The most-cited sources on the orthopaedic in-training examination: question yield, reading efficiency, and time lag from publication.

BACKGROUND: Each Orthopaedic In-Training Examination (OITE) question references one or more journal articles or textbook sections as the evidence-based origin of its "preferred response." Previous studies identified the number of references to the top sources but not the number of questions covered by these top sources. The current study analyzes the question yield, time lag from publication, and sequential benefit-in terms of OITE questions covered-of the most referenced sources in order to provide residents and educators strategies for developing an efficient reading program. METHODS: We analyzed all OITE references from 2002 to 2009 and identified 1. The most referenced journals, text- books, authors, and journal articles; 2. The question yield of the top journals; 3. The time lag from article publication to OITE reference; and 4. The additional question benefit of the top sources when added sequentially. We repeated the analysis considering only journal articles published within 5 years of each respective OITE. RESULTS: The most referenced journals were the The Journal of Bone and Joint Surgery, American Edition (JBJS-Am), Clinical Orthopaedics and Related Research (CORR), and the The Journal of the American Academy of Orthopaedic Surgeons (JAAOS). JBJS-Am accounted for 14% of all references and was referenced on 24% of questions; CORR and JAAOS each contributed 6% of references and were referenced on 11% of questions. The average time from article publication to OITE reference was 8.1 years (median: 6 years, mode: 2 years). The top 29 authors were referenced on 15% of OITE questions. The two most-referenced articles were each referenced 7 times in 8 years. Regarding question yield, 18% of published JAAOS articles were referenced on an OITE, as opposed to 7% of JBJS-Am articles and 2% of CORR articles. Considering articles published within 5 years of an OITE, the number of questions referencing JBJS-Am decreased from 24% to 10%. The sequential benefit of adding JAAOS and CORR during the 5 years was an additional 8% of total questions. CONCLUSIONS: When developing a reading curriculum, educators and residents should be aware of the question yield, reading efficiency, and time lag to publication of the most common OITE reference sources.

Mini-C-arm fluoroscopy for emergency-department reduction of pediatric forearm fractures.

BACKGROUND: Reduction of pediatric forearm fractures with the patient under sedation in the emergency department is a common practice throughout the United States. We hypothesized that the use of a mini-c-arm fluoroscopy device as an alternative to routine radiographs for evaluation of fracture reduction would (1) allow a more anatomic fracture reduction, (2) decrease the number of repeat reductions or subsequent procedures, (3) reduce overall radiation exposure to the patient, and (4) decrease the orthopaedic consultation time in the emergency department. METHODS: A retrospective cohort analysis of 279 displaced forearm and wrist fractures treated with closed reduction and casting with the patient under sedation in the emergency department of a level-I pediatric trauma center was performed, and the data were compared with historical controls. One hundred and thirteen fracture reductions were assessed with a mini-c-arm device, and 166 fracture reductions were evaluated with radiographs. All patients had radiographs of the injury. Blinded, independent reviewers graded the quality of reduction for residual angulation and translation of the reduced fracture. Radiation exposure was determined by the average number of radiographs made through either modality. Emergency department and outpatient charts were reviewed to determine the total orthopaedic consultation time and the need for repeat reductions or operative intervention. RESULTS: Pediatric forearm fractures undergoing closed reduction with assistance of the mini c-arm had a significant improvement in reduction quality (average angulation [and standard deviation], 6° ± 4° vs. 8 ± 6°; p = 0.02), a decrease in repeat fracture reduction and need for subsequent operative treatment (two [2%] of 113 fractures vs. fourteen [8.4%] of 166 fractures; p = 0.0001), and a decrease in radiation exposure to the patient (mean, 14.0 ± 10.3 mrem vs. 50.0 ± 12.7 mrem). The average orthopaedic consultation time was decreased with use of a mini c-arm (28 ± 12 min vs. 47 ± 19 min, p < 0.001). CONCLUSIONS: Use of the mini c-arm to assist in the closed reduction of pediatric forearm and wrist fractures in the emergency department can improve the quality of the reduction, decrease the radiation exposure to the patient, and decrease the need for repeat fracture reduction or additional procedures. Mini-c-arm imaging can also decrease the average orthopaedic consultation time for fracture reduction.