Outcomes of Displaced Tibial Tubercle Fractures in Adolescents.

Tibial tubercle fractures are uncommon injuries. The purpose of this study is to report the outcomes of surgical treatment of displaced tibial tubercle fractures in adolescents. This study was approved by the College of Medicine Institutional Review Board. A retrospective review was performed at our institution for patients who underwent surgical treatment of tibial tubercle fractures. Patient demographics, injury characteristics, and outcomes were recorded. A p-value of <0.05 was considered statistically significant. Nineteen male patients were identified. The average age was 14.6 years, and the average body mass index was 25.8. Basketball (63%) was the most common mechanism of injury. No patient was treated with bicortical screws. Two patients had preoperative computed tomography. One patient presented with acute compartment syndrome (ACS), and fasciotomy was performed. Twelve patients (63%) without clinical signs of ACS received anterior compartment fasciotomy on a case-by-case basis according to surgeon's preference. No growth injury, including growth arrest, angulation, or shortening occurred. All patients returned to preinjury activities at an average of 18.5 weeks. Displaced tibial tubercle fractures in this series occurred in male adolescents during athletic activity. Unicortical screws/pins were used with no loss of fixation. Routine use of advanced imaging was unnecessary. One patient (5%) underwent fasciotomy. No growth arrest occurred. All patients returned to preinjury athletic activities.

Emergency Pediatric Orthopaedic Transfer Criteria: A Pilot Study.

The purpose of this study was to define pediatric orthopaedic transfer criteria for patients coming from a smaller facility to a Level I pediatric trauma center. A 10-question phone survey was utilized for every transfer request. Fifty-eight transfer requests were prospectively collected and retrospectively reviewed. The criteria were based on The American Academy of Pediatrics (AAP) guidelines and the expert opinion of the senior author. The AAP criteria included complex fractures/dislocations and bone and joint infections. The expert opinion criteria included a patient requiring admission to the hospital or a patient needing surgery. All centers requesting transfers were staffed by an on-call board-certified general orthopaedic surgeon with the ability to care for pediatric orthopaedic injuries. Of the 58 transfers, 37 (64%) did not meet transfer criteria; 21 (36%) met transfer criteria. Transfer requests came from Emergency Department (ED) physicians in 25/58 cases (43%), physician assistants in 11/58 (19%), orthopaedic attending physicians in 3/58 (5%), and orthopaedic residents in 3/58 (5%). The orthopaedic surgeon at the referring hospital examined the patient in only six instances (10%) prior to transfer. Of the 58 patients, 18 (31%) required a hospital admission, and 17 (29%) patients were indicated for surgery. In the current study, 64% of pediatric orthopaedic transfers did not meet criteria for an inter-facility hospital to hospital transfer and were potentially avoidable. (Journal of Surgical Orthopaedic Advances 32(3):182-186, 2023).

Late presenting developmental dysplasia of the hip after a normal hip ultrasound at 6 weeks of age: A report of two cases.

Developmental hip dysplasia (DDH) is a paediatric condition in which the 'ball and socket' hip joint fails to form properly during infancy. The increased mechanical stress on the hip joint from DDH can contribute to the development of osteoarthritis during adulthood. Therefore, careful physical examination and imaging of all infants to diagnose DDH is critical to provide the best possible functional outcome. Ultrasonography (US) is a useful diagnostic test in providing a real-time evaluation and three-dimensional view of the hip in infants less than 4 months. In infants with a normal hip ultrasound, the risk of subsequent development of hip dysplasia at an older age and the need for further follow-up is assumed to be unnecessary. In the present study, we report 2 cases of late presenting DDH in infant girls born breech with a previous normal hip exam and normal hip ultrasound at 6 weeks of age.

Referral patterns to a pediatric orthopedic clinic: pediatric orthopedic surgeons are primary care musculoskeletal medicine physicians.

In 2004, Reeder and in 2012, Schwend reported that inappropriate nonsurgical referrals to pediatric orthopedic clinics create a misuse of resources. Additional authors have called for re-emphasis and additional training in musculoskeletal medicine for primary care physicians (PCP) to improve the confidence, knowledge and performance when managing musculoskeletal conditions. The current study compares the diagnoses referred to a pediatric orthopedic clinic with diagnoses recommended for referral by the American Academy of Pediatrics (AAP) guidelines to determine if any improvement in the quality of referrals has occurred since Reeder and Schwend's article. A chart review of new referrals to a pediatric orthopedic clinic during a 3-month-period was performed. Data were collected on age, sex, referring diagnosis, referral source, final diagnosis and treatment. In total 230 new consults were evaluated. The referral source was a PCP in 169 (73.5%) cases, 30 (13%) self-referrals by a parent, 19 (8.3%) from another orthopedic surgeon, 9 (3.9%) from a neurologist and 3 (1.3%) from another specialist. Fifty percent of referrals met the criteria outlined in the AAP guidelines for referral to a pediatric orthopedic specialist and 48% were classified as primary care musculoskeletal conditions. During the 15 years since the publication of Reeder's study and despite a limited re-emphasis on musculoskeletal education, the percent of inappropriate referrals to a pediatric orthopedic clinic remains unchanged at 50%. We support an expanded musculoskeletal educational effort aimed at the medical, resident and pediatrician level, online decision-making aids, and implementation of a standardized referral form with the specific criteria of the AAP included.

Operative Outcomes for Accessory Navicular in Adolescents.

The purpose of this study is to report the operative outcomes in a consecutive series of adolescent patients with symptomatic accessory navicular (AN). A retrospective review was conducted. Patient characteristics, operative techniques, and outcomes were recorded. Radiographs were used to identify the type of AN, skeletal maturity, and presence of concurrent pes planus. Twenty-two patients and 24 feet were studied. All 22 patients had an excision of the AN, and 19 patients had an additional reefing of the tibialis posterior tendon. At final follow up, 22 cases reported no pain, one had minimal pain, and one reported no change in pain. Symptomatic AN is more common in females. Surgery technique was not correlated with postoperative pain. Surgery eliminated pain in 91% of patients and can be safely performed in athletes with high rate of return to their previous athletic performance. (Journal of Surgical Orthopaedic Advances 31(1):053-055, 2022).

Rate of orthopedic resident and medical student recognition of nonaccidental trauma: a pilot study.

The purpose of this study was to evaluate the efficacy and accuracy of mandated reporters to identify child abuse in children presenting with fractures. An Institutional Review Board approved survey-based study between January 2017 and December 2017 was conducted at a tertiary care academic medical center. 10 cases were combined to create one survey. Each case had information on presentation history, radiographic data, and social history. This study assesses the ability of 13 orthopedic residents and 11 medical students to diagnose child abuse. Participants had the option to explain their reasoning for a given case. To evaluate decision-making reasoning, we split responses into three cohorts, encompassing objective evidence, subjective evidence, or social evidence. Twenty-four participants completed the survey; 203 out of 240 (85%) included the rationale for the diagnosis of child abuse. The observed diagnostic odds ratio was 0.83 for medical students, 0.93 for junior residents, and 0.96 for senior residents. There was no statistically significant difference in diagnosing child abuse between a participant's level of experience, age, or whether participants had their own children. Participants who used more than one source of evidence were significantly more likely to make the correct diagnosis (P = 0.013). Participant decisions were no more accurate than a coin toss. The use of several data sources led to increased diagnostic accuracy. There is low accuracy in correctly diagnosing child abuse in our cohort of mandated reporters. Participants who highlighted using several sources of evidence were more likely to diagnose child abuse accurately.

The posterior tibial slope and Insall-Salvati index in operative and nonoperative adolescent athletes with Osgood-Schlatter disease.

INTRODUCTION: Osgood-Schlatter disease (OSD) is a common cause of anterior knee pain in adolescent athletes due to repetitive stress on the tibial tubercle. The posterior tibial slope angle (PTSA) and the Insall-Salvati Index (ISI) play a role in knee biomechanics. However, to our knowledge, the posterior tibial slope and patellar height have not been compared in operated versus nonoperative OSD patients. The purpose of the current study is to compare the differences in the PTSA and the ISI between operative and nonoperative patients with OSD. MATERIALS AND METHODS: The study was approved by the College of Medicine's Institutional Review Board. A retrospective review was performed on 75 adolescent athletes with OSD between 2008 and 2019. The data extracted included: age, sex, body mass index (BMI), sporting activity and type, mechanism of injury (MOI), chronicity of symptoms, PTSA, and the ISI. Descriptive and quantitative statistics were used. RESULTS: Seventy-five patients (88 knees) with OSD were studied (28 boys, 47 girls). The average age was 12.2 years and the average BMI was 22.3. The mechanism of injury (MOI) included repetitive stress (77%) and trauma (23%). The duration of knee pain averaged 10.3 months. Sixty-six patients were included in the nonoperative cohort. Nine patients were included in the operative cohort and underwent surgery due to persistent symptoms after skeletal maturity with tubercleplasty and/or ossicle excision. The average PTSA was 12.1° ± 1.7° and average ISI was 1.05 ± 0.15. Comparing the operative and nonoperative patients, we found no significant difference in PTSA (11.2° ± 0.73° versus 12.8° ± 1.8°, p < 0.064). However, we did find that patients treated operatively had a lower ISI (0.95 ± 0.18 versus 1.14 ± 0.13, p < 0.001). CONCLUSION: In patients with OSD, operative and nonoperative patients demonstrated a similar PTSA. On the other hand, the ISI was higher in nonoperative patients. In the current paper, a decreased ISI was helpful in predicting the need for operative intervention in symptomatic patients after skeletal maturity.

Perceptions of USMLE Step 1 Pass/Fail Score Reporting Among Orthopedic Surgery Residency Program Directors.

The United States Medical Licensing Examination (USMLE) Step 1 examination will transition from graded to pass/fail scoring starting no earlier than January 2022. Orthopedic surgery residency programs will need to adapt to these changes. The goal of this study was to investigate the perceptions of orthopedic surgery residency program directors on the change of Step 1 from a graded to a pass/fail examination. We also investigated how the change would affect the other factors that are typically considered in the selection of orthopedic surgery residents. A survey was distributed to 161 directors of allopathic orthopedic surgery programs. Contact information was obtained from a national database. Of those contacted, 75 (46.6%) program directors responded. Most (85.3%) did not support the pass/fail change. Most believe that greater importance will be placed on the Step 2 Clinical Knowledge examination (96.0%), audition elective with their department (84.0%), personal knowledge of the applicant (78.7%), grades (74.7%), letters of recommendation from recognizable orthopedic surgeons (74.7%), and Alpha Omega Alpha status (69.3%). Most also believe that this change will advantage allopathic students who attend highly regarded schools (58.7%). Most of the program directors support a graded preclinical curriculum (69.3%) and caps on the number of orthopedic surgery residency applications (70.7%). Although most orthopedic surgery program directors disagree with the change to a pass/fail Step 1 examination, residency programs will need to reevaluate how they screen applicants for an interview once the scored Step 1 is no longer available. With this change, other factors, such as Step 2 score, audition rotations, and grades in clerkships, will be emphasized more heavily. [Orthopedics. 2022;45(1):e30-e34.].

Outcomes of surgical treatment of symptomatic bipartite patella in teenage athletes.

Bipartite patella affects about 2% of people. Most cases are asymptomatic; however, some develop anterior knee pain during sports. When conservative treatment fails, surgery can be considered. This study reports the outcomes of fragment excision with or without lateral release in teenage athletes with symptomatic bipartite patella. The study was approved by the College of Medicine Institutional Review Board. A retrospective review was performed. Patients were excluded if age >18 or had prior knee surgery. Data collected included age, gender, BMI, sports played, Saupe classification, conservative and surgical treatment, advanced imaging used, duration of follow-up, Lysholm Score and postoperative complications. Five teenage patients were studied. The average age was 15.6 years and BMI was 23. Sports played included basketball, football, track-and-field and soccer. All patients complained of anterior knee pain exacerbated by sports. All patients failed >6 months of conservative treatment. Saupe classification included four type III (superolateral) and one type II (lateral). Two patients had an MRI. Surgical treatment included two open excisions and three arthroscopic-assisted open excisions with lateral releases. The average Lysholm Score was 97. Postoperatively, all patients returned to presurgery sporting activity at an average of 9.8 weeks (range, 6-13 weeks). A 16-year-old male treated by open excision developed a postoperative wound infection. He was successfully treated with irrigation & debridement and antibiotics and returned to sports at 6 weeks. Symptomatic bipartite patella is an uncommon cause of anterior knee pain in adolescent athletes. When pain persists despite conservative care, fragment excision with or without lateral release resulted in excellent pain relief and return to full sporting activity in all cases.

Descriptive Analysis of Orthopaedic Surgery Residency Program Directors.

The purpose of this study was to analyze the demographics and backgrounds of U.S. orthopaedic surgery residency program directors (PDs). We collected publicly available information on 189 orthopaedic surgery residency PDs. Of those PDs, 90% were male MDs with an average age of 52. The average age at PD appointment was 45. The average duration of appointment was 7 years. About 81% of programs were university-affiliated, and 61% were in an urban environment. PDs attended 100 medical schools, 129 residencies, and 96 fellowships. of PDs, 87% completed fellowships, commonly in trauma and sports medicine. There was no significant difference between male and female PDs when comparing age, academic appointment, or urban/rural environment. Most female PDs (89%) were at university-based hospitals. Of PDs at osteopathic-focused programs, 28% had an MD/PD. No program with an allopathic focus had a DO/PD. Lastly, 38% of PDs worked at the center where they completed residency. (Journal of Surgical Orthopaedic Advances 31(4):252-255, 2022).

A comparison of orthopaedic surgery and internal medicine perceptions of USMLE Step 1 pass/fail scoring.

BACKGROUND: United States Medical Licensing Examination Step 1 will transition from numeric grading to pass/fail, sometime after January 2022. The aim of this study was to compare how program directors in orthopaedics and internal medicine perceive a pass/fail Step 1 will impact the residency application process. METHODS: A 27-item survey was distributed through REDCap to 161 U.S. orthopaedic residency program directors and 548 U.S. internal medicine residency program directors. Program director emails were obtained from the American Medical Association's Fellowship and Residency Electronic Interactive Database. RESULTS: We received 58 (36.0%) orthopaedic and 125 (22.8%) internal medicine program director responses. The majority of both groups disagree with the change to pass/fail, and felt that the decision was not transparent. Both groups believe that the Step 2 Clinical Knowledge exam and clerkship grades will take on more importance. Compared to internal medicine PDs, orthopaedic PDs were significantly more likely to emphasize research, letters of recommendation from known faculty, Alpha Omega Alpha membership, leadership/extracurricular activities, audition elective rotations, and personal knowledge of the applicant. Both groups believe that allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates will be disadvantaged. Orthopaedic and internal medicine program directors agree that medical schools should adopt a graded pre-clinical curriculum, and that there should be a cap on the number of residency applications a student can submit. CONCLUSION: Orthopaedic and internal medicine program directors disagree with the change of Step 1 to pass/fail. They also believe that this transition will make the match process more difficult, and disadvantage students from less highly-regarded medical schools. Both groups will rely more heavily on the Step 2 clinical knowledge exam score, but orthopaedics will place more importance on research, letters of recommendation, Alpha Omega Alpha membership, leadership/extracurricular activities, personal knowledge of the applicant, and audition electives.

Surgical Treatment Outcomes of Unresolved Osgood-Schlatter Disease in Adolescent Athletes.

The purpose of this case series is to report the outcomes of ossicle excision and tubercleplasty for unresolved Osgood-Schlatter disease that has failed conservative treatment in six adolescent athletes. A retrospective chart review was completed, and data collected include age at onset of symptoms, age at surgery, sex, laterality, mechanism of injury, conservative treatment regimen, radiographic findings, sports played, time to return to sport, length of follow-up, and Lysholm score. Surgery involved an open ossicle excision, tubercleplasty, and repair of the patellar tendon to bone using a suture anchor. Postoperatively, patients were allowed to fully weight-bear in an extension knee brace for 4 weeks and then allowed to gradually resume activity. Four males and 2 females were studied. The right knee was involved in 3 cases and the left knee in 3. The average age at onset of symptoms was 15.8 (range 12-18) and at surgery was 17.3 (range 17-18). Radiographic findings included a large bump in 4 cases, an ossicle in 2, and free fragments at the tendon insertion in 3. Sports played included basketball, football, running, and dancing. All patients returned to sports at an average of 21 weeks and 6 days postsurgery (range 8-56). The average length of follow-up was 14.2 weeks (range 5-27). The average Lysholm score postsurgery was 97.2 (range 94-100). Surgical treatment of unresolved Osgood-Schlatter disease was successful in all patients. No patients reported any postoperative complications or additional surgery. For skeletally mature and symptomatic patients, we recommend removal of the ossicle and adjacent bursae, smoothing the bump, and repairing the patellar tendon to bone.

Open Supracondylar Humerus Fractures in Children.

PURPOSE: Supracondylar humerus (SCH) fractures are the most common elbow fracture in children; however, they rarely occur as open injuries. Open fractures are associated with higher rates of infection, neurovascular injury, compartment syndrome, and nonunion. The purpose of this study was to evaluate the treatment and outcomes of open SCH fractures in children. METHODS: Between 2008 and 2015, four children (1%) had open injuries among 420 treated for SCH fractures at a single center. The mean patient age was six years (range, four to eight years). Two patients had Gustilo-Anderson grade 1 open fractures and two had grade 2 fractures. Tetanus immunization was up-to-date in all. First dose of intravenous antibiotics was given on average 3hr 7min after onset of injury (range, 1hr 38min to 8hr 15min). Time from injury to irrigation and debridement (I&D) and closed reduction and percutaneous pinning (CRPP) was on average 8hr 16min (range, 4hr 19min to 13hr 15min). All patients received 24-hour intravenous antibiotics. Pins were removed at four weeks and bony union occurred by six weeks. RESULTS: After an average follow-up period of 12 months (range, 6 to 22 months), there were no infections, neurovascular deficits, compartment syndromes, cubitus varus deformities, or range of motion losses. All outcomes were excellent according to the Flynn criteria. Due to the unstable nature of open SCH fractures, a medial pin was used in all four cases. No loss of reduction or ulnar nerve injury occurred. CONCLUSION:  Open injuries occur in approximately 1% of all SCH fractures in children. The authors recommend urgent intravenous antibiotics, I&D, and CRPP involving a medial pin to treat open SCH fractures. Excellent outcomes based on the Flynn criteria were obtained in four cases.

Lyme Disease Misinterpreted as Child Abuse.

Child abuse is one of the most common causes for child fatality in the United States. Inaccurate reporting of child abuse combined with scarcity of resources for child abuse evaluations can lead to unintended consequences for children and their families. The differential diagnosis of child abuse is varied. To our knowledge, there are no reports in the literature on Lyme disease mimicking child abuse. The current study presents the case of a child from an endemic area for Lyme disease presenting with skin bruising, fracture, and swollen knee. The child was reported for child abuse by the pediatrician and then referred to the orthopaedic surgeon for fracture care.

Modern Day Scurvy in Pediatric Orthopaedics: A Forgotten Illness.

INTRODUCTION: Scurvy, or vitamin C deficiency, is rare. The goal of this study is to highlight the common risk factors and identify the orthopaedic presentation of scurvy in children. METHODS: A retrospective chart and radiograph review was performed of all patients consulted to the pediatric orthopaedic service from 2010 to 2019 who ultimately had the diagnosis of scurvy confirmed by an abnormally low serum vitamin C level. Data extracted included: patient age, sex, neurological conditions, prematurity, psychiatric conditions, dietary abnormalities, bone pain, arthritis, limb swelling, inability to walk, skin changes, child abuse evaluations, radiographic findings, additional vitamin deficiencies, lab studies, additional tests, response to treatment. Descriptive statistics were performed. RESULTS: Nine patients (7 males, 2 females) with scurvy were studied. The average age was 7 years (range 3 to 13 y). The average body mass index was 21.4 (range, 14 to 30). Five had autism, 2 had a neurological disorder. Two had been born premature. Two had a psychiatric disorder. Seven had an abnormal diet. One presented with bone pain. Four presented with limb swelling. Seven had unilateral and 2 had bilateral leg symptoms. Five presented with inability to walk. Six demonstrated skin changes with ecchymosis or petechiae. Three presented with gingival bleeding. Radiographic findings included subperiosteal hematoma in 2, ring epiphysis in 3, Pelkan spurs in 1, metaphyseal white lines (Frankel sign) in 6, and a metaphyseal zone of rarefaction (Trummerfeld zone) in 3. Seven had additional vitamin deficiencies including: A, B1, B6, B9, D, E, K, iron and zinc. Four had a bone marrow biopsy and 1 had lumbar puncture. All were anemic. The average erythrocyte sedimentation rate was 25.7 (range 6 to 35) and C-reactive protein was 1.5 (range 0.55 to 5.64). Six had a computed tomography, 3 had a magnetic resonance imaging. After treatment with vitamin C lasting 3.4 months (range, 2 wk to 7 mo), all symptoms gradually resolved, including leg pain and swelling. All children began to walk. CONCLUSION: The pediatric orthopaedic surgeon should have an increased awareness about the diagnosis of scurvy when consulted on a child with bone pain or inability to walk. The most common orthopaedic presentation was the refusal to bear weight, the most common radiographic finding was the metaphyseal line of increased density (Frankel sign) and treatment with vitamin c supplementation was excellent in all cases.

The Pediatric Open Supracondylar Fracture: Associated Injuries and Surgical Management.

BACKGROUND: While supracondylar (SC) fractures are relatively common in children, the incidence of open injuries is believed to be only 1%. Two prior studies on open SC fractures in children reported an increased incidence of vascular injuries. The purposes of our study were to clarify the incidence, associated conditions, and current treatment for open SC fractures. METHODS: The Pennsylvania Trauma Outcome Study database was queried. Subjects age 25 to 156 months old admitted to trauma centers between January 2000 and December 2015 with a SC fracture were included. Controls were those with closed fractures and the study group, those with open injuries. Study variables were age, sex, weight, injury severity score, length of stay (LOS), nerve injury, ipsilateral forearm fracture, compartment syndrome/fasciotomy, requirement for a vascular procedure. Other variables were mode of treatment, provisional reduction, repeat reduction, time interval between referring facility admission and operation, and time from emergency department admission to operation. RESULTS: A total of 4308 subjects were included, 104 (2.4%) of whom had an open SC fracture. LOS was 2 days for the study group versus 1 day for controls (P<0.001). Open SC fractures were more likely than closed to be associated with a nerve injury (13.5% vs. 3.7%), ipsilateral forearm fracture (18.3% vs. 6.4%) and/or a vascular procedure (6.7% vs. 0.3%) (P<0.001). 5.9% of those in the study group required repeat surgery compared with 0.4% for controls (P<0.001). Time from emergency department admission to operation was 3.2 versus 10.3 hours (P<0.001). CONCLUSIONS: We report the largest series to date of open SC fractures in children. Surgeons caring for such patients should be aware of their increased risks for both associated injuries and potential requirement for vascular reconstruction. The majority of children with an open SC fracture are managed with 1 operation and in the absence of vascular injury, seldom require an extended LOS. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Compartment Syndrome in Children With a Supracondylar Fracture: Not Everyone has Risk Factors.

OBJECTIVES: To clarify the incidence, associated conditions, and timing of fasciotomy for compartment syndrome (CS) in children with a supracondylar (SC) fracture of the humerus. DESIGN: A retrospective trauma system database study. SETTING: Accredited trauma centers in Pennsylvania. PATIENTS: A statewide trauma database was searched for children 2-13 years of age admitted with a SC fracture between January 2001 and December 2015. Four thousand three hundred eight children met inclusion criteria. INTERVENTION: Treatment of a SC fracture. MAIN OUTCOME MEASUREMENT: Diagnosis of CS/performance of a fasciotomy. RESULTS: During the study period, 21 (0.49%) children admitted with a SC fracture of the humerus were treated with fasciotomy. CS/fasciotomy was more likely in males (P = 0.031), those with a nerve injury (P = 0.049), and/or ipsilateral forearm fracture (P < 0.001). Vascular procedure, performed in 18 (0.42%) children, was strongly associated with CS/fasciotomy (P < 0.001). Closed reduction and fixation of a forearm fracture was associated with CS (P = 0.007). Timing of SC fracture treatment did not influence outcome. Fasciotomy was performed subsequent to reduction in 13 subjects; mean interval between procedures was 23.4 hours (r = 4.5-51.3). CONCLUSIONS: Risk factors for CS exist; however, they are not required for the condition to develop. CS may develop subsequent to admission and/or SC fracture treatment. In timing of operative management and hospitalization, the results support contemporary practice. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Attitude adjustments after global health inter-professional student team experiences.

How medical inter-professional (IP) education should be introduced to students is still a matter of research. We evaluated IP student attitudes before and after a busy "hands-on" clinical experience.During 3 separate trips, first/second year medical and physician assistant students and third/fourth year nursing students traveled to Central America to work together for 1 week in an underserved clinical setting. Student opinions on inter-professional education were obtained before and after Brigade-1 using the Readiness for Inter-professional Learning Scale validated questionnaire. From these results, a modified version of the survey was developed that included quantitative and qualitative responses. For brigades-2 and -3, students received this modified version of the survey pre and post brigade. Quantitative data was analyzed via paired student t test, and qualitative data was analyzed to identify emerging themes using constant comparative methodology by three separate investigators.No significant quantitative differences between IP student groups were observed in their evaluation of the importance of inter-professional education either before or after the brigades. Qualitative data noted pre-brigade expectations of positive IP, experiential and patient-centered cultural learning. Pre- and post-brigade student perspectives maintained a strong belief that high functioning IP care benefited the patient. Post-brigade perspectives revealed a shift in attitude from purely positive expectations to more practical aspects of teamwork, respect, and interpersonal relationships.Students believe that patient care benefits from IP collaboration. After a busy clinical experience requiring collaboration, students realized that functional teams require appropriate skills, roles, and respectful interpersonal relationships.