Postgraduate Orthopaedics: The CandidateLs Guide to the FRCS

Postgraduate Orthopaedics:The Candidate’s Guide to the FRCS(Tr & Orth) ExaminationSecond edition

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Cambridge University Press978-0-521-18510-3 - Postgraduate Orthopaedics: The Candidate’s Guide to the FRCS (Tr & Orth) Examination: Second EditionEdited by Paul A. Banaszkiewicz and DipclinedFrontmatterMore information

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Postgraduate Orthopaedics:The Candidate’s Guide to theFRCS (Tr & Orth) ExaminationSecond editionEdited by

Paul A. Banaszkiewicz FRCS (Glas) FRCS (Ed) FRCS (Eng) FRCS (Tr & Orth)DipClinEd FAcadMEdConsultant Orthopaedic SurgeonQueen Elizabeth Hospital and North East NHS Surgical Centre (NENSC)Gateshead

Associate Editor

Deiary F. Kader FRCS (Tr & Orth) MFSEM (UK)Consultant Orthopaedic SurgeonQueen Elizabeth Hospital and North East NHS Surgical Centre (NENSC)Gateshead






www.cambridge.orgInformation on this title: www.cambridge.org/9780521185103

# Cambridge University Press 2012

This publication is in copyright. Subject to statutory exceptionand to the provisions of relevant collective licensing agreements,no reproduction of any part may take place withoutthe written permission of Cambridge University Press.

First edition published 2009Second edition published 2012

Printed in the United Kingdom by Print on Demand, World Wide

A catalogue record for this publication is available from the British Library

Library of Congress Cataloguing-in-Publication Data

Postgraduate orthopaedics : the candidate's guide to the FRCS (Tr & Orth)examination/edited by Paul A. Banaszkiewicz ; associate editor,Deiary Kader. – 2nd ed.

p. ; cm.Includes bibliographical references and index.ISBN 978-0-521-18510-3 (Paperback)I. Banaszkiewicz, Paul A. II. Kader, Deiary F.[DNLM: 1. Orthopedic Procedures–Examination Questions. WE 18.2]

LC classification not assigned6170.9–dc23

2011033571

ISBN 978 0 521 18510 3 Paperback

Cambridge University Press has no responsibility for the persistence oraccuracy of URLs for external or third-party internet websites referred toin this publication, and does not guarantee that any content on suchwebsites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this book to provide accurateand up-to-date information which is in accord with accepted standardsand practice at the time of publication. Although case histories aredrawn from actual cases, every effort has been made to disguise theidentities of the individuals involved. Nevertheless, the authors, editorsand publishers can make no warranties that the information containedherein is totally free from error, not least because clinical standards areconstantly changing through research and regulation. The authors,editors and publishers therefore disclaim all liability for direct orconsequential damages resulting from the use of material contained inthis book. Readers are strongly advised to pay careful attention toinformation provided by the manufacturer of any drugs or equipmentthat they plan to use.

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Contents

List of contributors viiForeword by David C. Jaffray ixPreface xiList of abbreviations xii

Section 1 – The FRCS (Tr & Orth)examination

1 General advice for the FRCS (Tr & Orth) 1E. Prash Jesudason, Niall Munroand Paul A. Banaszkiewicz

Section 2 – The written paper2 MCQ and EMI paper guidance 9

Mohammed Al-Maiyah and Deiary F. Kader

Section 3 – The clinicals3 The short cases 17

Andrew Sprowson and Tom Symes

4 The intermediate cases 21Puneet Monga and Rajeev Bansal

5 Shoulder and elbow clinical cases 24Paul A. Banaszkiewicz and David Cloke

6 Hand and wrist clinical cases 36John W. K. Harrison

7 Spine clinical cases 59Paul A. Banaszkiewicz and Almas L. Khan

8 Hip clinical cases 69Paul A. Banaszkiewicz

9 Knee clinical cases 105Deiary F. Kader

10 Foot and ankle clinical cases 111Paul A. Banaszkiewicz and Paul Patterson

11 Paediatric clinical cases 127Sattar Alshryda and Philip Henman

Section 4 – The adult electiveorthopaedics oral

12 General structured oral exam guidance 149Tom Symes, Simon Spencerand Andrew Sprowson

13 Shoulder and elbow oral core topics 151Asir Aster and Shashi Kanth Godey

14 Hip oral core topics 170Paul A. Banaszkiewicz

15 Knee oral core topics 218Deiary F. Kader

16 Foot and ankle oral core topics 241Paul A. Banaszkiewicz and Paul Patterson

17 Spine oral core topics 263Alex Baker and Niall Craig

18 Orthopaedic oncology oral core topics 281Thomas B. Beckingsale and Craig H. Gerrand

Section 5 – The hand oral19 Hand oral core topics 299

John W. K. Harrison

Section 6 – The paediatric oral20 Paediatric oral core topics 357

Simon L. Barker

Section 7 – The trauma oral21 Trauma oral core topics 397

Gunasekaran Kumar

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Section 8 – The basic science oral22 Basic science oral core topics 433

Kevin P. Sherman

Section 9 – Miscellaneous topics23 Surgical exposures oral core topics 505

Jonathan Loughead and Santosh Venkatachalam

24 Anatomy oral core topics 532Sarkhell Radha and Paul A. Banaszkiewicz

25 SAS doctors and the FRCS (Tr & Orth) exam 568M. Abdul Bari

26 FRCS (Tr & Orth) and CESR (Article 14) 572Mohan Pullagura

27 Candidates’ accounts of the examination 576David Cloke and Shariff Hazarika

28 Examination failure 592Andrew Port and Paul A. Banaszkiewicz

Index 595

Contents

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Cambridge University Press978-0-521-18510-3 - Postgraduate Orthopaedics: The Candidate’s Guide to the FRCS (Tr & Orth) Examination: Second EditionEdited by Paul A. Banaszkiewicz and DipclinedrontmatterMore information




Contributors

Mr Mohammed Al-Maiyah MB ChB, FICMS, FRCS,MSc Orthop, FRCS (Tr & Orth)James Cook University Hospital, Middlesbrough, UK

Sattar Alshryda MRCS, FRCS (Tr & Orth), MSc, PhDFreeman Hospital, Newcastle upon Tyne, UK

Mr Asir Aster MBBS, FRCS (Surg), MSc (Orth Eng),FRCS (Tr & Orth)Royal National Orthopaedic Hospital, Stanmore, UK

Mr Paul A. Banaszkiewicz FRCS (Glas) FRCS (Ed) FRCS (Eng)FRCS (Tr & Orth) DipClinEd FAcadMEdQueen Elizabeth Hospital, Gateshead, UK

Mr Rajeev Bansal MSc, MCh Orth, FRCS (Tr & Orth)Shoulder Fellow, Royal Bournemouth Hospital, UK

Mr M. Abdul Bari FRCSG, FEBOT (Ortho), MCh (Ortho)FRCS (Tr & Orth)Tameside Hospital, Ashton under Lyne, UK

Mr Alex Baker BSc, MB ChB, MRCS, MSc, FRCS (Tr & Orth)Lancashire Teaching Hospitals NHS Trust, Royal PrestonHospital, UK

Mr Simon L. Barker BSc (Hons) MD FRCS (Tr & Orth)Royal Children’s Hospital, Aberdeen, UK

Mr Thomas B. Beckingsale FRCS (Tr & Orth)Freeman Hospital, Newcastle upon Tyne, UK

Mr David Cloke FRCS (Tr & Orth)North Tyneside Hospital, Newcastle upon Tyne, UK

Mr Niall Craig FRCS (Ed) FRCS (Tr & Orth)Aberdeen Royal Infirmary, Aberdeen, UK

Mr Craig H. Gerrand MB ChB, FRCS(Ed), MD, MBAFreeman Hospital, Newcastle upon Tyne, UK

Mr Shashi Kanth Godey MBBS, MS (Orth), MRCS,FRCS (Tr & Orth)University Hospital South Manchester Foundation Trust,Manchester, UK

Mr John W. K. Harrison MSc FRCS (Ed) FRCS (Tr & Orth),MFSEM (UK)Queen Elizabeth Hospital, Gateshead, UK

Mr Shariff Hazarika MRCS, FRCS (Tr & Orth)James Cook University Hospital, Middlesbrough, UK

Mr Philip Henman FRCS (Tr & Orth)Freeman Hospital, Newcastle upon Tyne, UK

Mr E. Prash Jesudason MB ChB, MSc, FRCSEd (Tr & Orth)HandFellowand Specialist Registrar,NorthwesternDeanery,UK

Mr Deiary F. Kader FRCS (Glas) FRCS (Ed) FRCS(Tr & Orth), MFSEM (UK)Queen Elizabeth Hospital, Gateshead, UK

Mr Almas L. Khan MBBS, PGCert ClinEd, FRCSEd (Tr & Orth)Freeman Hospital, Newcastle upon Tyne, UK

Mr Gunasekaran Kumar FRCS (Tr & Orth)Royal Liverpool University Hospital, Liverpool, UK

Mr Jonathan Loughead MSc, FRCS (Tr & Orth)Queen Elizabeth Hospital, Gateshead, UK

Mr Puneet Monga FRCS FRCSEd (Tr & Orth), Dip SportsMed, MSc, MS Orth, DNB, MBBSNorthwest Deanery Manchester, UK

Mr Niall Munro FRCS (Tr & Orth) MDGolden Jubilee National Hospital, Glasgow, UK

Mr Paul Patterson FRCS FRCS (Tr & Orth)Queen Elizabeth Hospital, Gateshead, UK

Mr Andrew Port MB ChB, BSc (Hons), FRCS (Ed),FRCS (Tr & Orth)James Cook University Hospital, Middlesbrough, UK

MrMohanK. PullaguraMSOrth,MRCS (Ed), FRCSEd (Tr &Orth)North Tyneside Hospital, Newcastle, UK

Mr Sarkhell Radha MB ChB, MRCS (Ed)Queen Elizabeth Hospital, Gateshead, UK

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Mr Kevin P. Sherman BA, MA, BM, BCh, FRCSHull Royal Infirmary, Hull, UK

Mr Simon Spencer FRCS (Tr & Orth)Golden Jubilee National Hospital, Glasgow, UK

Mr Andrew Sprowson MD, FRCS (Tr & Orth)Clinical Research Associate, Newcastle University, UK

Mr Tom Symes MSc, FRCS (Tr & Orth)Golden Jubilee National Hospital, Glasgow, UK

Mr Santosh Venkatachalam MBBS, MS (Orth),DNB (Orth), MRCS (Ed)Queen Elizabeth Hospital, Gateshead, UK

List of contributors

viii






Foreword

Success with the examination is about technique as much asknowledge. This book will be as good as others from theknowledge point of view but adds huge insight into technique.All examinations, whether it be your driving test or the FRCS(Tr & Orth), demand a disciplined technique. This book givesmany pointers as to where a good technique helps to overcomethe stress of the examination. Knowledge is a must but in itself isnot enough. I would advocate this book to all orthopaedic year 1trainees. That is when you need to start preparation – not year 4.

Use this book to guide preparation for the examination.If I can add my own advice, then it is to practise every day.Pester your consultants to viva you every day for 10 minutes.Understand the principles of everything you do in the courseof your orthopaedic practice.

David C. JaffrayThe Robert Jones and Agnes Hunt Orthopaedic and DistrictGeneral Hospital, Oswestry, UK

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Preface to second edition

One of the aims of the first edition was to cover the wholeFRCS (Tr & Orth) syllabus in one book, which had neverpreviously been attempted. As such there were always goingto be areas that could have read better. In addition, the examformat keeps changing with the long case format now droppedin favour of the intermediate cases. There was a feeling ofunfinished business and a need for a second edition.

Whilst ‘Examination corner’ has proved extremely popularwith candidates it has been criticized in some quarters. Ratherthan providing a list of topics asked in the orals we wanted togive a more detailed account of the interaction between candi-date and examiner but without going into minutiae. Examin-ation corner does not magically allow candidates to pass theexam but rather guides them better; it is not a substitute for thehard work and slog needed to get through the exam successfully.

As the first edition had been extensively edited we wereable to revisit and improve several examination corner scen-arios with more dialogue. If this has not been possible we havegone with the original first edition versions except where thedialogue is now dated and incorrect. We have continued toinclude long case material despite this format being dropped asthe material still offers good learning opportunities. The longcase material is still relevant because the same cases appear inthe exam, a comprehensive performance is still expected andthe examiners ask the same sorts of questions.

It is our great pleasure to be able to involve a number oftrainees who have used the first edition to navigate through the

exam successfully. It is vital that the book stays relevant and upto date, and involving newly exam-qualified trainees will hope-fully ensure the continued success of the book.

The second edition features five additional chapters: surgi-cal approaches, anatomy, Article 14, SAS doctors and ortho-paedic oncology. Whilst each chapter is an exciting newaddition to the book we are particularly pleased with theanatomy and surgical approaches chapters as they cover diffi-cult dry areas of the syllabus that still need to be learnt by acandidate. All other chapters have been thoroughly revised toimprove the content and cover the syllabus more thoroughly.

As with the first edition we continue to make no claim forthe originality of the material contained in the text. We areattempting to synthesize material in the wider orthopaedicdomain into a succinct and easily readable format to guidecandidates through the exam. The original core material evolvedfrom notes made whilst preparing for the FRCS (Tr & Orth)examination from a wide variety of differing sources. We arestill trying to avoid reinventing the wheel!

A special word of thanks to Nicholas Dunton at CambridgeUniversity Press who luckily had the foresight to agree fairlyquickly to a second edition. Life moves in many differentdirections very quickly and otherwise we may not have beenwriting this preface.

Paul A. BanaszkiewiczDeiary F. Kader

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Abbreviations

ABC airway, breathing, circulationACJ acromioclavicular jointACL anterior cruciate ligamentAD autosomal dominantADL activities of daily livingADM abductor digiti minimiAER apical ectodermal ridgeAFO ankle–foot orthosisAIIS anterior inferior iliac spineAIN anterior interosseous nerveAKP Anterior knee painALL anterior longitudinal ligamentALVAL aseptic lymphocyte-dominated vasculitis-

associated lesionsAP anterior–posteriorAPB abductor pollicis brevisAPL abductor pollicis longusAR autosomal recessiveARDS adult respiratory distress syndromeAS ankylosing spondylitisASB anatomical snuffboxASIS anterior superior iliac spineATD articular–trochanteric distanceATFL anterior talofibular ligamentATLS Advanced Trauma Life SupportATP adenosine triphosphateAVN avascular necrosisBDGF bone-derived growth factorBMG bone matrix gelatinBMP bone morphogenetic proteinBMUs basic multicellular unitsBOA British Orthopaedic AssociationBPTB bone patella tendon–boneCAP Clubfoot Assessment ProtocolCCL coracoclavicular ligamentCDH congenital dislocation of the hipCFL calcaneofibular ligamentCIA carpal injury adaptiveCIC carpal instability complexCID carpal instability dissociativeCIND carpal instability non-dissociative

CJD Creutzfeldt–Jakob diseaseCL capitolunateCMAP compound muscle action potentialCMC carpometacarpalCMT Charcot–Marie–ToothCMV cytomegalovirusCP cerebral palsyCPM continued passive motionCPN common peroneal nerveCR cruciate retainingCRP C-reactive proteinCRPS complex regional pain syndromeCSF cerebrospinal fluidCTEV congenital talipes equinovarusCVP central venous pressureDCP dynamic compression plateDCS dynamic condylar screwDD Dupuytren’s diseaseDDH developmental dysplasia of the hipDHS dynamic hip screwDI dorsal interosseousDIP distal interphalangealDIPJ distal interphalangeal jointDISH diffuse idiopathic skeletal hyperostosisDISI dorsal intercalated segmental instabilityDMARDS disease-modifying antirheumatic drugsDP distal phalanxDRUJ distal radioulnar jointDV dorsoventralDVT deep vein thrombosisECRB extensor carpi radialis brevisECM extracellular matrixECRL extensor carpi radialis longusECU extensor carpi ulnarisEDB extensor digitorum brevisEDC extensor digitorum communisEDL extensor digitorum longusEDM extensor digiti minimiEDQ extensor digiti quintiEGF epidermal growth factorEHL extensor hallucis longus

xii






EIP extensor indicis propriusEMG electromyographEMIs extended matching itemsEPB extensor pollicis brevisEPL extensor pollicis longusESR erythrocyte sedimentation rateEUA examination under anaesthesiaFBC full blood countFCR flexor carpi radialisFCU flexor carpi ulnarisFDB flexor digitorum brevisFDL flexor digitorum longusFDP flexor digitorum profundusFDQ flexor digiti quintiFDS flexor digitorum superficialisFFD fixed flexion deformityFGF fibroblast growth factorFHL flexor hallucis longusFPA foot progression angleFPB flexor pollicis brevisFPL flexor pollicis longusFTA foot thigh angleGA general anaestheticGAGs glycosaminoglycansGI gastrointestinalHEA Hilgenreiner’s epiphyseal angleHMSN hereditary motor sensory neuropathiesHNP herniated nucleus pulposusHO heterotopic ossificationHPT hyperparathyroidismHTO high tibial osteotomyHU Hounsfield unitsHVA hallux valgus angleIDGF insulin-derived growth factorII image intensifierILs interleukinsIMT intermetatarsalINR international normalized ratioIP interphalangealIPJ interphalangeal jointISB Intercollegiate Specialty BoardsITB iliotibial bandIVC inferior vena cavaJCA juvenile chronic arthritisJRA juvenile rheumatoid arthritisJRF joint reaction forceKAFOs knee–ankle–foot orthosesLCDCP low-contact dynamic compression platesLCFA lateral circumflex femoral arteryLCL lateral collateral ligamentLCP low compression platesLHB long head of bicepsLISS less invasive stabilization systemLLD limb length discrepancy

LRTI ligament reconstruction tendon interpositionLTL lunotriquetral ligamentMCFA medial circumflex femoral arteryMCL medial collateral ligamentMCP metacarpophalangealMCQs multiple choice questionsMDP methylene diphosphonateMDT multidisciplinary teamMEN multiple endocrine neoplasiaMEPs motor-evoked potentialsMFC medial femoral condyleMFH malignant fibrous histiocytomaMMP metalloproteinaseMOM metal-on-metalMS multiple sclerosisMSU monosodium urateMUA manipulation under anaestheticNCS nerve conduction studiesNf-1 neurofibromatosis type 1Nf-2 neurofibromatosis type 2NICE National Institute for Health and Clinical

ExcellenceNJR National Joint RegistryNSAIDs non-steroidal anti-inflammatory drugsOA osteoarthritisOCD osteochondritis dissecansODF osteoclast differentiation factor

(aka RANK ligand)OPG osteoprotegerinOPLL ossification of the posterior longitudinal

ligamentORIF open reduction with internal fixationORL oblique retinacular ligamentPCL posterior cruciate ligamentPD proximodistalPDGF platelet-derived growth factorPE pulmonary embolismPE polyethylenePEEK polyetheretherketonePET positron emission tomographyPFFD proximal focal femoral deficiencyPFJ patellofemoral jointPGE2 prostaglandin E2PICU paediatric intensive care unitPIN posterior interosseous nervePIP proximal interphalangealPIPJ proximal interphalangeal jointPL palmaris longusPLAD posterior lip augmentation devicePLC posterolateral cornerPLIF posterior interbody lumbar fusionPLL posterior longitudinal ligamentPMMA polymethylmethacrylatePNET primitive neuroectodermal tumour

List of abbreviations

xiii






POP plaster of ParisPP proximal phalanxPQ pronator quadratusPS posterior-stabilizedPT pronator teresPTFL posterior talofibular ligamentPTH parathyroid hormonePVNS pigmented villonodular synovitisRA rheumatoid arthritisRHK rotating-hinge kneeRLT radiolunotriquetralROM range of movementRSD reflex sympathetic dystrophyRSWP radial side wrist painRTA road traffic accidentRVAD rib vertebral angle differenceSACH solid ankle cushion heelSBA single best answerSCIWORA spinal cord injury without radiological

abnormalitySCJ sternoclavicular jointSEPs sensory-evoked potentialsSHH sonic hedgehogSI sacroiliacSL scapholunateSLAC scapholunate advanced collapse wristSLAP superior labrum anterior to posteriorSLL scapholunate ligamentSLR straight leg raiseSNAC scaphoid non-union advanced collapse wristSNAP sensory nerve action potentialSOMI Sternal Occipital Mandibular ImmobilizerSSEPs somatosensory evoked potentialsSTAR Scandinavian total ankle replacementSTR soft-tissue realignmentSTS soft-tissue sarcoma

STT scaphotrapeziotrapezoidSUFE slipped upper femoral epiphysisTAR total ankle arthroplastyTBW tension band wiringTENS transcutaneous electrical nerve stimulationTFA tibiofemoral angleTFCC triangular fibrocartilage complexTGF transforming growth factorTHA total hip arthroplastyTIMPs tissue inhibitory metalloproteinasesTKA total knee arthroplastyTKR total knee replacementTLHKAFO thoraco–lumbar–hip–knee–ankle–foot orthosisTLIF transforaminal lumbar interbody fusionTLSO thoracolumbar spinal orthosisTMA transmalleolar thigh angleTMJ temporomandibular jointTNF tumour necrosis factorTORCH toxoplasmosis, other, rubella,

cytomegalovirus, herpes simplexTT tibial tubercleUCL ulnar collateral ligamentUHMWPE ultra high molecular weight polyethyleneUKA unilateral knee arthroplastyUKR unilateral knee replacementUS ultrasoundUSS ultrasound scanUSWP ulnar side wrist painVIP vasoactive intestinal polypeptideVISI volar intercalated segment instabilityVMO vastus medialis obliquusVP ventriculoperitonealVTE venous thromboembolismVVC varus–valgus constrainedWCC white cell countZPA zone of polarizing activity

List of abbreviations

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Documents

Postgraduate Orthopaedics: The CandidateLs Guide to the FRCS