How to Pass the Orthopaedic Viva: Marking, Answer Structure and Pitfalls

The orthopaedic viva tests one thing above recall: whether you would make safe, reasoned decisions as a consultant in your first year of independent practice. The FRCS (Tr & Orth), FRACS and ABOS oral examinations all publish their standard in those terms, and their marking schemes reward organised, safe reasoning that needs little prompting. The short answer to how to pass is to give the headline first, structure every answer the same way, keep thinking aloud, follow the examiner's prompts and never bluff. This article sets out how the vivas are marked, how to build an answer and open a clinical case, and the pitfalls that cost marks. For the differential diagnosis structure examiners expect, see the surgical sieve.

What does the orthopaedic viva test?

The formats differ, but every board describes the same target. The JCIE structured oral question-writing guidelines (opens in a new tab) ask for questions that "follow a logical progression, increasing in complexity and mimicking the tasks which would be expected of a day one consultant". The RACS orthopaedic notes to candidates (opens in a new tab) set the benchmark as competency equivalent to "a specialist in Orthopaedic Surgery in his or her first year of independent practice". ABOS Part II examines the cases you have operated on yourself.

Sources: the JCIE Trauma & Orthopaedic Surgery regulations (opens in a new tab) (format from August 2022), the RACS orthopaedic notes to candidates for 2026, and the ABOS Part II FAQ (opens in a new tab). For the full format of each examination, read our guides to FRCS (Tr & Orth) Section 2, the FRACS orthopaedic exam, ABOS board certification and the EBOT/FEBOT exam, or the side-by-side comparison in the global orthopaedic board exam atlas.

How are orthopaedic vivas marked?

FRCS (Tr & Orth). Section 2 is marked against the JCIE marking descriptors (opens in a new tab) (policy G38, last reviewed February 2024). Each rating runs from 4 to 8 across four domains: basic knowledge; higher order processing (organisation, logical thought, judgement, decision making, prioritisation, interpretation of data, quality of response); clinical skills; and professionalism towards volunteers and examiners.

Two features of that scale should shape your preparation. First, prompting is written into the descriptors: good responses without prompting are described at 7, adequate responses with minimal prompting at 6, and responses that needed significant prompting at 5. Volunteer the next step before you are asked for it. Second, safety anchors the scale: "safe practice" is part of the 6 descriptor, and suggesting a course of action that would harm a volunteer is listed under 4. The JCIE's own question-review checklist asks whether each question makes it possible to score both a 4 and an 8, so expect every question to range from basic to difficult.

FRACS. The RACS orthopaedic examination uses the Expanded Close Marking System. Each marking point is graded 4 (well above the required standard), 3 (at or above), 2 (below) or 1 (well below). Two examiners mark each segment, reach a consensus pass or fail, and all seven segments carry equal weight. A candidate who passes all seven is recommended to pass; one who fails two or more fails; one who passes six is discussed by the Specialty Court.

ABOS. The ABOS scoring rubric (opens in a new tab) grades each case 3 (above expected level), 2 (expected), 1 (below) or 0 (unacceptable) across data gathering, diagnosis and interpretive skills, treatment plan, surgical indications, technical skill, surgical complications, outcomes, ethics and professionalism, and applied knowledge. Because the cases are your own, the rubric also judges whether your indications, records and follow-up stand up.

None of the three schemes awards marks for recall alone. The JCIE guidance tells question writers to avoid "list, define, what is" questions and to use open questions that make candidates apply knowledge and justify decisions, with "what if?" to probe problem solving and "and why?" to probe reasoning. Prepare for those two follow-ups on every topic.

How should you structure a viva answer?

Lead with the headline. State the conclusion first, then the evidence for it. The examiner relaxes once they know you have the diagnosis, and every later sentence reads as support rather than a search.

• Searching: "The fibula looks broken, quite high up, and the medial clear space looks wide, so the deltoid might be torn…"
• Headline: "This is a Weber C ankle fracture with features of syndesmotic disruption. The fibular fracture is above the syndesmosis, the medial clear space is widened and the tibiofibular overlap is lost."

Use one skeleton for management questions. It mirrors the ABOS domains and the JCIE higher order descriptors, so it scores under both:

1. Patient first. In trauma, resuscitate on ATLS principles before the limb. In elective work, state who the patient is and what the condition costs them.
2. Assessment. The history and examination findings that would change management, including red flags for infection or tumour.
3. Investigations in steps. Orthogonal plain radiographs first, then cross-sectional imaging or blood tests for a stated reason.
4. Diagnosis and classification. Describe first, then classify, then say what the classification means for treatment.
5. Options and choice. Non-operative and operative, then your choice and why, with consent.
6. Complications, follow-up and outcome. What you would watch for, and how you would know it worked.

Read images out loud in a fixed order. View, side, maturity and adequacy; the main abnormality; the soft tissues; then a one-sentence synthesis. For a differential diagnosis, group it rather than reciting it: the most likely cause in this patient, the most dangerous one you must exclude, then the rest.

Show the difference between a borderline and a clear answer. Take a displaced intracapsular neck of femur fracture in an older patient.

• Borderline: "I would consent for a cemented hemiarthroplasty through a lateral approach and mobilise full weight-bearing."
• Clear: "This is a fragility fracture with significant mortality, so care starts with orthogeriatric assessment and prompt surgery once the patient is optimised; delay is acceptable only to correct a correctable medical problem. Displaced fractures in this age group need arthroplasty. If she is cognitively intact, walks independently outdoors and is medically fit for anaesthesia and the procedure, NICE recommends a total hip replacement; otherwise a cemented hemiarthroplasty. During cementing I would warn the anaesthetist about bone cement implantation syndrome. Afterwards: out of bed within 24 hours where possible, thromboprophylaxis, and delirium prevention."

The second answer earns its marks by putting the patient, the system and the risks around the operation, not by naming more implants.

How do you open a clinical case?

In a short case the first sentence sets the examiner's expectations, and the time is short: JCIE short cases last 15 minutes and RACS video scenarios 9 minutes each. Our guide to orthopaedic short case presentation gives the full structure and model scripts for hip, hand and foot cases; the points below cover what applies across every clinical station.

Open with the patient and the dominant problem, not a list of normal findings. "I examined a 68-year-old man with a stiff, painful right hip and a fixed flexion deformity" tells the examiner where you are heading. "On inspection there were no scars" does not.

Group the evidence behind it. Give the two or three findings that carry the case, each with a number, a side and a comparison, then close with the diagnosis they are most consistent with. Avoid hedging phrases ("it could potentially be") and talk about talking ("what I would like to say is…"). If you could not perform a test, say why in one clause.

Use negatives only when they matter. Mention a normal finding when it excludes a serious differential or changes management: no warmth, erythema or sinus in a swollen joint after arthroplasty; intact distal neurovascular status in a suspected tumour.

If the diagnosis will not come, present the syndrome. Name the anatomical and functional deficit precisely. "There is a wrist and finger drop with triceps spared and sensory loss over the first dorsal web space. This is a radial nerve lesion distal to the branches to triceps, such as at the spiral groove." That still demonstrates synthesis.

Practise the opening until it is automatic. Record a 20-second opening for a common case and cut every filler word until it fits. Ask a colleague for three or four signs out of context ("quadriceps wasting, positive apprehension, lateral patellar subluxation in early flexion") and give the one-sentence synthesis at once. On ward rounds, present patients headline first; if your consultant needs to ask what the problem is, the opening was not clear enough.

What are the common viva pitfalls, and how do you rescue them?

Operating before resuscitating. Opening an open tibial fracture scenario with "I would nail it" skips the airway, the pelvis and the comorbidities. Start with the patient, and mention damage control, such as a spanning external fixator and senior orthoplastic debridement for an open fracture, before definitive fixation.

Lists without structure. Twenty differentials or "FBC, CRP, MRI, CT, bone scan and PET" show no reasoning. Group the differential and step up investigations: plain radiographs of the whole bone first, then the imaging that answers the next question.

Premature specialist imaging. "I would get an MRI" before the history, examination and radiographs reads as skipping clinical assessment.

Histology from a radiograph. Say "an aggressive lesion in the distal femoral metaphysis with a wide zone of transition and a sunburst periosteal reaction, concerning for a primary bone sarcoma such as osteosarcoma", then refer to a sarcoma service before biopsy. Do not announce the histology.

"Fix it now." Rushing to theatre without optimisation and consent sounds unsafe. "Once the patient is optimised and consented, I would fix this" costs four seconds.

Silence over an image. Fifteen seconds of staring reads as blanking. Describe what you see, starting with the view and the patient. If you cannot find an abnormality, say what is absent ("no fracture, dislocation or destructive lesion"); the image may be normal, or the examiner may point you to the area.

Guessing the eponym. "I'm not sure, but I think it's…" invites the examiner to test the guess. Describe the injury anatomically instead: "an intra-articular, multifragmentary distal radius fracture with dorsal comminution, which is unstable".

Bluffing about an operation you have not done. The RACS notes say examiners "can usually deduce very quickly" whether you have managed a situation, and ask candidates to acknowledge it and describe management "from your reading and planning". Do that.

Arguing with the examiner. When the examiner adds new information ("what if he is an elite overhead athlete?"), they are testing whether your reasoning adapts. Accept the change, explain how it alters the balance of options, and move on. The RACS notes are explicit: if an examiner suggests reconsidering an answer, "they should be trusted, and the prompts followed. Examiners are trying to assist candidates, not trick them."

Freezing when the scenario changes. The JCIE's example questions for writers include an unexpected event during surgery and an unexpected post-operative complication. When the algorithm breaks, go back to principles. Unexpected purulence at an elective arthroplasty means stopping the planned procedure, taking at least five deep tissue samples, debriding and treating it as periprosthetic joint infection.

Rescue strategies

Stop when interrupted. The RACS orthopaedic notes state that examiners move candidates on when they "have clearly exhausted their knowledge in an area, or they have satisfied the examiners requirements". Either way, talking over the examiner wastes your scoring time.

Pivot cleanly. If you realise you have misread a case, say so and change course: "Looking again at the sclerotic, well-defined margin in an asymptomatic patient, this is more consistent with a benign latent lesion such as a non-ossifying fibroma, so my management changes to observation."

Fall back on safety. When you are lost on a complex case, state what keeps the patient safe: neurovascular assessment, stabilising the limb, and referral to the right specialist service.

Escalate with a plan. A consultant still calls for help, but brings a plan with them. For a haemodynamically unstable pelvic ring injury: binder over the greater trochanters, major haemorrhage protocol, haemorrhage control by angioembolisation or packing according to local pathways, and early contact with the pelvic surgeon or transfer to a major trauma centre.

How should you conduct yourself in the room?

The RACS orthopaedic notes ask candidates to treat vivas "as an interaction with colleagues", and say examiners want to hear "what you are actually going to do, not what you perceive they might want to hear". That is the register to aim for: a new consultant discussing a case with two senior colleagues.

• Answer the question asked, then stop. If you are unsure what is being asked, ask for clarification; RACS says examiners will clarify or move you on.
• Speak at a measured pace without filler words or rising intonation that turns statements into questions.
• Sit upright, keep your hands still, and divide eye contact between the examiners.
• Expect anonymity. RACS examiners address candidates by number, not name.
• Practise on screen. The RACS Clinical Investigation and Management and Operative Surgery vivas are computer-based, so rehearse describing images on a monitor as well as on paper.

How should you practise for the viva?

Speak answers aloud; reading silently does not train delivery. Record yourself, listen back for filler, backtracking and long pauses, and time each answer. Sit mock vivas with consultants who will interrupt, change the scenario and ask "and why?". If you are revising without a partner, our guide to practising viva answers alone sets out recorder, timer and self-questioning drills. If nerves are the limiting factor, read managing exam performance anxiety.