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Original Research

Program: Section on Orthopaedics

O2152: Accelerating Diagnostic Competency in Pediatric Musculoskeletal Radiograph Interpretation Among Orthopedic Post-graduate Trainnes

Saturday, September 27, 2025
1:15 PM - 1:19 PM MDT
Location: Colorado Convention Center, Mile High Ballroom 4E
Oral Presentation
Background: Despite the move towards competency based medical education, there is not currently a validated strategy for learning the interpretation of paediatric musculoskeletal (pMSK) radiographs by orthopedic surgery post-graduate trainees. This skill is generally acquired through case-by-case experience, but this can lead to knowledge gaps among practicing general orthopedic surgeons.

Methods: This was a multicenter prospective cohort study that enrolled a convenience sample of orthopedic surgery post-graduate trainees in Canada and Switzerland. We designed a web-based tool that included 1,609 pMSK radiograph-based cases categorized into six anatomical regions (clavicle/shoulder humerus; elbow; forearm/wrist/hand; pelvis/femur; knee/tibia-fibula; and ankle/foot). Of these, 1,093 cases (67.9%) had a fracture/dislocation; 150 (13.7%) were categorized as low-risk, 388 (35.5%) as medium-risk, and 555 (50.8%) as high risk. Participants were provided with a brief case description and radiographic views and asked to identify whether the case had a fracture/dislocation present or absent; if present, they then had to locate the fracture/dislocation and assign the case as low, medium, or high risk. Participants received corrective feedback after every case, and they kept doing cases until they achieved a pre-determined competency standard of 90% accuracy, 90% sensitivity (cases with a fracture/dislocation) and 90% specificity (cases without a fracture/dislocation), demo at https://drive.google.com/file/d/1VU8Jf3dmHczZHrN2Tcv4qQxcPh2U1FGp/view?usp=sharing. Main research outcomes included frequency of errors, changes in diagnostic performance, and competency achievement.

Results: We enrolled 115 orthopedic surgery post-graduate trainees who interpreted 64,489 unique cases; 39,565 involved cases with a fracture/dislocation and 24,924 involved cases without a fracture dislocation. In total, there were 7,075/64,489 (11.0%) incorrect interpretations; 4,100/39,565 (10.4%) were false negatives, while 2,975/24,924 (11.9%) were false positives. Furthermore, 1,049 (25.6%) errors were in low-risk cases, while 2,160 (48.0%) were in medium risk and 1,131 (26.4%) were in high risk cases. A comparison yielded a significant difference in frequency of errors across body regions (p < 0.001), with the highest among the ankle/foot region (14%, p < 0.05 for all comparisons). From the initial 25 to final 25 cases, there was a 10.5% (95% CI 9.4, 11.6) increase in diagnostic accuracy, 13.3% (95% CI 12.1, 14.6) in sensitivity (Figure 1), and 6.5% (95% CI 5.6, 7.4) in specificity. There was also an increase in correctly locating the fracture by 11.9% (95% CI 10.7, 13.0) and correct risk assignment by 20.5% (95% CI 18.9, 22.1). Overall, of the 115 participants 90 (78.3%) achieved the standard for a given body region, by completing a median of 144 cases (IQR 95, 313; min 58; max 909) within a median time of 34.9 minutes (IQR 23.8, 77.6; min 14.3, max 225.0), Figure 2.

Conclusion: The deliberate practice of interpreting pMSK radiographs and assigning risk to cases significantly and efficiently improved orthopedic surgery trainees’ diagnostic ability, with most successfully attaining the competency standard.