Exam Corner Vikas Khanduja, MSc, FRCS (Orth) Consultant Orthopaedic Surgeon, Addenbrooke’s Cambridge University Hospital NHS Trust, Cambridge CB2 0QQ, UK. Associate Editor, The Bone & Joint Journal e-mail: [email protected]
Advisory board: Mr Tim Board FRCS (Orth), MD Consultant Orthopaedic Surgeon Wrightington Hospital, Wigan, Lancaster Visiting Professor, University of Manchester Mr David Jones FRCS, FRCSEd (Orth) Consultant Advisor, The Bone & Joint Journal Mr Ajay Malviya MS, MSc, FRCSEd (Orth) Consultant Orthopaedic Surgeon Wansbeck General Hospital Ashington,
November 2013 - Questions
The FRCS (Tr & Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into five sections comprising Basic Science, Adult Pathology, Hands, Children’s Orthopaedics and Trauma. The Clinical Examination section is divided into upper- and lower-limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam every month. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.
MCQs and EMQs – Single Best Answer 1. Thermoregulation is substantially impaired in patients with complete spinal cord injuries above which level? a. T6 b. T8 c. T10 d. T12 e. L1
4. Which ligamentous structure is the primary restraint to inversion when the ankle joint is in a dorsiflexed position? a. Syndesmotic ligament b. Anterior talofibular ligament c. Posterior talofibular ligament d. Lateral talocalcaneal ligament e. Calcaneofibular ligament
2. Hypercalcaemia can be caused by all of the following conditions except: a. Hyperthyroidism b. Multiple myeloma c. Hypervitaminosis d. Bisphosphonate usage e. Tertiary hyperparathyroidism
5. Which of the following is an absolute indication for replacement of the radial head? a. Isolated Mason Type 3 fracture b. Essex–Lopresti pattern of injury with a positive radial pull test c. Pre-existing radiocapitellar osteoarthritis and radial head fracture d. Beighton score of > 3 in the setting of a comminuted radial head fracture e. Inability to fix a comminuted radial head fracture
3. What is the single most specific option to describe the nerve supply to each of the following structures in the hand? I. Pronator quadratus II. Abductor pollicis brevis III. Extensor carpi radialis brevis a. Suprascapular nerve b. Anterior interosseous branch of median nerve c. Palmar digital branch of ulnar nerve d. Posterior antebrachial cutaneous nerve e. Recurrent motor branch of median nerve f. Posterior interosseous nerve g. Radial nerve h. Dorsal digital branch of ulnar nerve i. Palmar cutaneous branch of median nerve j. Ulnar nerve
6. Peri-prosthetic fractures of the distal femur around a knee replacement have been classified according to which of the following classification systems? a. Vancouver classification b. Lewis and Rorabeck classification c. Euler and Ruedi classification d. Ideberg classification e. Rowe classification
Northumberland Mr Sumedh Talwalkar MS, FRCS (Orth) Consultant Orthopaedic Surgeon Wrightington Hospital Wigan, Lancaster
@2013 British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.95B11 33226 $2.00 Bone Joint J 2013;95-B:1583–4.
Vivas Adult Pathology A 25-year-old footballer was involved in a tackle and sustained an injury to his knee joint. It was acutely swollen at the time of injury and an urgent MRI scan revealed an injury to his posterolateral corner. 1. What structures form the posterolateral corner of the knee joint? 2. How do you assess the knee joint for integrity of the posterolateral corner? 3. Describe the surgical approach to the posterolateral corner of the knee joint. 4. What is the relation between the insertion of the popliteus and the insertion of the lateral
VOL. 95-B, No. 11, NOVEMBER 2013
collateral ligament at the lateral femoral condyle? 5. What reconstruction techniques are you aware of in terms of reconstruction of the posterolateral corner of the knee joint? Describe them in detail. 6. What are the long-term results of posterolateral reconstruction of the knee joint?
Trauma A 56-year-old man fell on his dominant right elbow on a rocky beach whilst fishing. He sustained a transverse open wound on the anteromedial aspect
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of his elbow, through which the distal end of the humerus was protruding. He also had paraesthesia in the ulnar nerve territory. These are his radiographs (Figs 1a & 1b).
1. 2. 3. 4. 5.
What is the likely diagnosis? What are the other likely findings on physical examination? What is the aetiopathogenesis of this condition? What are the options of management? What is the surgical treatment of the above condition?
Children’s Orthopaedics Here is a radiograph (Fig. 3) of a four-year-old girl who sustained this fracture four days earlier in a low-energy injury. She is currently on traction.
Fig. 1a Fig. 3
1. How would you manage the case? Fig. 1b
1. Describe the radiographs. 2. What are the structures at risk? 3. How would you assess and manage this patient? 4. What are the primary and secondary stabilisers of the elbow joint? 5. When would you commence range of movement exercises following treatment?
2. In terms of diagnosis and treatment, what might you reasonably infer from the radiograph of this child (Fig. 4)?
Hands A 34-year-old woman presents with persistent pain over the radial aspect of her left wrist, which worsens when she does house work, particularly the heavier aspects of the same. The symptoms persist after a course of anti-inflammatory medication and splintage. She notices it when she lifts heavy files. On physical examination, she has tenderness on the radial border of the wrist and has pain with ulnar deviation of the wrist with the thumb clenched within a fist. This is the clinical photograph obtained in clinic (Fig. 2).
Fig. 4
Basic Science 1. Describe the Smith–Peterson approach to the hip joint. 2. Describe the anterolateral approach to the distal tibia for fixation of distal tibial fractures. 3. Describe the surgical approach to the radial head. 4. Describe the posteromedial approach to the knee joint with a view to fixation of a tibial plateau fracture (depressed posteromedial fragment). 5. Describe the surgical approach to the anterior aspect of the cervical spine with a view to C5-C6 discectomy. Fig. 2
For answers to previous Exam Corner questions please visit http://www.boneandjoint.org.uk/site/education/exam_corner THE BONE & JOINT JOURNAL
Advisory board: Mr Tim Board FRCS (Orth), MD Consultant Orthopaedic Surgeon Wrightington Hospital, Wigan, Lancaster Visiting Professor, University of Manchester Mr David Jones FRCS, FRCSEd (Orth) Consultant Advisor, The Bone & Joint Journal Mr Ajay Malviya MS, MSc, FRCSEd (Orth) Consultant Orthopaedic Surgeon Wansbeck General Hospital Ashington,
November 2013 - Questions
The FRCS (Tr & Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into five sections comprising Basic Science, Adult Pathology, Hands, Children’s Orthopaedics and Trauma. The Clinical Examination section is divided into upper- and lower-limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam every month. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.
MCQs and EMQs – Single Best Answer 1. Thermoregulation is substantially impaired in patients with complete spinal cord injuries above which level? a. T6 b. T8 c. T10 d. T12 e. L1
4. Which ligamentous structure is the primary restraint to inversion when the ankle joint is in a dorsiflexed position? a. Syndesmotic ligament b. Anterior talofibular ligament c. Posterior talofibular ligament d. Lateral talocalcaneal ligament e. Calcaneofibular ligament
2. Hypercalcaemia can be caused by all of the following conditions except: a. Hyperthyroidism b. Multiple myeloma c. Hypervitaminosis d. Bisphosphonate usage e. Tertiary hyperparathyroidism
5. Which of the following is an absolute indication for replacement of the radial head? a. Isolated Mason Type 3 fracture b. Essex–Lopresti pattern of injury with a positive radial pull test c. Pre-existing radiocapitellar osteoarthritis and radial head fracture d. Beighton score of > 3 in the setting of a comminuted radial head fracture e. Inability to fix a comminuted radial head fracture
3. What is the single most specific option to describe the nerve supply to each of the following structures in the hand? I. Pronator quadratus II. Abductor pollicis brevis III. Extensor carpi radialis brevis a. Suprascapular nerve b. Anterior interosseous branch of median nerve c. Palmar digital branch of ulnar nerve d. Posterior antebrachial cutaneous nerve e. Recurrent motor branch of median nerve f. Posterior interosseous nerve g. Radial nerve h. Dorsal digital branch of ulnar nerve i. Palmar cutaneous branch of median nerve j. Ulnar nerve
6. Peri-prosthetic fractures of the distal femur around a knee replacement have been classified according to which of the following classification systems? a. Vancouver classification b. Lewis and Rorabeck classification c. Euler and Ruedi classification d. Ideberg classification e. Rowe classification
Northumberland Mr Sumedh Talwalkar MS, FRCS (Orth) Consultant Orthopaedic Surgeon Wrightington Hospital Wigan, Lancaster
@2013 British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.95B11 33226 $2.00 Bone Joint J 2013;95-B:1583–4.
Vivas Adult Pathology A 25-year-old footballer was involved in a tackle and sustained an injury to his knee joint. It was acutely swollen at the time of injury and an urgent MRI scan revealed an injury to his posterolateral corner. 1. What structures form the posterolateral corner of the knee joint? 2. How do you assess the knee joint for integrity of the posterolateral corner? 3. Describe the surgical approach to the posterolateral corner of the knee joint. 4. What is the relation between the insertion of the popliteus and the insertion of the lateral
VOL. 95-B, No. 11, NOVEMBER 2013
collateral ligament at the lateral femoral condyle? 5. What reconstruction techniques are you aware of in terms of reconstruction of the posterolateral corner of the knee joint? Describe them in detail. 6. What are the long-term results of posterolateral reconstruction of the knee joint?
Trauma A 56-year-old man fell on his dominant right elbow on a rocky beach whilst fishing. He sustained a transverse open wound on the anteromedial aspect
1583
1584
of his elbow, through which the distal end of the humerus was protruding. He also had paraesthesia in the ulnar nerve territory. These are his radiographs (Figs 1a & 1b).
1. 2. 3. 4. 5.
What is the likely diagnosis? What are the other likely findings on physical examination? What is the aetiopathogenesis of this condition? What are the options of management? What is the surgical treatment of the above condition?
Children’s Orthopaedics Here is a radiograph (Fig. 3) of a four-year-old girl who sustained this fracture four days earlier in a low-energy injury. She is currently on traction.
Fig. 1a Fig. 3
1. How would you manage the case? Fig. 1b
1. Describe the radiographs. 2. What are the structures at risk? 3. How would you assess and manage this patient? 4. What are the primary and secondary stabilisers of the elbow joint? 5. When would you commence range of movement exercises following treatment?
2. In terms of diagnosis and treatment, what might you reasonably infer from the radiograph of this child (Fig. 4)?
Hands A 34-year-old woman presents with persistent pain over the radial aspect of her left wrist, which worsens when she does house work, particularly the heavier aspects of the same. The symptoms persist after a course of anti-inflammatory medication and splintage. She notices it when she lifts heavy files. On physical examination, she has tenderness on the radial border of the wrist and has pain with ulnar deviation of the wrist with the thumb clenched within a fist. This is the clinical photograph obtained in clinic (Fig. 2).
Fig. 4
Basic Science 1. Describe the Smith–Peterson approach to the hip joint. 2. Describe the anterolateral approach to the distal tibia for fixation of distal tibial fractures. 3. Describe the surgical approach to the radial head. 4. Describe the posteromedial approach to the knee joint with a view to fixation of a tibial plateau fracture (depressed posteromedial fragment). 5. Describe the surgical approach to the anterior aspect of the cervical spine with a view to C5-C6 discectomy. Fig. 2
For answers to previous Exam Corner questions please visit http://www.boneandjoint.org.uk/site/education/exam_corner THE BONE & JOINT JOURNAL
