The origins of hand surgery as a distinct surgical field in the United States are often credited to the pioneering efforts of Asa Sterling Bunnell around the time of the Second World War1. It has since evolved into an increasingly complex specialty involving hand transplantation, joint arthroplasty, and microsurgery2-6. Recognizing the need for oversight to ensure proper training and education, the orthopaedic, plastic, and surgery primary boards jointly approved a Certificate of Added Qualification in Hand Surgery in 1985, and the first examination for certification in hand surgery was administered in 19897. Because of the continually emerging complexities in this field, it has become increasingly important to evaluate the training of orthopaedic residents in order to ensure that their education and understanding of hand surgery is adequate prior to graduation and possible application for fellowship.
The Orthopaedic In-Training Examination (OITE) was established as a measure for orthopaedic resident education and knowledge in the 1960s8. The OITE provides a standardized format to evaluate the hand knowledge of orthopaedic residents. This examination is designed to focus on evidence-based knowledge and skills that a surgeon should know in order to be able to practice effectively. Recent orthopaedic publications are often recommended as one of the main sources of information for surgeons in training, and it has recently been reported that there is a positive correlation between performance on the OITE and frequent review of current orthopaedic journals9. However, we know of no published study that has assessed the correlation between the literature and the hand surgery content tested in the OITE.
The primary questions in the present study were: (1) What literature should be recommended to orthopaedic residents who are receiving training and instruction regarding hand surgery and are preparing for their board examinations? and (2) How well does the current scientific literature correspond to the content tested in the OITE? More specifically, we asked six questions: (1) What is the content of the hand-related OITE questions? (2) What journals have the highest percentage of their hand-related studies referenced for the hand questions on the OITE? (3) Are the OITE questions and the content in high-impact clinical orthopaedic journals similar in terms of the overall proportion of articles and/or questions that are hand-related? (4) Is the content of the questions similar to that of the hand-related articles with respect to anatomy, diagnosis, and treatment? (5) Is the hand-related content in the orthopaedic journals similar? and (6) What textbooks are most frequently recommended for OITE hand-related content?
A systematic review of the OITE was conducted to identify all hand or forearm-related questions tested during a five-year period from 2002 to 2006. Forearm questions that were associated with the elbow or the proximal end of the radius and/or ulna were excluded from our analysis. All questions included in the analysis were characterized by the anatomical location, diagnosis, and treatment discussed. For anatomical location, it was noted whether the question was related to the finger, wrist, forearm, hand and/or palm, or was not specific. In order to determine appropriate categories of diagnosis and treatment, we reviewed the current organization of hand material provided by the American Society for Surgery of the Hand review courses and educational textbooks. On the basis of these reviews, we used the following diagnoses for grouping the questions: (1) fractures, (2) amputations or avulsions, (3) nerve-related pathological conditions, (4) tendon-related problems, (5) degenerative disease, (6) wounds, (7) tumors or cysts, (8) congenital conditions, and (9) no diagnosis discussed. The treatment categories were: (1) pharmacological, antibiotic, or wound treatment, (2) physical or occupational therapy or rehabilitation, (3) reduction or fixation, (4) flaps or replantation, (5) tendon transfers or grafting, (6) tendon or carpal tunnel release, (7) surgical resection, reconstruction, or repair, and (8) no treatment discussed. We also determined an overall focus category for each question according to whether it required (1) recall of pathology, etiology, or anatomy; (2) diagnosing the case or knowledge of appropriate diagnostic modalities; or (3) determining appropriate treatment or prognosis following treatment. Some questions were included in more than one focus category. For example, a question that required the resident to make a diagnosis on the basis of a given radiograph in order to select an appropriate treatment would have been categorized as both a diagnosis and treatment-focused question.
In order to evaluate the relevance of specific journals as study material for residents preparing for the OITE, we determined which publications were most frequently recommended as resources for hand-related questions. This was determined by first reviewing the recommended readings provided by the American Academy of Orthopaedic Surgeons (AAOS) in the score key for the five examinations that were included in this study. Next, for the journals that were frequently cited as recommended references in the score key, the number of hand-related studies published during the five years (2001 to 2005) that preceded the OITE was determined by conducting a systematic review of the MEDLINE bibliographic database. Finally, the proportion of hand articles in each journal that was cited on the OITE was estimated by dividing the number of references on the examination by the number of hand-related articles.
The content of the hand studies in the three journals with the highest percentage of hand-related articles used for reference on the OITE was characterized. The overall proportion of hand-related articles was noted for the journals and was compared with the percentage of OITE questions that were hand-related. The proportions were also stratified for each of the five years to determine whether there were any differences over time.
Each hand-related article from these three journals was classified with use of the same stratifications and categories for anatomical location, diagnosis, and treatment that were used for the OITE questions. Some articles were included in more than one of these categories. The articles were also stratified according to focus categories similar to those used for the OITE questions: (1) pathology, etiology, or anatomy; (2) diagnostic evaluation and modalities; or (3) treatment options. The proportion of articles in each category was compared with the corresponding percentage of test questions.
In addition to our comparison between the OITE and the current literature, an analysis to compare the hand-related content in each of the journals was conducted. For each of the previously noted categories, the percentage of articles with hand-related content in each journal was compared with the percentage for all of the journals combined.
The OITE score key and recommended readings provided by the AAOS were also reviewed to identify the most frequently referenced textbooks. The percentage of the total number of references for the hand-related OITE questions was determined for each textbook, with the top three identified.
Statistical Methods
The difference in proportions was assessed with use of a chi-square analysis with the Yates correction, where a p value of <0.05 was considered significant. A power analysis was conducted with use of the difference in overall percentage of hand-related questions on the OITE compared with the proportion of corresponding articles as the primary research question. It was determined that there was a sufficient sample size to reveal the p values necessary to answer the primary research question at a power of >80%.
Source of Funding
There was no funding source.
A total of 112 (8%) of the 1375 questions on the OITE over the five-year period were related to the forearm and hand. A review of the categories of diagnoses showed that the most frequently tested diagnosis was a fracture (27%), and stratification of the treatment options showed that the most commonly tested modality was fracture reduction or fixation (16%). The most frequently tested anatomic site was the finger (33%), and the most frequent type of hand-related question required knowledge regarding treatment options and outcomes (64%).
The three orthopaedic clinical journals with the highest percentage of their hand-related studies referenced on the OITE were The Journal of Bone and Joint Surgery (American Volume), The Journal of Bone and Joint Surgery (British Volume), and Clinical Orthopaedics and Related Research. Although the Journal of Hand Surgery and Hand Clinics were frequently referenced on the OITE, the percentage of the hand-related studies for the other journals was higher (Fig. 1). For example, approximately one of every thirteen hand-related articles published in Clinical Orthopaedics and Related Research was referenced on the OITE, while only one of every forty-three articles from The Journal of Hand Surgery was cited.
In our literature review of The Journal of Bone and Joint Surgery (American Volume), The Journal of Bone and Joint Surgery (British Volume), and Clinical Orthopaedics and Related Research from 2001 to 2005, we found that 384 (6%) of 6064 articles were related to the hand. This was lower than the 8% of OITE questions that were related to hand surgery during the corresponding time (p = 0.001). When the percentages for each year were compared, the differences were not significant, which may have been due to the smaller sample sizes (Fig. 2).
Overall, the proportions of questions and articles for the majority of the anatomical, diagnostic, and treatment categories were similar. One of the largest discrepancies between the OITE and the literature was the percentage of questions compared with the percentage of articles related to the finger. The finger was the most commonly cited anatomical location of the OITE hand-related questions (33%), but it was the third most frequently reported anatomical area in the hand-related articles (16%) (p < 0.001). The most common category of treatment for both the OITE and the literature was fracture reduction and/or fixation. However, the proportion of articles related to fracture reduction and/or fixation (30%) was higher than the proportion of such questions on the OITE (16%) (p = 0.005). This was also the case for the fracture diagnosis category, in which the proportion of articles was higher than the proportion of OITE questions (42% compared with 27%) (p = 0.006). Comparison of the OITE and the literature showed that the proportions of questions and articles that were focused on treatment modalities were similar (64% and 70%, respectively) (p = 0.356). A table in the Appendix provides a complete list of all of the categories compared.
The comparison between the content of each journal showed only a few significant differences. The Journal of Bone and Joint Surgery (British Volume) had fewer tumor-related articles (4%) than the proportion for all journals combined (14%) (p = 0.01). Additionally, Clinical Orthopaedics and Related Research was found to have significantly more articles focused on anatomy, pathology, and/or etiology (44%) compared with all journals combined (28%) (p < 0.001).
The review of the references for the OITE hand-related questions showed that 72% of the questions had more than one recommended reference provided, and textbooks encompassed 40% of the total number of citations. The most frequently cited textbooks and their percentage of the total number of provided references were Hand Surgery Update10 (16%), Orthopaedic Knowledge Update11 (8%), and Green's Operative Hand Surgery12 (4%).
The continued expansion of technology as well as the development of novel instruments and procedures have greatly influenced the direction of the modern field of hand surgery. Education is essential for the continuation of high-quality health care, and it is important to learn how hand surgery can best be taught to residents. Knowledge of the content and categories of questions on the OITE can guide orthopaedic chairs and residency directors as they focus their programs to enhance the available educational opportunities for residents. This was the primary reason for conducting this study. The results suggest that residents who are preparing for the OITE would benefit from reading the current literature and focusing mostly on material related to treatment modalities used in hand surgery, especially those associated with fractures and amputations. The most frequently referenced journal and textbook were The Journal of Bone and Joint Surgery (American Volume) and Hand Surgery Update, respectively.
The use of the current literature as an educational tool has flourished in the United States since its establishment by Sir William Osler at McGill University in 187513. Journal clubs are common in orthopaedic residency programs, with as many as 99% of program directors reporting regular participation14. Melchior and Meals surveyed hand surgery fellowship directors and found that forty-nine (86%) of the fifty-seven hand fellowship directors who responded reported that they use a journal club to aid in their educational efforts15. In a recent study, Burstein et al. assessed the use of a structured article review checklist at journal club16. They reported that this tool effectively increased resident satisfaction and the perceived educational value of the sessions. We believe that a journal club could also become more effective if residents were able to associate the material in the literature with questions on the OITE. The use of the results of the present hand study and similar studies that assess other areas of orthopaedics will help with the further development of educational programs to provide residents with the structure necessary to best utilize recent publications in order to prepare for the OITE.
The use of current literature as a study instrument for the OITE was recently assessed in a study by Miyamoto et al.9. They reported that there is a direct correlation between successful performance on the OITE and the use of specific current orthopaedic literature as well as other relevant study habits. The correlation between OITE scores and frequent review of The Journal of Bone and Joint Surgery (American Volume) and The Journal of the American Academy of Orthopaedic Surgeons was significant, with correlation coefficients of 0.6 (p < 0.001) and 0.36 (p = 0.02), respectively. They also reported that studying prior examinations (r = 0.53, p < 0.001) and daily orthopaedic reading (r = 0.34, p = 0.03) were among the factors that had a positive correlation with OITE performance.
The Internet has allowed residents to have easy access to the orthopaedic literature, with all major journals providing articles that can be downloaded directly from their respective web sites or with the use of links from MEDLINE. A recent article by Sinkov et al. evaluated the use of the Internet by surveying thirty-five orthopaedic residents17. The residents reported using online resources for a mean of 3.1 hours (range, one to 8.5 hours) per week, mainly from the hospital and home. The residents ranked online textbooks as the most frequently used source for online clinical information, and they reported using online practice examinations mainly in order to prepare for the in-training (OITE) or board examinations. The three most commonly used online sites were the Wheeless' Textbook of Orthopaedics (), the American Academy of Orthopaedic Surgeons web site (), and the Orthopedics Hyperguide ().
In addition to the use of current literature, experience and exposure to relevant cases are critical components of resident education. Black et al. suggested that the lack of clinical caseload had a negative impact on OITE performance18. They found that the average scores on the OITE of residents who stopped clinical work in order to conduct laboratory research decreased from the 86th percentile during their first year to the 48th percentile by their fourth year. Because that study did not characterize the specific number or type of orthopaedic cases at their program or the areas on the OITE that showed the largest decrease, the impact of decreased caseload on performance for the hand-related OITE questions is unclear.
A recent national survey by Nawar et al. underscored the importance of preparing orthopaedic residents for hand surgery19. They reported that 4,375,000 (10.4%) of 41,937,000 injury-related visits to emergency departments in the United States involved the hand, making it the most frequent body site for injury. To our knowledge, no similar study has assessed the proportion of cases seen in an orthopaedic program that are hand related. The volume and types of hand cases may vary greatly depending on whether a program is at an academic center or is community-based. In a separate study, we have begun to assess these factors and whether there is a correlation between the proportion and types of hand cases seen at various centers and the questions on the OITE.
The results of this study suggest that select, current orthopaedic literature may reflect the material tested on the OITE. However, some subject areas (such as finger injuries) may not be adequately represented. While residents may benefit by studying from The Journal of Bone and Joint Surgery (American Volume), which is the most frequently referenced journal, and Hand Surgery Update, which is the most common textbook reference, additional studies are necessary to verify any correlation between OITE performance and the use of various reference materials. In general, an understanding of both the material tested on the OITE and the types of articles available to the resident can guide academic orthopaedic hand surgeons in the development of an educational program.
A table showing the distribution of topics by journal and in the OITE is available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD/DVD (call our subscription department, at 781-449-9780, to order the CD or DVD).