Example FRCS Plast questions

Lower limb: FRCS(Plast) example questions

Our lower limb coverage spans the whole JCST curriculum - from primary management of open tibial fractures through to flap complications and paediatric injuries - with illustrated questions and referenced explanations throughout.

Open lower limb trauma

Compartment syndrome

Soft tissue reconstruction

Flap complications

Paediatric lower limb

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Question 1

Lower Limb

A 47-year-old smoker sustains an open fracture of the proximal tibia in a motorcycle collision. He is managed at a major trauma centre under a combined orthoplastic approach, with definitive plate fixation and soft tissue cover planned at 48 hours. Following the fixation, there is a 7 × 4 cm anterior defect over the proximal third of the tibia with exposed plate. No further bony or ligamentous reconstruction is anticipated. CT angiography demonstrates three-vessel run-off; the posterior compartment is uninjured.

Which is the most appropriate option for definitive soft tissue cover?

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CORRECT ANSWER

The medial gastrocnemius remains first-line for proximal third tibial defects when the posterior compartment is uninjured: its medial sural artery pedicle lies outside the zone of injury, and well-vascularised muscle obliterates dead space over exposed metalwork.

The key discriminators here are the single-stage fix-and-flap and the absence of planned secondary surgery. Where staged orthopaedic reconstruction is anticipated (e.g. delayed ligamentous knee reconstruction), a free fasciocutaneous flap (such as the ALT) is preferable, as it can be re-raised for subsequent access; a skin-grafted muscle flap cannot easily be re-elevated.

Herre, with definitive fixation completed in the same sitting, the ALT adds microsurgical risk without advantage, and evidence does not show superiority of fasciocutaneous over muscle cover in open fractures.

Other answers:

Hemisoleus - suits middle third defects.
Distally based sural flap - addresses the distal third and is unreliable in smokers.
Propeller flap - risks a perforator within the zone of trauma.

REFERENCE

Chan JK, Harry L, Williams G, Nanchahal J. Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps. Plastic and reconstructive surgery. 2012;130(2):284e-295e.

Question 2

Lower Limb

A 38-year-old man who emigrated back to the UK having spent 10 years in rural southern India is referred to your plastic surgery clinic with progressive swelling of the right leg and scrotum over the past 12 months. He describes recurrent episodes of fever with tender red streaking tracking up the limb. On examination there is non-pitting oedema, skin thickening and a positive Stemmer sign. Bloods show a marked eosinophilia.

Which is the single most likely underlying cause of his presentation?

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CORRECT ANSWER

The presentation is classic for filariasis: an endemic-region patient with limb lymphoedema, genital/scrotal involvement, recurrent acute filarial lymphangitis (fever with retrograde tender streaking), and eosinophilia.

Wuchereria bancrofti causes ~90% of cases, in which adult worms obstruct the lymphatics. Diagnosis is via a midnight blood film for microfilariae (nocturnal periodicity), filarial antigen testing, or the ultrasound "filarial dance sign."

Epidemiology to remember:

Worldwide, the commonest cause of secondary lymphoedema is filariasis.
In the UK/Western world, it is iatrogenic - often secondary to lymph node dissection for malignancy (e.g. axillary clearance for breast cancer; ilioinguinal dissection for melanoma, vulval or penile cancer).

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Lower limb: FRCS(Plast) example questions

Better questions. Better preparation.

Better questions.
Better preparation.