Fellowship of the Royal College of Surgeons (FRCS) Trauma and Orthopaedic Surgery Syllabus

Trauma and Orthopaedic Surgery syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Trauma and Orthopaedic Surgery in Fellowship of the Royal College of Surgeons (FRCS), not a summary of it.

1. 1

   Principles of Fracture Management

   5 topics

   • Fracture classification and healing
     • Patterns of fracture and biomechanics
     • Primary versus secondary bone healing
     • Delayed union and non-union
   • Principles of fracture fixation
     • Conservative management and casting
     • Internal fixation and AO principles
     • External fixation
   • Open fractures and soft tissue management
     • Gustilo-Anderson classification
     • Antibiotic and debridement principles
   • Compartment syndrome
   • Polytrauma and damage control orthopaedics
2. 2

   Adult Elective Orthopaedics

   5 topics

   • Osteoarthritis and joint replacement
     • Hip arthroplasty principles and complications
     • Knee arthroplasty
     • Periprosthetic infection and loosening
   • Inflammatory arthritis surgical management
   • Sports injuries of the knee
     • Ligament and meniscal injuries
   • Shoulder and elbow disorders
   • Foot and ankle pathology
3. 3

   Spinal Disorders

   4 topics

   • Degenerative spinal disease
     • Disc prolapse and radiculopathy
     • Spinal stenosis
   • Spinal trauma and cord injury
     • Spinal stability assessment
     • Cauda equina syndrome
   • Spinal infection and tumours
   • Spinal deformity
4. 4

   Specialist Orthopaedics

   5 topics

   • Paediatric orthopaedics
     • Developmental dysplasia of the hip
     • Perthes and slipped upper femoral epiphysis
     • Paediatric fractures and the growth plate
   • Hand and wrist surgery
     • Carpal tunnel and nerve compression
     • Hand trauma and tendon injuries
   • Bone and soft tissue tumours
     • Benign and malignant bone tumours
     • Metastatic bone disease
   • Orthopaedic infection
     • Osteomyelitis
     • Septic arthritis
   • Peripheral nerve injury and repair

Trauma and Orthopaedic Surgery flashcards for Fellowship of the Royal College of Surgeons (FRCS)

22 of 51 cards from the Trauma and Orthopaedic Surgery deck — real questions with worked answers.

1. What four factors form the basis of the Gustilo-Anderson classification of open fractures?

   Wound size, degree of soft tissue damage, level of contamination, and the presence of vascular injury. Type I: wound <1 cm, clean. Type II: 1-10 cm, moderate soft tissue damage. Type IIIA: extensive soft tissue but adequate coverage. Type IIIB: extensive soft tissue loss requiring flap coverage. Type IIIC: any open fracture with arterial injury requiring repair.

2. Describe the stages of secondary (endochondral) fracture healing in order.

   1) Haematoma formation and inflammation (haematoma, cytokine release). 2) Soft callus formation (fibrocartilage, days to ~2-3 weeks). 3) Hard callus formation (woven bone via endochondral and intramembranous ossification). 4) Remodelling (woven bone replaced by lamellar bone along stress lines via Wolff's law). Occurs with relative stability.

3. What is the difference between primary and secondary bone healing?

   Primary (direct) healing occurs with absolute stability (rigid fixation, <2% strain) and no callus, via cutting cones / Haversian remodelling across the fracture gap (contact or gap healing). Secondary (indirect) healing occurs with relative stability (some interfragmentary motion) and proceeds through callus formation by endochondral ossification.

4. State Perren's strain theory and the strain thresholds for bone healing.

   Interfragmentary strain = change in gap length divided by original gap length: $\varepsilon = \frac{\Delta L}{L}$. Granulation tissue tolerates up to ~100% strain, cartilage ~10%, and lamellar bone <2%. Bone cannot form if local strain exceeds ~2%; this governs whether absolute or relative stability is needed.

5. What are the AO principles of fracture fixation?

   1) Anatomical reduction (especially intra-articular fractures). 2) Stable fixation appropriate to the fracture (absolute or relative stability). 3) Preservation of blood supply to bone and soft tissues. 4) Early, active, pain-free mobilisation of the patient and limb (function).

6. How does a lag screw produce absolute stability, and what is the principle of overdrilling?

   A lag screw compresses two fragments together. The near cortex is overdrilled to the screw's outer (thread) diameter (gliding hole) so threads do not engage it, while the far cortex is drilled to core diameter (threaded hole). Tightening pulls the far fragment toward the near cortex, generating interfragmentary compression and absolute stability.

7. Compare absolute and relative stability in terms of construct, strain, and healing.

   Absolute stability: interfragmentary compression (lag screw, compression plate), near-zero motion (<2% strain), heals by primary (direct) bone healing with no callus. Relative stability: controlled micromotion (bridging plate, intramedullary nail, external fixator), heals by secondary healing with callus.

8. What is compartment syndrome and what is the critical perfusion concept behind it?

   A condition where raised pressure within a closed osseofascial compartment compromises tissue perfusion, leading to ischaemia. Perfusion depends on the difference between diastolic blood pressure and compartment pressure; a low perfusion pressure (delta pressure) causes capillary collapse and tissue necrosis even with palpable distal pulses.

9. What delta pressure threshold indicates fasciotomy in compartment syndrome, and what is the clinical hallmark?

   Fasciotomy is indicated when delta pressure (diastolic BP minus compartment pressure) is $\leq 30$ mmHg. The earliest and most reliable clinical sign is pain out of proportion, worsened by passive stretch of the muscles in the compartment. Pulselessness and paralysis are late signs.

10. List the classic clinical features (the P's) of compartment syndrome and which are early vs late.

    Pain (out of proportion, on passive stretch) - early and most reliable; Paraesthesia - early-intermediate; Pallor, Pulselessness, Paralysis, Poikilothermia (cold) - late and unreliable signs indicating established ischaemia. Diagnosis should be made before late signs appear.

11. What is damage control orthopaedics (DCO) and when is it preferred over early total care?

    DCO is temporary stabilisation (usually external fixation), control of haemorrhage and contamination, with definitive fixation delayed until the patient is physiologically stable. It is preferred in unstable/borderline polytrauma patients to avoid a 'second hit' that worsens the systemic inflammatory response (SIRS). Early total care suits stable patients.

12. What physiological parameters define an unstable polytrauma patient suitable for damage control?

    Markers of the 'lethal triad' and shock: persistent hypotension, lactate >2.5 mmol/L, base deficit, hypothermia (<35 C), coagulopathy, low platelets, and severe chest/head/abdominal injury. These patients are at high risk of the second hit; definitive long-bone surgery is deferred.

13. Define osteoarthritis and list its four cardinal radiographic features.

    A degenerative, non-inflammatory disorder of synovial joints with focal loss of articular cartilage and reactive bone change. Radiographic features (LOSS): Loss of joint space (asymmetrical), Osteophytes, Subchondral Sclerosis, Subchondral cysts (geodes).

14. Contrast the radiographic features of osteoarthritis and rheumatoid arthritis.

    OA: asymmetrical joint space loss, osteophytes, subchondral sclerosis and cysts, no osteopenia. RA: symmetrical (concentric) joint space loss, periarticular osteopenia, marginal erosions, soft tissue swelling, and absence of osteophytes/sclerosis. RA is inflammatory and erosive; OA is degenerative and productive.

15. What are the main bearing surface options in total hip replacement and a key drawback of each?

    Metal-on-polyethylene (cheap, reliable; polyethylene wear and osteolysis). Ceramic-on-polyethylene (low wear; cost). Ceramic-on-ceramic (lowest wear, hard; risk of squeaking and fracture of ceramic). Metal-on-metal (largely abandoned due to metal ion release / ALVAL / pseudotumours).

16. What is the main surgical principle of joint replacement for inflammatory arthritis, and a key perioperative concern?

    Surgery (synovectomy, arthroplasty, arthrodesis, tendon repair) aims to relieve pain, restore function and prevent deformity once medical control fails. Key concerns: cervical spine instability (atlantoaxial subluxation) risking cord injury at intubation, increased infection risk from immunosuppression/DMARDs, and poor bone/soft tissue quality.

17. Which knee structure is the primary restraint to anterior tibial translation, and what test assesses it?

    The anterior cruciate ligament (ACL) is the primary restraint to anterior translation of the tibia on the femur. It is assessed by the Lachman test (most sensitive), the anterior drawer test, and the pivot-shift test (assesses rotational/functional instability).

18. Describe the 'unhappy triad' of the knee and its mechanism.

    Classically a valgus force with rotation (e.g., lateral blow to a planted leg) injuring the ACL, the medial collateral ligament (MCL), and a meniscus. Originally described as medial meniscus, but the lateral meniscus is now recognised as more commonly involved with this mechanism.

19. What is the difference between primary and secondary impingement of the shoulder?

    Primary (subacromial) impingement is structural narrowing of the subacromial space (e.g., type III hooked acromion, osteophytes) causing rotator cuff compression. Secondary impingement results from glenohumeral instability or scapular dyskinesia causing dynamic narrowing, typically in younger overhead athletes.

20. What nerve is most commonly injured in anterior shoulder dislocation, and how is it tested?

    The axillary nerve (C5-C6), injured as it passes around the surgical neck of the humerus through the quadrangular space. Tested by sensation over the 'regimental badge' area (lateral upper arm over deltoid) and deltoid motor function (abduction). Always assess before and after reduction.

21. What is the 'terrible triad' of the elbow?

    Posterolateral rotatory elbow dislocation with: 1) radial head fracture, 2) coronoid process fracture, and 3) lateral collateral ligament (LCL) complex injury. It is highly unstable and usually requires surgical reconstruction to restore the bony and ligamentous stabilisers.

22. What is hallux valgus and what radiographic angles define it?

    Lateral deviation of the great toe at the first MTP joint with medial deviation of the first metatarsal. Defined by the hallux valgus angle (HVA, normal $<15^{\circ}$) and the intermetatarsal angle (IMA, normal $<9^{\circ}$). Surgical procedure choice (e.g., scarf/chevron vs basal osteotomy/Lapidus) depends on the IMA severity.

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