Factors impacting musculoskeletal knowledge and clinical confidence in graduating medical students.

BACKGROUND: Despite the prevalence of musculoskeletal disorders, the degree to which medical schools are providing students with the knowledge and confidence to treat these problems is unclear. This study evaluated the factors that impact musculoskeletal knowledge and clinical confidence among fourth-year medical students. METHODS: Over a three-year period, 253 fourth-year medical students participated in the study at a single institution. Musculoskeletal knowledge was evaluated using a National Board of Medical Examiners' musculoskeletal medicine subject examination. Factors analyzed included sex, class year, musculoskeletal elective experience, duration of musculoskeletal elective, career choice, and musculoskeletal curriculum satisfaction. RESULTS: The participation rate was 95%. The mean National Board of Medical Examiners' musculoskeletal assessment score (and standard deviation) was 70.7 ± 9.5 points for all fourth-year medical students. Taking a musculoskeletal elective significantly increased knowledge (p < 0.001) but not clinical confidence. Increased satisfaction with how musculoskeletal medicine was taught was associated with increased clinical confidence (p < 0.001). No significant differences were seen if students were going into musculoskeletal medicine or primary care for either musculoskeletal knowledge or clinical confidence. Multivariate analysis of musculoskeletal knowledge found that taking a musculoskeletal elective for two weeks led to an increase of 6 points (from a possible 100 points) in the National Board of Medical Examiners' subject examination scores. CONCLUSIONS: This study reveals that participation in a clinical elective is the only factor that led to a significant increase in musculoskeletal knowledge in fourth-year medical students. A two-week clinical elective can be sufficient time to have an impact on musculoskeletal knowledge, but it alone does not increase clinical confidence. Further studies are needed to determine how to improve musculoskeletal clinical confidence.

A systematic review of postoperative hand therapy management of basal joint arthritis.

BACKGROUND: There are a variety of postoperative immobilization and therapy options for patients with basal joint arthritis. Although prior systematic reviews have compared surgical procedures used to treat basal joint arthritis, none to our knowledge compares therapy protocols for this condition, which are considered an important part of the treatment. QUESTIONS/PURPOSES: (1) We sought to determine whether differences in the length and type of postoperative immobilization affect clinical results after basal joint arthritis surgery. (2) We also compared specific therapy protocols that were prescribed. (3) Finally, we evaluated published protocols to determine when patients were released to full activity to see whether these appeared to affect clinical results. METHODS: A systematic review of English-language studies in the PubMed and Cochrane databases was performed. Studies were then reviewed to determine what postoperative immobilization and therapy protocols the authors used and when patients were released to full activities. A total of 19 studies were identified using the search criteria. RESULTS: All but one of the studies included a postoperative period of immobilization in either a cast or splint. Immobilization time varied depending on whether Kirschner wires were used for the surgery and whether an implant was placed. Postoperative therapy protocols also varied but followed three general patterns. Some therapy protocols involved teaching patients a home exercise program only, whereas some authors described routine referral to a therapist. The third group consisted of studies in which patients were only referred for therapy if the physicians determined it was necessary during followup. Many studies did not give a specific time for full return to activity and instead described a gradual transition to full activity after immobilization was discontinued. Because of the variability and small numbers, no conclusive recommendations could be made on any of the three study questions. CONCLUSIONS: Comparative, multicenter studies comparing different immobilization and therapy protocols after the surgical treatment of basal joint arthritis would be helpful for both surgeons and therapists looking to refine their treatment protocols.

Comparison of an all-inside suture technique with traditional pull-out suture and suture anchor repair techniques for flexor digitorum profundus attachment to bone.

PURPOSE: One goal in repairing zone 1 flexor digitorum profundus (FDP) injuries is to create a tendon-bone construct strong enough to allow early rehabilitation while minimizing morbidity. This study compares an all-inside suture repair technique biomechanically with pull-out suture and double-suture anchor repairs. METHODS: Repairs were performed on 30 cadaver fingers. In all-inside suture repairs (n = 8), the FDP tendon was attached to bone with two 3-0 Ethibond sutures and tied over the dorsal aspect of distal phalanx. Pull-out suture repairs (n = 8) were performed with 2-0 Prolene suture and tied over a dorsal button. There were 2 suture anchor repair groups: Arthrex Micro Corkscrew anchors preloaded with 2-0 FiberWire suture (n = 7) and Depuy Micro Mitek anchors preloaded with 3-0 Orthocord suture (n = 7). Repair constructs were tested using a servohydraulic materials testing system and loaded until the repair lost 75% of its strength. RESULTS: There were no statistically significant differences in tensile stiffness, ultimate load, or work to failure between the repairs. Failure mode was suture stretch and gap formation greater than 2 mm at the repair site for all pull-out suture repairs and for 7 of 8 all-inside suture repairs. Two of the Arthrex Micro Corkscrew repairs and 5 of the Depuy Micro Mitek repairs failed by anchor pull-out. CONCLUSIONS: This cadaveric biomechanical study showed no difference in tensile stiffness, ultimate load, and work to failures between an all-inside suture repair technique for zone 1 FDP repairs and previously described pull-out suture and suture anchor repair techniques. The all-inside suture technique also has the advantages of avoiding an external button and the cost of anchors. Therefore, it should be considered as an alternative to other techniques. CLINICAL RELEVANCE: This study introduces a new FDP reattachment technique that avoids some of the shortcomings of current techniques.

Maturation of medical student musculoskeletal medicine knowledge and clinical confidence.

PURPOSE: Despite the prevalence of musculoskeletal (MSK) disorders, the degree to which medical schools are providing students the knowledge and confidence to treat these problems is unclear. This study evaluated MSK knowledge in second and fourth year medical students using a newly developed written assessment tool and examined the maturation of clinical confidence in treating core MSK disorders. METHODS: Over a 3-year period, the National Board of Medical Examiners (NBME) MSK subject examination consisting of 75 items was administered to 568 second and fourth year students at a single institution. Students were also asked to rate their confidence in treating a selection of medicine/pediatric and MSK clinical scenarios on a 5-point Likert scale. RESULTS: Participation rate was 98%. The NBME MSK assessment score was 59.2 ± 10.6 for all second year medical students and 69.7 ± 9.6 for all fourth year medical students. There was a significant increase in NBME scores between the second and fourth years (p<0.0001). Students were more confident in treating internal medicine/pediatric conditions than MSK medicine conditions (p=0.001). Confidence in treating MSK medicine conditions did not improve between the second and fourth years (p=0.41). CONCLUSIONS: To our knowledge, this is the first study to report increased MSK medicine knowledge as measured by a standardized examination after completing medical school core clinical rotations. Despite increased MSK knowledge, low levels of MSK clinical confidence among graduating students were noted. Further research is needed to determine the factors that influence MSK knowledge and clinical confidence in medical students.

Complications after pinning of supracondylar distal humerus fractures.

BACKGROUND: Supracondylar distal humerus fractures are one of the most common skeletal injuries in children. The current treatment of choice in North America is closed reduction and percutaneous pin fixation. Often surgeons leave the pins exposed beneath a cast but outside the skin. Great variation exists with respect to preoperative skin preparation, and perioperative antibiotic administration. Few data exist regarding the rate of infection and other complications. The purpose of this study is to review a large series of children to evaluate the rate of infection and other complications. METHODS: A retrospective review was carried out of all patients treated at our institution over an 11-year period. A total of 622 patients were identified that were followed for a minimum of 2 weeks after pin removal. Seventeen patients had flexion-type fractures, 294 had type II fractures, and 311 had type III fractures. Seventy-four fractures (11.9%) had preoperative nerve deficits with anterior interosseous palsies being the most common (33 fractures, 5.3%). Preoperative antibiotics were given to 163 patients (26.2%). Spray and towel draping were used in 362 patients, paint and towel draping were used in 65 patients, alcohol paint and towel draping were used in 146 patients, and a full preparation and draping were used in 13 patients. The pins were left exposed under the cast in 591 fractures (95%), and buried beneath the skin in 31 fractures (5.0%). A medial pin was placed in 311 fractures with a small incision made to aid placement in 18 of these cases. RESULTS: The most common complication was pin migration necessitating unexpected return to the operating room for pin removal in 11 patients (1.8%). One patient developed a deep infection with septic arthritis and osteomyelitis (0.2%). Five additional patients had superficial skin infections and were treated with oral antibiotics for a total infection rate of 6 of 622 patients (1.0%). One patient ultimately had a malunion and 4 others returned to the operating room for repeat reduction and pinning. Three patients developed compartment syndromes. Ulnar nerve injury was rare with only 1 postoperative ulnar nerve injury occurring in 311 patients treated with a medial pin (0.3%). CONCLUSIONS: Closed reduction with percutaneous pinning is effective and has a low complication rate with a very low rate of infection even when simple betadine preparation and towel draping are used. Preoperative antibiotics seem to have little effect on infection rate. LEVEL OF EVIDENCE: Level III retrospective comparative study.