Can an Orthopedic Hip Fracture Simulator Advance Orthopedic Residents' Hip Fracture Fixation Skills to an Expert Level?

OBJECTIVE: This study was undertaken to evaluate hip fracture simulator training and orthopedic resident skill attainment. We hypothesized that after 6 training sessions, improvement in post-training scores in junior residents would exceed that of senior residents and that senior residents would attain expert level proficiency sooner. DESIGN: Thirty orthopedic residents from a single institution completed 6 training sessions. Sessions included a pretest, 9 training modules, and post-test. An expert score was obtained from the average scores of 8 trauma fellows and attending orthopedic traumatologists. The primary outcome measure was overall score. SETTING: A single academic institution. PARTICIPANTS: Orthopedic residents (postgraduate years [PGYs] 1-5). RESULTS: Twenty-six residents completed the study. The mean overall post-training score was 87% of the expert level. Factors associated with post-training score changes were additional training sessions (4.2% improvement [p < 0.01]), time between training sessions (0.3% decrease [p = 0.05]) and PGY5 class (12.1% improvement [p = 0.03]). Fifty-four percent of residents attained the expert overall score. Expert score attainment was not associated with an additional year of training or case log volume. Post-training scores plateaued for the PGY1s and showed linear improvement for the PGY5s. CONCLUSIONS: Differences in trends between training levels suggest this simulator is a useful adjunct to a 5-year orthopedic residency training program.

3-D Printed Fracture Models Improve Resident Performance and Clinical Outcomes in Operative Fracture Management.

OBJECTIVE: To determine if preoperative examination of patient additive manufactured (AM) fracture models can be used to improve resident operative competency and patient outcomes. DESIGN: Prospective cohort study. Seventeen matched pairs of fracture fixation surgeries (for a total of 34 surgeries) were performed. Residents first performed a set of baseline surgeries (n = 17) without AM fracture models. The residents then performed a second set of surgeries randomly assigned to include an AM model (n = 11) or to omit it (n = 6). Following each surgery, the attending surgeon evaluated the resident using an Ottawa Surgical Competency Operating Room Evaluation (O-Score). The authors also recorded clinical outcomes including operative time, blood loss, fluoroscopy duration, and patient reported outcome measurement information system (PROMIS) scores of pain and function at 6 months. SETTING: Single-center academic level one trauma center. PARTICIPANTS: Twelve orthopaedic residents, between postgraduate year (PGY) 2 and 5, participated in this study. RESULTS: Residents significantly improved their O-Scores between the first and second surgery when they trained with AM models for the second surgery (p = 0.004, 2.43 ± 0.79 versus 3.73 ± 0.64). Similar improvements were not observed in the control group (p = 0.916, 2.69 ± 0.69 versus 2.77 ± 0.36). AM model training also significantly improved clinical outcomes, including surgery time (p = 0.006), fluoroscopy exposure time (p = 0.002), and patient reported functional outcomes (p = 0.0006). CONCLUSIONS: Conclusions: Training with AM fracture models improves the performance of orthopaedic surgery residents during fracture surgery.

Simulation Training in Fracture Surgery.

The current surgical training environment has sparked a paradigm shift toward the use of surgical training simulation. An apprentice-based model has historically been used in surgical education, but current financial and practical constraints have led to a more variable training experience. Surgical simulation has demonstrated efficacy in many facets of orthopaedic training and has most recently been implemented to fine-tune surgical skill in reconstruction of traumatic skeletal injuries. Although some surgical skills learned during residency training are not fully used in later practice, most surgeons require a baseline level of competence in managing skeletal trauma. Fracture surgery is heavily dependent on technical skill. Trainee simulation use in skill acquisition has potential to improve proficiency during actual surgery. Furthermore, in a specialty where the standard axiom has been repetition matters, education augmentation with simulation provides overall benefit. Work remains to maximize the effectiveness of surgical simulation in fracture treatment through improved model integration and access.

Improved precision of radiographic measurements for distal radius fractures after a technique-teaching tutorial.

Background: For the management of distal radius fractures, surgical decision-making depends on radiographic measurements of indicators including radial inclination (RI), ulnar variance (UV) and radial tilt (RT). Evaluation of the inter- and intrarater reliability of surgeons' measurements of these criteria has been limited. Methods: Twelve physicians were invited to participate in this study. Anonymously, they measured RI, UV and RT on 30 digitally stored radiographs of distal radius fractures on 3 occasions, each at least 1 week apart, using online measuring tools. After taking the third set of measurements, the participants were given a tutorial by the senior author (G.J.) on a single technique to measure all 3 indicators. The participants then took 3 more sets of measurements using only the technique they had been taught. Intraclass correlation coefficients (ICCs) were used to evaluate interrater reliability each week. Multiple logistic regression was used to calculate the effect of the tutorial, controlling for week of study along with reader (participant) and patient variance. Results: The ICCs indicated that the participants' measurement precision improved promptly after the tutorial, and this improvement was sustained through subsequent readings. The odds of an "accurate" measurement (within 2° of the senior author's measurements for RI, 1 mm for UV and 4° for RT) was 1.7 times higher for RI, 2.7 times higher for UV and 2.3 times higher for RT after the tutorial; all of these results were statistically significant. Conclusion: Surgeons ought to be familiar with a method to reproducibly measure the indicators used in the published guidelines for surgical intervention. The tutorial on a single standardized technique for online measurement of RI, UV and RT in distal radius fractures improved measurement precision.

Contexte: Pour la prise en charge des fractures du radius distal, la prise de décisions chirurgicales dépend de la mesure de plusieurs indicateurs sur les images radiographiques : l'inclinaison radiale (IR), la variance ulnaire (VU) et l'inclinaison sagittale du radius (ISR). La fiabilité interévaluateurs et intra-évaluateur des mesures de ces critères par les chirurgiens a été peu étudiée. Méthodes: Nous avons invité 12 médecins à participer à l'étude. En tout anonymat, ils ont déterminé l'IR, la VU et l'ISR au moyen d'outils de mesure en ligne sur 30 radiographies numérisées de fractures du radius distal. Ils ont répété l'exercice à 3 reprises, à au moins 1 semaine d'intervalle. Après la troisième série, les participants ont suivi un tutoriel de l'auteur principal (G. J.) sur une technique qui peut à elle seule mesurer les 3 indicateurs. Les participants ont ensuite fait 3 autres séries de mesures en utilisant seulement cette technique. Nous avons évalué la fiabilité interévaluateurs pour chaque semaine à partir des coefficients de corrélation intraclasse (CCI). De plus, nous avons calculé l'effet du tutoriel par régression logistique multiple, en tenant compte de la semaine de l'étude et de la variation selon les lecteurs (participants) et les patients. Résultats: Les CCI indiquent que la précision des mesures s'est améliorée rapidement après le tutoriel; cette amélioration a d'ailleurs persisté tout au long des séries subséquentes. La probabilité d'une mesure « exacte ¼ (dont l'écart par rapport aux mesures de l'auteur principal est inférieur à 2° pour l'IR, à 1 mm pour la VU et à 4° pour l'ISR) était 1,7 fois plus grande pour l'IR, 2,7 fois plus grande pour la VU et 2,3 fois plus grande pour l'ISR après le tutoriel. Tous ces résultats sont statistiquement significatifs. Conclusion: Les chirurgiens doivent connaître une méthode de mesure reproductible des indicateurs utilisés dans les directives cliniques publiées pour guider l'intervention chirurgicale. Le tutoriel sur la technique normalisée de mesure en ligne de l'IR, de la VU et de l'ISR dans les cas de fracture du radius distal a amélioré la précision des mesures.

A Cadaver-Based Course for Humanitarian Surgery Improves Manual Skill in Powerless External Fixation.

BACKGROUND: General surgery residents interested in humanitarian careers may benefit from supplemental training beyond modern residency. The Colorado Humanitarian Surgical Skills Workshop is a 2-d cadaver-based course for senior surgical residents, teaching low-resource skills across multiple specialties, including orthopedics. We assessed the course's ability to transmit manual competence in a critical humanitarian surgical skill, powerless lower extremity external fixation. MATERIALS AND METHODS: We created a novel standardized manual skills test of powerless lower extremity external fixation. Course participants had no prior experience with this technique. At course initiation, paired participants attempted to stabilize a proximal tibia-fibula fracture in a cadaver. Subsequently, participants received didactics from orthopedic surgeons followed by hands-on practice. At course completion, paired participants repeated the exercise. Fixator constructs were scored using standardized criteria. Precourse and postcourse surveys measured participants' level of confidence in performing external fixation. RESULTS: Twelve senior surgical residents were included. Average scores of external fixator constructs improved significantly (23% pre versus 75% post, P < 0.01). On pretesting, none of the participants completed the exercise within 15 min. Only one of six constructs was marginally stable, and none were aligned. On post-testing, five of six teams completed the exercise in an average of 12.4 min. Four of six constructs were stable and two of six were also well aligned. Confidence with external fixation also improved significantly. CONCLUSIONS: Participants in a short cadaver-based workshop demonstrated significant improvements in manual skill and confidence related to powerless external fixation. However, additional training is likely required to achieve clinical competence.

Effectiveness of a step-by-step oral recount before a practical simulation of fracture fixation.

OBJECTIVE: To evaluate the effectiveness of a step-by-step oral recount by residents before the final execution of a practical exercise simulating a surgical fixation of a radial diaphyseal fracture. MATERIAL AND METHODS: The study included 10 residents of orthopaedics and traumatology (four second- year and six first-year residents) divided into two groups with five residents each. All participants initially gathered in a room in which a video was presented demonstrating the practical exercise to be performed. One group (Group A) was referred directly to the practical exercise room. The other group (Group B) attended an extra session before the practical exercise, in which they were invited by instructors to recount all the steps that they would perform during the practical exercise. During this session, the instructors corrected the residents if any errors in the step-by-step recount were identified, and clarified questions from them. After this session, both Groups A and B gathered in a room in which they proceeded to the practical exercise, while being video recorded and evaluated using a 20-point checklist. RESULTS: Group A achieved a 57% accuracy, with results in this group ranging from 7 to 15 points out of a total of a possible 20 points. Group B achieved an 89% accuracy, with results in this group ranging from 15 to 20 points out of 20. CONCLUSION: An oral step-by-step recount by the residents before the final execution of a practical simulation exercise of surgical fixation of a diaphyseal radial fracture improved the technique and reduced the execution time of the exercise.

Teaching the Basics: Development and Validation of a Distal Radius Reduction and Casting Model.

BACKGROUND: Approximately one-third of reduced pediatric distal radius fractures redisplace, resulting in further treatment. Two major modifiable risk factors for loss of reduction are reduction adequacy and cast quality. Closed reduction and immobilization of distal radius fractures is an Accreditation Council for Graduate Medical Education residency milestone. Teaching and assessing competency could be improved with a life-like simulation training tool. QUESTIONS/PURPOSES: Our goal was to develop and validate a realistic distal radius fracture reduction and casting simulator as determined by (1) a questionnaire regarding the "realism" of the model and (2) the quantitative assessments of reduction time, residual angulation, and displacement. METHODS: A distal radius fracture model was created with radiopaque bony segments and articulating elbows and shoulders. Simulated periosteum and internal deforming forces required proper reduction and casting techniques to achieve and maintain reduction. The forces required were estimated through an iterative process through feedback from experienced clinicians. Embedded monofilaments allowed for quantitative assessment of residual displacement and angulation through the use of fluoroscopy. Subjects were asked to perform closed reduction and apply a long arm fiberglass cast. Primary performance variables assessed included reduction time, residual angulation, and displacement. Secondary performance variables consisted of number of fluoroscopic images, casting time, and cast index (defined as the ratio of the internal width of the forearm cast in the sagittal plane to the internal width in the coronal plane at the fracture site). Subject grading was performed by two blinded reviewers. Interrater reliability was nearly perfect across all measurements (intraclass correlation coefficient range, 0.94-0.99), thus disagreements in measurements were handled by averaging the assessed values. After completion the participants answered a Likert-based questionnaire regarding the realism of simulation. Eighteen participants consented to participate in the study (eight attending pediatric orthopaedic surgeons, six junior residents, four senior residents). The performances of junior residents (Postgraduate Year [PGY] 1-2), senior residents (PGY 3-5), and attending surgeons were compared using one-way ANOVA with Tukey's-adjusted pairwise comparisons. RESULTS: The majority of participants (15 of 18) felt that the model looked, felt, and moved like a human forearm. All participants strongly agreed that the model taught the basic steps of fracture reduction and should be implemented in orthopaedic training. Attending surgeons reduced fractures in less time than junior residents (60 ± 27 seconds versus 460 ± 62 seconds; mean difference, 400 seconds; 95% CI, 335-465 seconds; p < 0.001). Residual angulation was greater for junior residents when compared with attending surgeons on AP (7° ± 5° versus 0.7° ± 0.9°; mean difference, 6.3°; 95% CI, 3°-11°; p = 0.003) and lateral (27° ± 7° versus 7° ± 5°; mean difference, 20°; 95% CI, 13°-27°; p = 0.001) radiographs. Similarly, residual displacement was greater for junior residents than either senior residents (mean difference, 16 mm; 95% CI, 2-34 mm; p = 0.05) or attending surgeons (mean difference, 15 mm; 95% CI, 3-27 mm; p = 0.02) on lateral images. There were no differences identified in secondary performance variables (number of fluoroscopic images, casting time, and cast index) between groups. CONCLUSIONS: This is the first distal radius fracture reduction model to incorporate an elbow and shoulder and allow quantitative assessment of the fracture reduction. This simulator may be useful in an orthopaedic resident training program to help them reach a defined minimum level of competency. This simulator also could easily be integrated in other accreditation and training programs, including emergency medicine. LEVEL OF EVIDENCE: Level II, therapeutic study.

Video Review as a Tool to Improve Orthopedic Residents׳ Performance of Closed Manipulative Reductions.

OBJECTIVE: Orthopedic residents commonly perform closed manipulative reductions as a part of their training. Traditionally, this skill is taught early in training but difficult to simulate. Proficiency is achieved through repetition and experience; faculty observation and instruction is unfortunately often limited. Direct resident teaching has been shown to increase competency, comfort, and long-term skill retention. We hypothesize that video review of closed fracture reductions will provide an inexpensive and valuable tool for resident education and improve skill performance. DESIGN: Closed reductions performed by orthopaedic residents were recorded using a secured mobile tablet device in the emergency department (ED). Video review sessions were performed with both peer and faculty feedback/analysis of reduction technique. Anonymous resident and faculty surveys were completed following each session to evaluate the usage and perceived benefit of the program. SETTING: University-based Level I Trauma Center. PARTICIPANTS: Orthopedic surgery residents and faculty. RESULTS: All junior orthopedic residents (postgraduate year [PGY] 1-3) reported that direct video observation by faculty was beneficial. Furthermore, 97% of junior resident and 100% of faculty responses reported that they would use this educational technology in the future. Residents and faculty both strongly agreed that video review was more useful than other methods, improved resident preparation for ED fracture care, and felt this technique would improve patient care and outcomes. Compared with senior residents (PGY 4-5), PGY-1s believed that this technique helped them prepare for ED fracture care (p = 0.02). CONCLUSIONS: Video review provides a useful, innovative, and inexpensive method to improve resident competency in closed fracture reduction-a critical skill in orthopedic patient care. These procedures are uncommonly available for direct faculty observation. We have demonstrated that both residents and faculty were satisfied with the ability to review procedures, identify weaknesses, and obtain or provide direct feedback on this skill. Additionally, fracture reduction video review may help residents meet and achieve clinical milestones, an area of future investigation.

Timing of fracture fixation from an Intensive Care Unit perspective: the obstacles to early fracture fixation.

Trauma is one of the leading causes of death worldwide, with road traffic accidents being the leading cause of death in the age group of 15-29 years However, with modern advances in management and the introduction of specialised trauma centres, more and more are surviving severe and life-threatening trauma. The ideal timing of fracture fixation has been the subject of debate for a number of decades. There is evidence to suggest that fracture fixation in the patient with polytrauma is best achieved early on to reduce the incidence of morbidity and mortality, with damage control surgery in the more appropriate option in those patients who are haemodynamically unstable. However, early fracture fixation is not always possible, and the focus of this article is to review the common contributing factors resulting in delayed fixation. For the purpose of this discussion, we will consider all trauma as a single entity, taking into account that each type of fixation has its own complications, which are outside the scope of this article.

Simulation and Web-based learning increases utilization of Bier block for forearm fracture reduction in the pediatric emergency department.

OBJECTIVES: Bier block (BB) is a safe and effective alternative to procedural sedation for analgesia during forearm fracture reductions, yet remains infrequently used in the pediatric emergency department (PED). No standardized methods of BB training have previously been described. The objective of this study was to determine whether a multimodal instructional course increases comfort with BB and translates to increased use of this technique. METHODS: A novel interdisciplinary simulation and Web-based training course was developed to teach the use of BB for forearm fracture reduction at a tertiary PED. Participants were surveyed pre-/post-training, and at 2 and 6 months regarding their comfort with BB. In parallel, we prospectively assessed the clinical use of BB for children ages 6 to 18 years requiring closed reduction of forearm fractures during the 24-month post-course period. RESULTS: Course participation included 26 physicians and 12 nurses. Survey response rate was 100%. Course participation increased both comfort (10% pre-training v. 89% post-training, p<0.001) and the willingness to use BB (51% pre-training v. 95% post-training, p<0.001), an effect sustained at 6 months post-course (66% and 92%, respectively, p<0.001 for both). In clinical practice, there were no BBs performed prior to course administration. We observed a consistent and sustained increase in clinical use among the BB-trained physicians, with 37% of all forearm reductions performed using BB at 24 months post-course completion. CONCLUSIONS: A novel combined simulation and Web-based training course increased comfort and willingness to use BB and was associated with increased use of this technique for forearm fracture reduction in the PED.

Trends in Upper Extremity Fracture Caseload Reporting During Orthopaedic Residency.

BACKGROUND: The objectives of this investigation were to report temporal trends in resident performed upper extremity fracture procedures and analyze case volume variability. METHODS: Orthopaedic resident case logs from the Accreditation Council for Graduate Medical Education were reviewed for graduating years 2007 to 2014. The mean number of wrist, forearm, elbow, humerus, and shoulder fracture-dislocation procedures performed by residents was analyzed. The median number of procedures reported by the top 30% and bottom 30% of residents (by case volume) was also recorded. Linear regression modeling was used to assess temporal trends. RESULTS: The mean number of wrist and forearm fracture cases performed per resident fell from 55.3 in 2007 to 46.7 in 2014 (p = 0.325) while the number of elbow and humerus fracture procedures remained relatively constant (45.6 to 45.4; p = 0.224). The mean number of shoulder fracture cases increased significantly (14.7 to 22.5; p < 0.001). Over the 8-year period, residents in the 70th percentile of caseload performed significantly more wrist and forearm (62.6 versus 39.5; p < 0.001), elbow and humerus (55 versus 34.9; p < 0.001), and shoulder (23 versus 12.9; p < 0.001) fracture procedures than residents in the 30th percentile. CONCLUSION: Resident case volume for wrist, forearm, elbow, and humerus fractures is constant or falling. However, shoulder fracture caseloads are increasing. Regardless, there is substantial disparity in upper extremity fracture case volume among residents. Further investigation is needed to assess possible educational effects of resident caseload disparity.

Value Added: the Case for Point-of-View Camera use in Orthopedic Surgical Education.

BACKGROUND: Orthopedic surgical education is evolving as educators search for new ways to enhance surgical skills training. Orthopedic educators should seek new methods and technologies to augment and add value to real-time orthopedic surgical experience. This paper describes a protocol whereby we have started to capture and evaluate specific orthopedic milestone procedures with a GoPro® point-of-view video camera and a dedicated video reviewing website as a way of supplementing the current paradigm in surgical skills training. We report our experience regarding the details and feasibility of this protocol. METHODS: Upon identification of a patient undergoing surgical fixation of a hip or ankle fracture, an orthopedic resident places a GoPro® point-of-view camera on his or her forehead. All fluoroscopic images acquired during the case are saved and later incorporated into a video on the reviewing website. Surgical videos are uploaded to a secure server and are accessible for later review and assessment via a custom-built website. An electronic survey of resident participants was performed utilizing Qualtrics software. Results are reported using descriptive statistics. RESULTS: A total of 51 surgical videos involving 23 different residents have been captured to date. This includes 20 intertrochanteric hip fracture cases and 31 ankle fracture cases. The average duration of each surgical video was 1 hour and 16 minutes (range 40 minutes to 2 hours and 19 minutes). Of 24 orthopedic resident surgeons surveyed, 88% thought capturing a video portfolio of orthopedic milestones would benefit their education. CONCLUSIONS: There is a growing demand in orthopedic surgical education to extract more value from each surgical experience. While further work in development and refinement of such assessments is necessary, we feel that intraoperative video, particularly when captured and presented in a non-threatening, user friendly manner, can add significant value to the present and future paradigm of orthopedic surgical skill training.

Cognitive and Psychomotor Entrustable Professional Activities: Can Simulators Help Assess Competency in Trainees?

BACKGROUND: An entrustable professional activity describes a professional task that postgraduate residents must master during their training. The use of simulation to assess performance of entrustable professional activities requires further investigation. QUESTIONS/PURPOSES: (1) Is simulation-based assessment of resident performance of entrustable professional activities reliable? (2) Is there evidence of important differences between Postgraduate Year (PGY)-1 and PGY-4 residents when performing simulated entrustable professional activities? METHODS: Three entrustable professional activities were chosen from a list of competencies: management of the patient for total knee arthroplasty (TKA); management of the patient with an intertrochanteric hip fracture; and management of the patient with an ankle fracture. Each assessment of entrustable professional activity was 40 minutes long with three components: preoperative management of a patient (history-taking, examination, image interpretation); performance of a technical procedure on a sawbones model; and postoperative management of a patient (postoperative orders, management of complications). Residents were assessed by six faculty members who used checklists based on a modified Delphi technique, an overall global rating scale as well as a previously validated global rating scale for the technical procedure component of each activity. Nine PGY-1 and nine PGY-4 residents participated in our simulated assessment. We assessed reliability by calculating the internal consistency of the mean global rating for each activity as well as the interrater reliability between the faculty assessment and blinded review of videotaped encounters. We sought evidence of a difference in performance between PGY-1 and PGY-4 residents on the overall global rating scale for each station of each entrustable professional activity. RESULTS: The reliability (Cronbach's α) for the hip fracture activity was 0.88, it was 0.89 for the ankle fracture activity, and it was 0.84 for the TKA activity. A strong correlation was seen between blinded observer video review and faculty scores (mean 0.87 [0.07], p < 0.001). For the hip fracture entrustable professional activity, the PGY-4 group had a higher mean global rating scale than the PGY-1 group for preoperative management (3.56 [0.5] versus 2.33 [0.5], p < 0.001), postoperative management (3.67 [0.5] versus 2.22 [0.7], p < 0.001), and technical procedures (3.11 [0.3] versus 3.67 [0.5], p = 0.015). For the TKA activity, the PGY-4 group scored higher for postoperative management (3.5 [0.8] versus 2.67 [0.5], p = 0.016) and technical procedures (3.22 [0.9] versus 2.22 [0.9], p = 0.04) than the PGY-1 group, but no difference for preoperative management with the numbers available (PGY-4, 3.44 [0.7] versus PGY-1 2.89 [0.8], p = 0.14). For the ankle fracture activity, the PGY-4 group scored higher for postoperative management (3.22 [0.8] versus 2.33 [0.7], p = 0.18) and technical procedures (3.22 [1.2] versus 2.0 [0.7], p = 0.018) than the PGY-1 groups, but no difference for preoperative management with the numbers available (PGY-4, 3.22 [0.8] versus PGY-1, 2.78 [0.7], p = 0.23). CONCLUSIONS: The results of our study show that simulated assessment of entrustable professional activities may be used to determine the ability of a resident to perform professional tasks that are critical components of medical training. In this manner, educators can ensure that competent performance of these skills in the simulated setting occurs before actual practice with patients in the clinical setting.

A Radiation Safety Training Program Results in Reduced Radiation Exposure for Orthopaedic Residents Using the Mini C-arm.

BACKGROUND: Fluoroscopy during fracture reduction allows a physician to assess fractures and immediately treat a pediatric patient. However, concern regarding the effects of radiation exposure has led us to find ways to keep radiation exposures as low as reasonably achievable. One potentially simple way, which to our knowledge has not been explored, to decrease radiation exposure is through formal education before mini C-arm use. QUESTIONS/PURPOSES: We questioned whether a radiation safety educational program decreases radiation (1) time and (2) exposure among residents and patients. PATIENTS AND METHODS: This is a retrospective study in which second-year residents underwent a 3-hour educational program regarding mini C-arm use and radiation safety taught by our institution's health physics department. We evaluated the records of all patients who underwent a pediatric both-bone forearm or distal radius fracture reduction in the emergency department 3 months before the educational program or after the program. To be included in the study, records included simple both-bone forearm fractures, simple distal radius fractures, and patient age younger than 18 years, and could not include patients with multiple fractures in the same limb. This resulted in study groups of 53 and 45 patients' records in the groups before and after the educational session, respectively. Radiation emission from the mini C-arm between both groups were compared. RESULTS: Exposure time with the mini C-arm was longer in patients treated before the educational intervention than in those treated after the intervention (patients with both-bone forearm fractures: mean = 41.2, SD = 24.7, 95% CI, 23.14-59.26 vs mean = 28.9, SD = 14.4, 95% CI, 15.91-41.89, p = 0.066; patients with distal radius fractures: mean = 38.1, SD = 26.1, 95% CI, 25.1-51.1 vs mean = 26.7, SD = 15.8, 95% CI, 16.44-36.96, p = 0.042). Calculated radiation exposure with the mini C-arm was larger in patients treated before the educational intervention than in those treated after the intervention (patients with both-bone forearm fractures: mean = 90.9, SD = 60.9, 95% CI, 51.06-130.74 vs mean = 30.4, SD = 18.5, 95% CI, 16.73-44.07, p < 0.001; patients with distal radius fractures: mean = 83.1, SD = 58.9, 95% CI, 54.75-111.45 vs mean = 32.6, SD = 26.4, 95% CI, 20.07-45.13, p < 0.001). CONCLUSIONS: A radiation-safety program resulted in decreased radiation exposure to residents and patients, and in decreased mini C-arm exposure time during pediatric fracture reductions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Objective Structured Assessments of Technical Skills (OSATS) Does Not Assess the Quality of the Surgical Result Effectively.

BACKGROUND: Performance assessment in skills training is ideally based on objective, reliable, and clinically relevant indicators of success. The Objective Structured Assessment of Technical Skill (OSATS) is a reliable and valid tool that has been increasingly used in orthopaedic skills training. It uses a global rating approach to structure expert evaluation of technical skills with the experts working from a list of operative competencies that are each rated on a 5-point Likert scale anchored by behavioral descriptors. Given the observational nature of its scoring, the OSATS might not effectively assess the quality of surgical results. QUESTIONS/PURPOSES: (1) Does OSATS scoring in an intraarticular fracture reduction training exercise correlate with the quality of the reduction? (2) Does OSATS scoring in a cadaveric extraarticular fracture fixation exercise correlate with the mechanical integrity of the fixation? METHODS: Orthopaedic residents at the University of Iowa (six postgraduate year [PGY]-1s) and at the University of Minnesota (seven PGY-1s and eight PGY-2s) undertook a skills training exercise that involved reducing a simulated intraarticular fracture under fluoroscopic guidance. Iowa residents participated three times during 1 month, and Minnesota residents participated twice with 1 month between their two sessions. A fellowship-trained orthopaedic traumatologist rated each performance using a modified OSATS scoring scheme. The quality of the articular reduction obtained was then directly measured. Regression analysis was performed between OSATS scores and two metrics of articular reduction quality: articular surface deviation and estimated contact stress. Another skills training exercise involved fixing a simulated distal radius fracture in a cadaveric specimen. Thirty residents, distributed across four PGY classes (PGY-2 and PGY-3, n = 8 each; PGY-4 and PGY-5, n = 7 each), simultaneously completed the exercise at individual stations. One of three faculty hand surgeons independently scored each performance using a validated OSATS scoring system. The mechanical integrity of each fixation construct was then assessed in a materials testing machine. Regression analysis was performed between OSATS scores and two metrics of fixation integrity: stiffness and failure load. RESULTS: In the intraarticular fracture model, OSATS scores did not correlate with articular reduction quality (maximum surface deviations: R = 0.17, p = 0.25; maximum contact stress: R = 0.22, p = 0.13). Similarly in the cadaveric extraarticular fracture model, OSATS scores did not correlate with the integrity of the mechanical fixation (stiffness: R = 0.10, p = 0.60; failure load: R = 0.30, p = 0.10). CONCLUSIONS: OSATS scoring methods do not effectively assess the quality of the surgical result. Efforts must be made to incorporate assessment metrics that reflect the quality of the surgical result. CLINICAL RELEVANCE: New objective, reliable, and clinically relevant measures of the quality of the surgical result obtained by a trainee are urgently needed. For intraarticular fracture reduction and extraarticular fracture fixation, direct physical measurement of reduction quality and of mechanical integrity of fixation, respectively, meet this need.

Fractures de stress dans un centre hospitalier et universitaire en Afrique Subsaharienne

Introduction: La fracture de stress est une lésion de surmenage osseux. L'objectif de cette étude était décrire le profil de ces fractures dans un centre hospitalier et universitaire en Afrique subsaharienne. Matériels et méthodes: Cette étude prospective de janvier 2008 à décembre 2011 a concerné tous les patients ayant des douleurs ostéo-articulaires récentes et survenues après le début d'un entraînement physique intensif (entraînement militaire ou sportif). Nous avons étudié les caractéristiques sociodémographiques, les circonstances de survenue, le diagnostic, le traitement, et l'évolution. Résultats: Cette étude a concerné 17 patients. Treize fractures de stress ont été notées chez 11 patients. Il s'agissait de huit femmes et trois hommes âgés en moyenne de 21 ans. La symptomatologie douloureuse évoluait depuis trois semaines en moyenne. La fracture a concerné les os longs des membres pelviens. Le siège le plus fréquent était la jonction métaphysaire proximale du tibia. Deux fractures bilatérales ont intéressé la fibula. Le traitement a été non opératoire. La consolidation sans séquelle a été obtenue après six semaines. Au recul moyen de 20 mois tous les patients avaient une excellente récupération fonctionnelle. Conclusion: La fracture de stress est rare dans notre contexte et touche les recrues féminines de l'armée. La fracture siège surtout sur la corticale postéro-médiale du tibia. Leur évolution est simple

The Inadequacy of Pediatric Fracture Care Information in Emergency Medicine and Pediatric Literature and Online Resources.

BACKGROUND: Emergency medicine and pediatric physicians often provide initial pediatric fracture care. Therefore, basic knowledge of the various treatment options is essential. The purpose of this study was to determine the accuracy of information commonly available to these physicians in textbooks and online regarding the management of pediatric supracondylar humerus and femoral shaft fractures. METHODS: The American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for pediatric supracondylar humerus and femoral shaft fractures were used to assess the content of top selling emergency medicine and pediatric textbooks as well as the top returned Web sites after a Google search. Only guidelines that addressed initial patient management were included. Information provided in the texts was graded as consistent, inconsistent, or omitted. RESULTS: Five emergency medicine textbooks, 4 pediatric textbooks, and 5 Web sites were assessed. Overall, these resources contained a mean 31.6% (SD=32.5) complete and correct information, whereas 3.6 % of the information was incorrect or inconsistent, and 64.8% was omitted. Emergency medicine textbooks had a mean of 34.3% (SD=28.3) correct and complete recommendations, 5.7% incorrect or incomplete recommendations, and 60% omissions. Pediatric textbooks were poor in addressing any of the American Academy of Orthopaedic Surgeons guidelines with an overall mean of 7.14% (SD=18.9) complete and correct recommendations, a single incorrect/incomplete recommendation, and 91.1% omissions. Online resources had a mean of 48.6% (SD=33.1) complete and correct recommendations, 5.72% incomplete or incorrect recommendations, and 45.7% omissions. CONCLUSIONS: This study highlights important deficiencies in resources available to pediatric and emergency medicine physicians seeking information on pediatric fracture management. Information in emergency medicine and pediatric textbooks as well as online is variable, with both inaccuracies and omissions being common. This lack of high-quality information could compromise patient care. Resources should be committed to ensuring accurate and complete information is readily available to all physicians providing pediatric fracture care. In addition, orthopaedic surgeons should take an active role to ensure that nonorthopaedic textbooks and online resources contain complete and accurate information.

On orthopedic surgical skill prediction--the limited value of traditional testing.

OBJECTIVES: Primary: to assess the utility of our distal radius fracture repair model as a tool for examining residents' surgical skills. Secondary: to compare the residents' ability to achieve specific biomechanically measured fracture stability with traditional test scores. DESIGN: Our laboratory pioneered a model that measures biomechanical qualities of a repaired distal radius fracture. Before participation, all residents to be tested completed specified knowledge examinations. During the laboratory exercise, proctors observed each resident and completed Objective Structured Assessment of Technical Skills forms. At the completion of the laboratory, each specimen was tested biomechanically. Written examinations were completed in a proctored setting and computer examinations at home following the honor system. The laboratory exercise had adequate space and materials and allowed 60 minutes to complete the procedure. Residents had equal access to x-ray imaging. SETTING: The examination environment of the study resembled an operating room. PARTICIPANTS: Postgraduate years 3 and 4 orthopedic residents in our program were asked to participate. The institutional review board reviewed and approved the study as exempt. RESULTS: Fracture repair constructs capable of resisting loads expected during rehabilitation were created by approximately half the residents tested. However, traditional written and computer-based testing methods failed to predict which resident's fracture construct would pass the biomechanical testing. Prior in vivo similar case experience was not predictive. CONCLUSIONS: The idea that "book smart does not equal street smart" applies to the tested model. To measure surgical skill acquisition and increase public safety related to surgery, it will be necessary to employ new and specific examination methods that identify the skill to be acquired and test the acquisition of this skill as precisely as possible.