: No X-ray provided; discuss non-accidental injury (NAI) in detail.
- My Answer: I emphasized the importance of considering NAI in infants with femur fractures, discussing red flags such as inconsistent history, delay in seeking treatment, and multiple fractures at different healing stages. I also mentioned involving a multidisciplinary team for assessment and safeguarding.
- Left Thoracic Scoliosis
- Question: Discuss history, examination, differential diagnosis, investigation, and management.
- My Answer: I outlined a thorough history and examination focusing on the curve’s severity and progression. For investigation, I recommended a full spine X-ray and MRI. Management options included observation for mild curves, bracing for moderate curves, and surgery for severe or progressive scoliosis.
- Rheumatoid Hand
- Question: Describe the findings, history, expectations, and patient conditions.
- My Answer: I described common deformities such as ulnar deviation, swan neck, and boutonniere deformities. History should include duration of symptoms, functional impairment, and systemic involvement. Examination would reveal joint tenderness and swelling.
- Central Wrist Pain in a Young Patient
- Question: Discuss differential diagnosis, history, and examination; X-ray revealed Kienböck’s disease.
- My Answer: I listed differential diagnoses including Kienböck’s disease, TFCC injury, and scaphoid fracture. The history included pain exacerbation with activity and past trauma. Examination focused on wrist tenderness and range of motion.
- Proximal Phalanx Fracture
- Question: Discuss the management of a 90-degree dorsal angulated fracture.
- My Answer: Initial management involved manipulation under sedation and possible fixation with a temporary splint or buddy taping. I discussed sedation options, local anesthesia techniques, and doses.
Basic Science
- Compression Stress-Strain Curve of Bone
- Question: Draw and explain the stress-strain curve for normal bone, osteomalacia, and osteoporosis.
- My Answer: I drew the standard stress-strain curve and explained differences in osteomalacia and osteoporosis, noting decreased stiffness and strength.
- Hip Osteolysis and Wear
- Question: Discuss the X-ray findings and bearing surfaces.
- My Answer: I identified osteolysis and linear wear, and discussed the types of bearing surfaces, their wear patterns, and lubrication mechanisms.
- Anatomy of the Hand
- Question: Identify structures in a cadaveric image.
- My Answer: I detailed the anatomy of hand muscles, vascular arches, and compartments, and explained the surgical release techniques.
- Non-Accidental Injury (NAI)
- Question: Discuss NAI and consent in children.
- My Answer: I covered the signs of NAI and the importance of multidisciplinary assessment, including Gillick competency for consent.
- Theatre Design
- Question: Discuss theatre ventilation and prerequisites for arthroplasty.
- My Answer: I explained laminar flow systems, pros and cons of different ventilation types, and essential theatre requirements for arthroplasty.
- Cartilage Defect
- Question: Discuss arthroscopic findings and treatment options.
- My Answer: I described cartilage structure, stages of damage, and treatments such as microfracture, autologous chondrocyte implantation, and osteochondral grafting.
Trauma
- Neck of Femur (NOF) Intracapsular Fracture
- Question: Discuss treatment options for different age groups.
- My Answer: For a 73-year-old, I recommended total hip replacement (THR), discussing types, bearings, and approaches. For a 37-year-old, I suggested open reduction and internal fixation (ORIF).
- Shoulder Dislocation
- Question: Management of unstable shoulder dislocation.
- My Answer: I described imaging findings, management of bony Bankart lesions, and surgical stabilization techniques.
- Open Tibia Fracture
- Question: Management according to BOAST guidelines.
- My Answer: I discussed initial debridement, external fixation, and definitive fixation methods.
- Floating Knee with Cold Pulseless Limb
- Question: Management and surgical approach.
- My Answer: I emphasized on-table angiography and staged external fixation during vascular repair.
- Trimalleolar Ankle Fracture
- Question: Discuss management and approaches.
- My Answer: I detailed initial reduction, definitive fixation, and post-operative rehabilitation.
- Olecranon Fracture in Elderly
- Question: Discuss management options.
- My Answer: I reviewed conservative management versus surgical options, considering comorbidities and functional demands.
Adult Pathology
- Foot Ulcer with Amputated Toe
- Question: Management and assessment.
- My Answer: I used the SINBAD classification for ulcer severity and discussed management options, including offloading and wound care.
- Medial Knee Osteoarthritis (OA)
- Question: Discuss High Tibial Osteotomy (HTO).
- My Answer: I explained indications, surgical technique, and expected outcomes of HTO.
- Shoulder Post-Traumatic Avascular Necrosis (AVN)
- Question: Management options.
- My Answer: I discussed total shoulder arthroplasty (TSA) and the importance of rotator cuff integrity.
- Primary Elbow OA
- Question: Management options in a manual worker.
- My Answer: I reviewed conservative treatments, arthroscopic debridement, and the option of total elbow replacement (TER) versus fusion.
- Hip Loosening Post-THR
- Question: Approach and differential diagnosis.
- My Answer: I detailed the diagnostic workup, including infection assessment, and discussed revision strategies.
- Pathological Subtrochanteric Fracture
- Question: Management in metastatic RCC.
- My Answer: I emphasized the importance of staging with bone scans and PET scans, and discussed surgical management for solitary versus multiple metastases.
Final Thoughts
Reflecting on my FRCS experience, the journey was challenging but immensely rewarding. The preparation and exam process enhanced my orthopedic knowledge and clinical skills. For those preparing for the FRCS, remember that consistency, thorough preparation, and support from peers and mentors are key to success. Keep pushing forward, as the rewards are truly worth the effort.
The FRCS exam is known for its rigorous standards and comprehensive evaluation of a candidate’s knowledge and clinical skills. Having gone through this challenging yet rewarding journey, I aim to share my experience to help future candidates navigate their preparation and exam process.
VIVA:
Trauma:
- Open Tibia Fracture:
- Question: How would you manage an open tibia fracture?
- My Answer: This was a straightforward case where I discussed the initial management, including debridement, stabilization, and antibiotics.
- ACJ Dislocation:
- Question: How would you manage an ACJ dislocation?
- My Answer: This was another straightforward question, where I discussed conservative and surgical treatment options.
- Shoulder Pain in a 50-Year-Old Man Post-Trauma:
- Question: What is your differential diagnosis?
- My Answer: I listed traumatic cuff tear, frozen shoulder, cervical spine issues, and biceps tendinitis. When asked about the investigation, I suggested MRI for detailed assessment, explaining that it would show cuff retraction, muscle atrophy, and other pathologies. The examiner was not fully convinced and pressed further.
- Hypertrophic Non-Union of the Humerus:
- Question: How would you manage a 10-week-old closed fracture with hypertrophic non-union and angulation?
- My Answer: I suggested ORIF without bone graft initially but added that an iliac autograft might be necessary if the condition persisted for six months.
- Posterior Hip Dislocation with Sciatic Palsy:
- Question: How would you manage this case?
- My Answer: I would perform an open reduction if closed reduction failed. When asked about my approach, I detailed the Kocher-Langenbeck approach and emphasized preserving femoral head vascularity and exploring the nerve during the same session.
- Ankle Fracture Dislocation:
- Question: What are the critical steps in managing this condition?
- My Answer: I highlighted the importance of identifying the posterior malleolus fracture, obtaining a CT scan, and understanding the classification of posterior malleolus fractures.
Adult Pathology:
- Infected Loose Charnley Hip:
- Question: What are the risk factors for infection?
- My Answer: I categorized them into general (e.g., diabetes, RA) and local factors. I discussed diabetes management using HbA1c levels and the impact of RA medications like NSAIDs, steroids, and DMARDs.
- Hallux Valgus in a 50-Year-Old Lady:
- Question: How would you manage this condition?
- My Answer: I detailed history, examination, and investigation steps. For treatment, I suggested fusion for arthritic joints but also discussed SCARF, ATKIN, and lateral release for non-arthritic cases. When complications like metatarsalgia were introduced, I mentioned troughing and first CMC hypermobility as potential causes.
- Necrotizing Fasciitis:
- Question: Explain the classification, causative organisms, and management.
- My Answer: I covered the classification, listed causative organisms, and detailed management, including LRINEC scoring and surgical debridement.
- Degenerative Lumbar Scoliosis:
- Question: How would you approach this condition?
- My Answer: I discussed history, examination, and suggested full spine X-rays to assess sagittal balance before proceeding to MRI. I outlined conservative treatments and mentioned nerve root injections and surgical options.
- Valgus Knee with OA:
- Question: What are the treatment options?
- My Answer: I initially suggested TKR but corrected to include varus osteotomy for earlier stages. I also detailed the steps involved in TKR.
- Osteochondroma at the Proximal Fibula:
- Question: How would you manage this condition?
- My Answer: I outlined history, examination, MRI evaluation, and treatment via marginal excision.
Basic Science:
- MRI Mechanics:
- Question: Explain how MRI works and interpret specific sequences.
- My Answer: I described the principles of MRI and attempted to interpret a complex cervical spine MRI, although I struggled with some technical terms.
- Pregnancy-Related Imaging:
- Question: How would you manage imaging in a pregnant lady with thigh pain?
- My Answer: I suggested using precautions for X-rays and explained the guidelines for MRI use in pregnancy. Later, I discussed the management of a fracture through an aggressive lesion post-delivery.
- Compartment Syndrome:
- Question: What is the differential diagnosis and management of leg pain post-rugby match?
- My Answer: I discussed compartment syndrome and detailed the cross-sectional anatomy of the leg.
- Tendon Healing:
- Question: What are the factors affecting tendon healing and its blood supply?
- My Answer: I described the healing process, the role of vincula, and blood supply dynamics.
- Kaplan-Meier Survival Analysis:
- Question: Draw and interpret a survival curve.
- My Answer: I explained how censoring affects the curve and mentioned alternative survival analysis methods.
- Thenar Wasting and CTS:
- Question: How would you examine and manage bilateral thenar wasting?
- My Answer: I suggested NCS for routine confirmation of CTS and differentiation from cervical or double crush syndrome.
Paediatric and Hand Cases:
- Monteggia Fractures:
- Question: How would you manage these fractures?
- My Answer: I provided a straightforward approach to diagnosis and treatment.
- DDH in a 2-Month-Old Baby:
- Question: How would you manage this condition?
- My Answer: I discussed history, examination, management, and handling complications post-Pavlik harness application.
- LLD and Neurofibromatosis:
- Question: Discuss differential diagnosis and management.
- My Answer: I mentioned neurofibromatosis and hemihypertrophy, detailing concerns and guided growth procedures.
- Scaphoid Waist Fracture:
- Question: What is the conservative management protocol?
- My Answer: I discussed the SWIFT trial and management of suspected scaphoid fractures.
- Rugger Jersey Finger:
- Question: Describe the classification and treatment.
- My Answer: I explained the classification, examination for FDP and FDS, and acute injury treatment. I mistakenly suggested extending the incision too far proximally.
- Post-Op Dupuytren’s with Skin Graft:
- Question: Explain the rationale for skin graft use.
- My Answer: I described full-thickness grafts, donor sites, and patient examination.
Clinicals:
- Scoliosis with Previous Leg Surgeries:
- Question: What is your differential diagnosis?
- My Answer: I suggested possible neurofibromatosis.
- Shoulder Pain in a 40-Year-Old:
- Question: How would you approach this case?
- My Answer: I provided a history and examination but struggled to reach a definitive diagnosis due to non-specific MRI findings.
- Lower Limb Short Cases:
- Questions: Discuss PCL injury, tibialis posterior dysfunction with flat foot, and valgus knee with OA.
- My Answer: I provided detailed assessments and management plans for each condition.
- Upper Limb Short Cases:
- Questions: Discuss high-pressure injection injuries, 1st CMC OA with STT arthritis, and hand rheumatoid arthritis.
- My Answer: I detailed history, examination, and management for each case, including compartment syndrome and surgical options for arthritis.
Final Thoughts
The FRCS exam was challenging, but the thorough preparation and structured approach helped me succeed. Future candidates should focus on consistent study, form study groups, find mentors, and utilize multiple resources. The experience was demanding but immensely rewarding, significantly enhancing my clinical skills and knowledge.
My FRCS Exam Experience: A Personal Reflection
Preparing for the Fellowship of the Royal College of Surgeons (FRCS) exam is a demanding and transformative process. This blog provides a detailed account of my experience with the FRCS exam, highlighting the structure, the challenges faced, and the strategies used to overcome them. For candidates aspiring to take the exam, this reflection serves as a guide to understanding what to expect and how to prepare effectively.
Intermediate Cases
- Upper Limb – Post-Traumatic Shoulder Pain
A middle-aged patient presented with shoulder pain and difficulty performing his plumbing work, following previous surgery for a proximal humerus fracture.
- Examination and Discussion:
The patient had wasting in the supraspinatus and infraspinatus fossae, full range of motion with impingement pain, though impingement tests were negative. I was asked about rotator cuff tests and potential differential diagnoses, which included a rotator cuff tear and suprascapular nerve injury. Management options discussed included conservative treatment with physiotherapy, corticosteroid injections, and surgical intervention if required.
- Lower Limb – Hip Pain Following Trauma
A middle-aged man with hip pain had a history of subtrochanteric fracture treated with a dynamic condylar screw (DCS) plate, with subsequent hip arthritis and implant loosening.
- Examination and Discussion:
After ruling out infection using the Sepsis Six approach and routine history-taking, I examined the patient with focus on gait analysis, Trendelenburg test, and Thomas test. I suggested investigations, including blood tests and imaging, and explained that I would proceed with aspiration or implant removal for cultures to exclude infection. For management, I emphasized ruling out infection first, using microbiological guidance, and planning arthritis surgery. There was also a discussion about cement antibiotic beads and their duration of antibiotic elution.
Short Cases
Upper Limb:
- Rheumatoid Hand with Dropped Fingers:
The patient presented with dropped fingers affecting the ring and little fingers. I discussed differential diagnoses, including extensor tendon rupture and joint instability, and outlined the investigative and management approach.
- Elbow Osteoarthritis:
Examination findings were discussed, including reduced range of motion and crepitus. I elaborated on investigations such as X-rays and MRI and management options, including conservative treatment and surgical options like arthroplasty.
Lower Limb:
- Necrotizing Fasciitis:
The focus was on recognizing the condition clinically, discussing emergency surgical debridement, and outlining principles of antibiotic therapy and intensive care management.
Basic Sciences
- Neural Tube Formation and Limb Bud Development:
The examiners explored the genes involved, such as HOX and SHH, and their respective roles in embryological development.
- Patient Refusing Blood Transfusion for Hip Replacement Surgery:
This case required discussing the preoperative, intraoperative, and postoperative strategies to minimize blood loss, including cell salvage, iron supplementation, and erythropoietin.
- DEXA Scan Interpretation:
Questions covered T and Z scores, indications for investigations in high Z scores, and the mechanism of action of bisphosphonates.
- Tuberculosis Histopathology:
A histopathology slide with Ziehl-Neelsen staining was shown. I described the findings and discussed the management of osteoarticular tuberculosis.
Trauma
- Acetabular Fracture with Medial Wall Involvement:
Management involved preoperative planning, imaging studies, and surgical stabilization.
- Open Ankle Fracture with Talus Subluxation:
The case required emergency management principles, including wound care, reduction, stabilization, and antibiotic prophylaxis.
Adult Pathology
- Complex Regional Pain Syndrome (CRPS):
A patient presented with persistent foot pain following a minor injury. The discussion revolved around the Budapest criteria for CRPS diagnosis, clinical features, and management strategies.
- Hallux Valgus with Additional Forefoot Deformities:
A photo showed hallux valgus, hammer toes, claw toes, and a crossover toe. I discussed the evaluation and surgical management options for each deformity.
Paediatric Cases
- Genu Varum:
Discussion included Selenius curve, Blount’s disease classification, and surgical management options.
- Clavicle Pseudoarthrosis and Sprengel’s Deformity:
The patient had a combination of conditions requiring detailed evaluation and discussion of surgical management.
Hands and Miscellaneous Cases
- Jersey Finger:
A middle finger injury in a rugby player was discussed. The Leddy and Packer classification was highlighted, along with surgical techniques for tendon repair and rehabilitation protocols.
- Thenar Wasting:
The examiners focused on diagnosing carpal tunnel syndrome and discussing advanced presentations, investigations, and management.
Reflections and Advice
- Start Early:
Begin preparation as early as possible, focusing on both theoretical knowledge and practical skills. Clinical examination techniques should be second nature by the time of the exam.
- Practice Vivas:
Regular viva practice is essential. Engage with colleagues, mentors, and consultants to simulate exam scenarios. Focus on clear, concise, and structured answers.
- Attend Courses:
FRCS preparation courses provide valuable exposure to real-life cases and exam simulations. Prioritize courses offering patient interactions and mock exams.
- Stay Consistent:
Consistent study routines, combined with focused revision in the final months, help reinforce core concepts and clinical decision-making skills.
- Stay Calm During the Exam:
The examiners are there to assess your knowledge and thought process. Even when faced with challenging or unfamiliar scenarios, focus on systematic problem-solving and avoid getting flustered.
Final Thoughts
The FRCS journey was undoubtedly one of the most challenging experiences of my career, but it was also incredibly rewarding. It refined my clinical skills, deepened my knowledge, and prepared me for the responsibilities of independent practice. For those preparing for the exam, remember that perseverance, dedication, and structured preparation will lead to success. Keep practicing, stay focused, and trust in your training. Good luck!
FRCS (Tr & Orth) Glasgow 2021 – Reflections from the Hot Seat
Sitting the FRCS (Tr & Orth) in April 2021 was one of the most intense professional experiences of my life. It was a true test of composure, clinical reasoning, and the ability to think under pressure. The examiners were fair but unrelenting, and every minute felt like a rapid-fire test of knowledge, judgment, and calmness.
What follows is a personal account of the viva and clinical stations — the questions that came my way, how they unfolded, and what I learned along the journey.
Viva Day
Table 1: Paediatrics and Hands
The first case set the tone:
A 3-year-old girl presented with a limp for three months. Framing the history under time pressure was challenging, and the examiner wanted a brisk pace. The X-ray showed a small, solitary cystic lesion crossing the physis — prompting differentials such as simple bone cyst, fibrous dysplasia, and chondroblastoma. I was asked to identify the most likely diagnosis and outline next steps.
Next, a 10-year-old child with a completely displaced Salter–Harris II ankle fracture and blanching skin on the medial side — a reminder that in paediatric trauma, recognition of impending skin necrosis and urgent reduction can be life-saving.
Then, an image of an 8-week-old baby with torticollis. The discussion focused on history, examination, and management, but the examiner particularly wanted to hear the phrase “packaging disorder” — a subtle but key learning point.
Hands
The hand questions followed swiftly:
A 55-year-old woman with a fusiform swelling over the dorsum of the wrist. The history and examination pointed toward extensor tenosynovitis secondary to inflammatory arthritis. I was asked to describe management and discuss when to investigate for underlying systemic disease.
Next, a 50-year-old woman with a swelling over the dorsum of the thumb IPJ and a faint scar — consistent with a recurrent dermoid cyst. I nearly lost the term in the moment but recovered by describing the surgical principles: excision of the osteophyte and local rotational flap for poor-quality overlying skin.
Finally, a “fight bite” three days old from a pub brawl abroad. A classic hand emergency — debridement, washout, antibiotics, and awareness of potential joint involvement.
Basic Science
A mix of biomechanics, pathology, and applied principles made this section particularly unpredictable.
The first image showed an external fixator with distal Schanz screws inserted into the fracture zone of a segmental tibia. I was asked to critique it and suggest how to improve stability (adding a bone bar and pins outside the fracture site). The discussion moved into modes of fracture healing.
Next, an X-ray of a dislocated total hip replacement just two days post-op. The questions explored causes of early dislocation, implant design, patient factors, and whether larger heads always reduce dislocation risk — leading into a conversation about wear mechanics and modes of wear.
Then came an image of necrotising fasciitis — unmistakable once described. The discussion focused on BOAST guidelines, LRINEC score parameters, surgical debridement zones, and indications for amputation.
A question on tourniquet safety followed. I was asked to describe ideal length, width, pressure, padding, and timing. Then came curveballs: what happens if wrapped twice? What if it’s too narrow? Do tourniquets actually occlude blood vessels? I smiled — this was one for humility.
An X-ray of a loose total knee replacement tested planning for revision surgery, bone graft integration, and graft incorporation timelines.
Finally, a governance scenario: “As a new consultant, how do you monitor your performance?” I drew a control chart, discussed special vs common cause variance, and mentioned MDT review and governance action. The examiner smiled — not because I was perfect, but because I’d stayed logical under fire.
Adult Pathology
The cases came quickly and covered the spectrum:
Rheumatoid elbow: describe features, discuss stability and indications for total elbow replacement, referencing NJR data and Morrey’s 1998 paper.
Pathological subtrochanteric fracture in metastatic prostate cancer: pre-operative optimisation, oncological input, and the role of proximal femoral replacement per BOOS guidelines.
Varus knee OA with previous femoral shaft fixation visible on X-ray: detailed discussion of history, examination (including rotational profile), and staged arthroplasty when navigation unavailable.
Achilles tendon rupture in a weekend athlete: clinical tests, imaging, and modern rehabilitation principles — referencing Claire Topliss’ enhanced recovery paper.
Diabetic foot ulcer: NICE and BOFAS guidelines, MDT approach, and three domains of management — mechanical, biological, and infection control. In the final seconds, I was asked to describe a ray amputation.
Osteosarcoma of distal femur in an 8-year-old with a pathological fracture: discussed red flags, referral pathways, and biopsy principles.
Trauma
This section truly tested decision-making:
Open subtalar and talonavicular dislocation: discussion centred on obstacles to reduction and safe surgical sequencing.
Comminuted distal humerus fracture in a 70-year-old: management options including acute total elbow replacement.
Thoracolumbar fracture after a fall from a horse: I mentioned sacral injury before being redirected to the L2 fracture with complete neurological loss. Discussion included decompression, realignment, and stabilisation principles — though I misread what the examiner wanted.
Missed posterior shoulder dislocation two months post-fall: X-rays showed a large reverse Hill–Sachs lesion. The examiner wanted imaging workup and discussion of reverse vs anatomic replacement.
Femoral head fracture: fixation versus replacement, surgical approaches (Ganz vs posterior), and fixation options with headless screws.
Young adult with displaced intracapsular neck of femur fracture: fixation strategy, approach, intraoperative setup, and complications such as AVN — referencing the FAITH trial. The bell finally rescued me mid-answer.
Clinical Section
Intermediate Upper Limb
A 34-year-old right-handed woman presented with hand tingling during presentations. The history evolved into episodes of discoloration, neck pain, and mixed sensory symptoms — a combination suggesting double crush syndrome. Nerve conduction and EMG findings supported the diagnosis, and the discussion moved toward carpal tunnel injection, decompression, and vascular referral.
Intermediate Lower Limb
A 23-year-old man with knee instability one year after a rugby injury. Examination videos demonstrated positive Lachman and valgus stress tests — indicating combined ACL and MCL injury. We discussed staged reconstruction and rehabilitation strategies before the bell.
Short Upper Limb Cases
A 50-year-old woman post-FOOSH with wrist pain — the image showed Madelung’s deformity.
A 55-year-old with a wrist scar and draining sinus — non-union after fusion with plate failure.
A middle-aged man with limited shoulder abduction after ORIF of a proximal humerus fracture — ultimately a failed hemiarthroplasty with tuberosity non-union.
Short Lower Limb Cases
A 23-year-old with recurrent knee instability — ACL and PLC injury; key principle: “sheath before the core.”
A 20-year-old with a medial knee swelling — osteochondroma; discussed red flags and malignant transformation risk.
A 4-year-old girl with blue sclera and multiple deformities — osteogenesis imperfecta, and the examiner tested differential diagnosis and safeguarding principles before confirming NAI had been excluded.
Final Reflections
The FRCS (Tr & Orth) exam is not about perfection. It tests how you think, how you adapt, and how you hold composure when you don’t know the answer.
Some examiners push, some smile, some stay silent — but all want to see if you can stay calm, safe, and logical under scrutiny. Preparation helps, but resilience is what carries you through.
It’s not just an exam of orthopaedics — it’s an exam of character. Lessons for Future Candidates Practise fast, structured thinking. Time moves faster than you expect. Never bluff — explain your reasoning clearly. Be systematic with every patient image. Expect cross-topic jumps — anatomy, biomechanics, and governance may appear in one sitting. Stay human. A smile and honesty often score better than panic. The FRCS experience reminded me that surgical success is not only in the hands — but in the head and heart.
As an orthopedic surgeon, preparing for the Fellowship of the Royal College of Surgeons (FRCS) exam was one of the most challenging and rewarding experiences of my career. Here, I recount my journey through the FRCS (Orth) exam, held from 29th April to 1st May 2018 in Northumberland, detailing the questions I encountered and how I approached them.
Clinicals:
Intermediate Cases
Lower Limb Case: 64-Year-Old Man with Left Ankle Pain
- History: The patient’s primary complaint was stiffness. He described walking as if on pebbles. He had sustained an ankle fracture 30 years prior, treated with a cast. He was diabetic, and surgery was not being offered at the time.
- Examination: The ankle was deformed with swelling on both sides and a varus heel. He stood on the lateral border of his foot with the first metatarsophalangeal joint off the floor. There was a prominent osteophyte on the lateral side with skin erosion and minimal tenderness. The ankle and subtalar movements were significantly restricted. There was a psoriasis-like patch on the shin.
- Discussion: The X-rays indicated a Charcot ankle. I discussed the stages of Charcot arthropathy, the conservative management involving offloading and custom footwear, and the indications for surgery, which include severe deformity, ulceration, or instability. The skin patch could be related to psoriasis or chronic venous stasis changes.
Upper Limb Case: 15-Year-Old Girl with Right Shoulder Issues
- History: The patient had recurrent shoulder dislocations up to ten times a day for the last four years and was diagnosed with Ehlers-Danlos Syndrome. Other family members were also affected.
- Examination: The shoulder showed a visible sulcus sign, anterior subluxed humeral head (palpable) with a posterior dip, and wobbling on active movements. Scapular movement was minimal, and provocative tests were unnecessary as dislocations occurred easily.
- Discussion: The primary issue was multidirectional instability due to Ehlers-Danlos Syndrome. Management included physical therapy to strengthen shoulder muscles and stabilize the joint. Investigations would include MRI to assess soft tissue integrity and plan surgical interventions if necessary. For an arthrogram, gadolinium could be used. Surgical options might include capsular plication or labral repair depending on the specific pathology identified.
Short Cases
Lower Limb Cases
- Hallux Valgus:
- Examination: I examined the left forefoot, noting the crease on the toe due to the bunion deformity.
- Discussion: X-rays would guide the choice of surgical procedure, with options including osteotomy or fusion depending on severity and patient preference.
- Leg Length Discrepancy:
- Examination: I assessed the leg length discrepancy using tape measurements, the Galeazzi test, and Bryant’s triangle.
- Complex Knee Osteoarthritis:
- History: The patient had multiple scars on the femur and tibia, varus knee, and a short leg with a range of motion from 0-35 degrees.
- Discussion: The primary challenges in offering total knee replacement (TKR) included previous osteomyelitis and extensive scarring. Preoperative planning and possibly staged surgery were necessary.
Upper Limb Cases
- Left Elbow Problem:
- Examination: The elbow showed no scars, swelling, wasting, deformity, or tenderness, but had a slight loss of extension. The patient experienced clicking.
- Discussion: Posterolateral rotatory instability (PLRI) tests were stable, but coronal instability tests were needed for further assessment.
- Rheumatoid Hands:
- Examination: The left hand exhibited caput ulnae, MCP joint swellings, and an extensor pollicis longus (EPL) rupture. Functional assessment was good with no other tendon ruptures or neurodeficits.
- Gouty Tophi in Fingers:
- Discussion: The tophi were consistent with gout. The patient had scars on the posterior elbows and left index finger, suggesting possible previous surgeries. Other differentials included rheumatoid nodules. Tophi could also be found on the ear helix and Achilles tendon.
VIVA:
Adult Pathology
- Loose Cemented Femoral Stem:
- Discussion: I described the osteolysis around the cemented femoral stem and differentiated between aseptic and infected loosening using clinical and imaging criteria. Management included infection workup and revision surgery.
- Cauda Equina Compression:
- Discussion: The MRI showed compression, and I detailed patient assessment, types of disc prolapse, and the pathophysiology of cauda equina syndrome. Surgical decompression was essential.
- Jehovah’s Witness Requiring TKR:
- Discussion: Preoperative planning involved consulting with the patient and a Jehovah’s Witness liaison committee. Intraoperative strategies included blood conservation techniques and possibly using a cell saver. Postoperative care required careful monitoring.
- Humeral Head AVN:
- Discussion: The X-ray showed advanced osteoarthritis and collapse due to avascular necrosis (AVN), often associated with steroid use. Management options included total shoulder replacement.
- Knee with Medial Compartment Osteoarthritis:
- Discussion: The X-ray showed bone-on-bone contact. Surgical options included TKR, and I discussed high tibial osteotomy (HTO) versus unicompartmental knee replacement (UKR), citing relevant evidence.
- Diabetic Foot Ulcer:
- Discussion: The ulcer at the 2nd metatarsophalangeal joint was likely due to pressure points and previous toe amputation. Expected findings included neuropathy and poor peripheral circulation.
Trauma Cases
- Resurfaced Hip with Displaced NOF:
- Discussion: I discussed the management of a traumatic neck of femur fracture in a resurfaced hip, including surgical options and required equipment.
- Displaced Galeazzi Fracture:
- Discussion: Initial management involved stabilization, with surgical intervention planned based on the patient’s condition. The approach included open reduction and internal fixation.
- Pelvis Fracture:
- Discussion: The X-ray showed a bilateral pelvic fracture. I discussed associated injuries, management according to ATLS guidelines, and preparation for possible laparotomy.
- Trimalleolar Ankle Fracture:
- Discussion: The fracture required immediate reduction and stabilization. Post-reduction CT showed subluxation, necessitating surgical intervention.
- Non-Union of Distal Femur Fracture:
- Discussion: The X-ray showed a failed retrograde IM nail in a diabetic patient. Causes of non-union included poor vascularity and infection. Management involved revision surgery.
- Distal Humerus Shaft Fracture:
- Discussion: I identified the fracture, discussed associated complications, and outlined surgical management, including ulnar and radial nerve considerations.
Hands Cases
- Wasted Thenar Eminence:
- Discussion: The patient likely had carpal tunnel syndrome. Assessment included median nerve tests and differentiation from anterior interosseous nerve (AIN) syndrome.
- Transverse Laceration on Volar PP:
- Discussion: The injury suggested flexor tendon damage. Management included appropriate surgical repair with core suture techniques.
- Intraarticular Base of MP Fracture:
- Discussion: Management involved surgical fixation, with a detailed approach to the volar plate and PIP joint.
Paediatrics Cases
- Intoeing in a 2-Year-Old:
- Discussion: Assessment involved examining the rotational profile and measuring femoral anteversion and tibial version clinically.
- Rigid Flatfeet in a 10-Year-Old:
- Discussion: X-rays showed a C-sign, indicating tarsal coalition. Treatment options ranged from conservative management to surgical resection.
- Scoliosis in a 12-Year-Old:
- Discussion: The X-ray showed a right thoracic curve with fused ribs. I identified the apical and end vertebrae, estimated the Cobb angle, and discussed possible causes and further examination.
Basic Science Cases
- Types of Plates:
- Discussion: I described various plates, including locking and non-locking plates, their mechanisms, and applications in fracture fixation.
- Cut Median Nerve:
- Discussion: I outlined types of nerve injuries, repair techniques for different gap sizes, and the use of sural nerve grafts.
- Large Swelling on Dorsum of Hand:
- Discussion: Differential diagnoses included chondrosarcoma and enchondroma. Further investigation with imaging and biopsy was discussed.
- Muscle Types:
- Discussion: I explained unipennate and bipennate muscles, their differences, and examples.
- Articular Cartilage Injury:
- Discussion: I described the consequences of cartilage injury and management strategies for various defect sizes.
- VTE Management:
- Discussion: I outlined preoperative and intraoperative management for patients with a history of VTE, including those with PE, venacava filters, and on anticoagulants.
Conclusion
The FRCS exam was a rigorous but immensely rewarding experience. The detailed preparation and comprehensive understanding required not only enhanced my clinical skills but also provided a solid foundation for my orthopedic practice. For those preparing for the
As I prepared for the FRCS exam, I embarked on a journey of intense study and preparation, drawing from a variety of resources to ensure a well-rounded understanding of orthopaedics.
Study Materials
Books
To consolidate my knowledge, I created my own notes from a mix of several key texts:
- The Concise Orthopaedic Notes by Firas Arnaout
- The last 5 years of JAAOS review papers
- Orthobullets and Stryker Hyperguide – These provided a great source of MCQs, though not exactly like the exam questions, so they couldn’t be relied upon solely.
- The OrthoQuiz MCQs by the Orthopaedic Academy
Each of these sources provided valuable insights, but no single book was comprehensive. Together, they formed a robust foundation. Additionally, Hoppenfeld’s Surgical Exposures in Orthopaedics was crucial for viva preparation, especially the approaches I was less familiar with, like the posterior approach to the knee and shoulder. Mastering these techniques was essential, and I practiced discussing all approaches until it became second nature.
Courses
Courses booked out quickly, so I planned strategically, booking early to address deficient areas and then closer to the exam for intensive preparation. I attended several key courses:
- The FRCS Mock-Exam Course by the ORUK
- Wrightington Course – A week-long course held seven months before the exam, which was invaluable for identifying key areas to focus on.
- Norwich Course – This course had an impressive patient load and was well-organized, providing ample hands-on experience.
- Oxford Course – Though not great for patient exposure, it offered numerous viva sessions and a worthwhile practice exam.
In hindsight, I realized I might have overdone it with the number of courses, given their high cost.
Workload and Preparation
Having a study partner was invaluable. We sought out bosses willing to viva us at any convenient time, even early mornings or late evenings. Persistence was key, and although it sometimes felt humiliating, the experience was definitely worthwhile. Practicing speaking and refining viva techniques were crucial, as they made up a significant part of the exam.
Seeing patients early and often was another essential aspect of preparation. Treating each new patient in the clinic as if they were part of the exam helped refine my examination techniques and diagnostic skills, focusing on quick and accurate assessments.
MCQs and Clinicals
After the MCQs, many of us felt we had failed. It was difficult to gauge performance, so it was important not to be disheartened.
Clinical Examinations
The key to clinicals was efficiency. They expected answers within 3 minutes, with 2 minutes for questions and moving to the next patient. Functional tests often yielded more information than palpating every joint.
Upper Limb Shorts
- FPL rupture after volar distal radius plate placement – With no history or clues, functional tests were crucial.
- Dupuytren’s Contracture
- Elbow Osteoarthritis – Discussed surgical options, including the OK procedure.
Lower Limb Shorts
- PCL rupture – Again, no clues or history provided.
- Foot drop post-tumor surgery
- Stiff hip post-acetabular ORIF
Intermediate Cases
- SLAC wrist for the upper limb.
- Left leg hip and knee OA with left knee pain for the lower limb. This was my toughest station, with a complicated patient and a challenging examiner. The key takeaway was to focus on the surgical problem and not get flustered.
Vivas
Adult Pathology
- Osteomyelitis – Discussed an infected distal femur with a sequestrum.
- Loose Charnley Total Hip Replacement – Focused on ruling out infection and discussing modes of failure.
- Rheumatoid Arthritis in the Elbow – Covered types and indications for total elbow replacement, and management of soft tissue breakdown.
- Massive Disc Prolapse – Discussed indications for surgery and management of cauda equina.
- Metastatic Breast Cancer to Bone – Covered Mirel’s score and management of spinal metastasis.
Trauma
- Locked Posterior Shoulder Dislocation – Managed an acute injury with an AP view only.
- Pelvic Trauma – Detailed management of an APC pelvic fracture, including the Massive Haemorrhage Protocol.
- Comminuted Femur Fracture in a 10-Year-Old – Compared plate fixation and TENS nails.
- Lisfranc Injury – Discussed acute and operative management.
- Capitellum Fracture – Classification and operative management.
Upper Limb and Pediatrics
- CMC Osteoarthritis – Classification and management.
- SLAC Wrist Stage 3 – Classification and management.
- Cuff-Deficient Shoulder Osteoarthritis – Discussed reverse TSR principles.
- Cerebral Palsy – Covered hip problems and management of bilateral hip dislocations.
- Perthes Disease
- Swanson’s Classification – Classified various conditions and discussed a curly toe.
Basic Science
- Principles of External Fixation – Strengthening constructs.
- Biomechanics of Different Running Styles – Analyzed differences between sprinters, long-distance runners, and walkers.
- Proximal Humerus Destruction – Differentiated between infection, Charcot, and tumor.
- Stress-Strain Curve
- Osteoclast Function – Detailed mechanism and impact of bisphosphonates.
- Osteoporosis and DEXA Scan – Discussed results and management.
Final Thoughts and Advice
Throughout my orthopaedic training, I often hid in the back, avoiding questions out of fear of looking foolish. However, preparing for the FRCS exam required shedding this