Flashcards for short cases for Orthopaedic FRCS Exam । Orthopaedic Academy.

Summary

The presenter offers a structured, FRCS-focused approach to orthopaedic short cases, concentrating on the upper limb. The lower-limb section is deferred. The central message is to recognise the diagnosis quickly, examine selectively, and use the remaining time to discuss the case as a viva.

Overall approach to short cases

• Manage time tightly. A station may last five minutes, but introductions and moving to the patient reduce the practical examination time. Avoid unnecessary steps.
• State a clear diagnosis as soon as the key finding is apparent. For example, identify Dupuytren contracture, trigger finger, or a tendon rupture rather than continuing a broad examination once the diagnosis is clear.
• Move into viva discussion. Cover the relevant clinical context, management and, when appropriate, supporting evidence. The presenter says this is where candidates can gain higher marks.
• Look for clues before and during the examination. Splints, orthoses, walking aids, inhalers, scars and other details may reveal the diagnosis or shape the discussion. Use a “360-degree” scan of the patient and surroundings.
• Use a system and practise it repeatedly. Practise with colleagues, supervisors or real patients where appropriate, using a timer. Regular rehearsal helps make the examination fluent and reduces prompting.
• Know the anatomy and anticipate likely questions. Short cases may combine conditions or include subtle findings, so consider associated problems rather than assuming the case is straightforward.
• Stay systematic if the diagnosis is unclear. Describe what is visible, assess function, offer a sensible differential, and explain how you would investigate or refer the patient. The presenter advises staying calm and being candid rather than guessing.
• Keep a few questions ready if asked to take a limited history: What is the problem? When did it start? How does it affect the patient? What treatment have they had? What are their expectations? Ask about relevant medical problems as needed.

General examination reminders

• Treat scars as clues: describe them, but avoid claiming their cause with certainty if it is unclear.
• A scar with a joint that does not move should raise the possibility of fusion, which can then be checked.
• Deformity with preserved sensation may suggest a primarily motor problem, such as the polio example discussed.
• Consider associated conditions:
  • Foot deformities may warrant consideration of spinal pathology.
  • A rheumatoid hand may make rheumatoid involvement elsewhere more apparent.
  • Dupuytren disease can coexist with other hand or nerve problems.
  • The presenter cites an association between thumb CMC arthritis and carpal tunnel syndrome, estimating it at about 48%.
• Avoid painful or unnecessary manoeuvres when they are unlikely to add value; explain why you would omit them.

Upper-limb examination framework

Hand screening

The presenter recommends a slow, deliberate screening examination to catch subtle abnormalities:

• Inspect the hand for muscle wasting, deformity, abnormal posture, scars and splints.
• Ask the patient to open and close the hand slowly to reveal subtle triggering, tendon problems or deformity.
• Check thumb movements, including thumb abduction and extension, to assess relevant muscles and screen for tendon rupture.
• Inspect the palm and dorsum for wasting, “guttering,” scars and rheumatoid changes.
• Look at the elbows for rheumatoid nodules when relevant.
• If inspection and movement do not explain the case, assess sensation.

Sensory and motor nerve examination

• Be precise about the site tested and compare with the other side.
• For nerve assessment, distinguish proximal from distal involvement. Use recognised autonomous sensory zones and know the relevant anatomy.
• Ask permission before testing more proximal areas, such as the forehead.
• For motor testing:
  • Assess the muscle against resistance and palpate or identify the relevant muscle where appropriate.
  • State the power grade clearly rather than simply saying it is “normal.”
  • For FDS testing, stabilise the other fingers and test against resistance.
  • For ulnar nerve function, inspect and test the interossei; consider proximal muscles such as FDP or FCU when appropriate.
  • For radial nerve function, choose a suitable muscle and distinguish radial nerve palsy from posterior interosseous nerve involvement.
• Explain characteristic signs without waiting to be prompted. For example, describe the mechanism behind Froment’s sign: weakness of adductor pollicis leads the patient to recruit FPL, flexing the thumb.
• For ulnar clawing, know the ulnar paradox: a more distal lesion can produce a more obvious claw deformity.
• Be ready to discuss nerve compression sites, nerve conduction studies and the anatomy relevant to the suspected lesion.

Hand function and tendon transfers

• Know a consistent way to demonstrate hand function. The speaker describes five grip types: three precision grips and two power grips, with examples including tip-to-tip, tripod, key, pen or coin handling, hook grip and power grip.
• A torch pen may be useful for transillumination of a suspected ganglion, but it should not replace a sound basic examination.
• For tendon transfers, understand the factors relating to:
  • The donor tendon and muscle.
  • The recipient and the condition of the joints and tissues.
  • The patient’s motivation, understanding and ability to complete rehabilitation.

Case-specific points

Dupuytren contracture

• Describe the deformity and relevant findings, such as cords, skin pitting or puckering, and flexion posture.
• Assess whether other areas are involved and ask about disease elsewhere when appropriate.
• Demonstrate the correct examination of the metacarpophalangeal and proximal interphalangeal joints by positioning one joint to assess the other.
• Check neurovascular status, consider a digital Allen test where appropriate, and assess hand function.
• In the viva, be prepared to discuss family history, genetics, disease patterns and management options.

Thumb CMC arthritis

• Look for features such as shouldering and hyperextension at the MCP joint.
• Use a pillow to support the hand examination.
• If a grind test is likely to be painful, explain why you would avoid it.
• Assess hand function and consider associated carpal tunnel syndrome.
• Discuss non-operative options and then operative management, including trapeziectomy. The presenter recommends being prepared to discuss the evidence.

Trigger finger

• Slow opening and closing of the hand may reveal subtle catching.
• Once identified, focus the examination on the affected finger, including the nodule, relevant movement, neurovascular status and function.
• The presenter stresses rehearsing a concise, repeatable sequence so it can be completed quickly.

Rheumatoid hand

• Describe the bilateral, symmetrical pattern and proceed from proximal to distal.
• Avoid forceful or unnecessary handling, particularly where the skin is fragile.
• Inspect carefully for scars that may indicate prior fusion or replacement, and assess function.

Unusual or congenital hand deformity

• Describe the deformity and its functional effect, then use a systematic assessment rather than trying to force a precise diagnosis.
• If a syndrome is suspected but not recognised, explain the need for further investigation, specialist input and potentially a specialised centre.

Wrist and elbow

• At the wrist, divide the examination into radial, central and ulnar zones to help localise the problem.
• For the elbow, assess carrying angle, active and passive movement, stability and neurovascular status. Also consider the joints above and below.
• Do not forget the ulnar nerve in elbow cases. Check for nerve subluxation as well as nerve function.
• If short of time, functional movements such as reaching the mouth or the buttock can provide a quick assessment of elbow function.

Shoulder and brachial plexus

• Use age as an initial guide, not a substitute for examination:
  • Younger patients may have instability.
  • Older patients may have rotator-cuff disease or arthritis.
  • Middle-aged patients may have impingement.
  • Frozen shoulder is also possible and should not be overlooked.
• In suspected instability, remember to assess and discuss the Beighton score.
• For the brachial plexus, the goal is to identify the level and pattern of involvement:
  • Use a rapid screen for Horner syndrome, muscle wasting, abnormal attitude, scars and splints.
  • Test sensation at the specified dermatomal points and motor function using the recognised examination framework.
  • Be alert to unusual patterns that may indicate conditions such as Parsonage–Turner syndrome or previous tendon-transfer surgery.

References and preparation mentioned

The presenter recommends practising from clinical-case resources and cites books by Banaszkiewicz, Maffulli and Cassini, and Sharma. Case-based flashcards can help identify the few examination findings most relevant to each condition and present them in a consistent order.

Speakers and sources featured

• Amgad/Amjad Medani — main presenter; the subtitles render his name inconsistently as “Amjet” and “Anj.”
• Osman — introduced as a colleague and senior mentor; also participates in the session.
• Mustafa — introduced as the session moderator.
• Unidentified participant or moderator — brief interjections and the closing thanks are heard, but the subtitles do not clearly establish the speaker’s identity.
• Sanjit — mentioned in the closing remarks as having discussed the examination approach; not clearly identified as a speaker in this excerpt.

Educational sources and people cited: Banaszkiewicz, Maffulli and Cassini, Sharma, Fazal Ali, and a YouTube video on drawing the brachial plexus quickly. The presenter also refers to the FRCS mentor group, teaching courses and consultant-led practice.