We analyzed all questions that were labeled by the AAOS to be musculoskeletal trauma-related questions on the OITE from the years 2005 to 2009. Questions that were removed by the testing committee at a later date were not analyzed. We recorded the number of musculoskeletal trauma questions administered each year from 2005 to 2009 and the total number of questions that were scored for each OITE examination. With use of these data, the percentage of questions that were in the musculoskeletal trauma section for each examination was calculated. The national average scores in the musculoskeletal trauma section in all years in training were recorded for each OITE. Performance by the residents who had accomplished four years in training (YIT-4) or five years in training (YIT-5) were grouped together, in conformity with the published report of the AAOS to program directors. The data for YIT-0 (i.e., postgraduate year [PGY]-1) were not analyzed.
The authors recorded the general topic tested in each question, such as the type of fracture or specific surgical procedure. Questions that did not test a specific type of fracture or surgical procedure, but instead tested on topics such as implant biomechanics, fixation technique, and bone biology, were placed into a basic-science category. The topics of surgical approaches and anatomy were also combined, as many of the questions on approaches dealt with surgical anatomy. Finally, topics that were repeatedly tested, such as questions dealing with fracture nonunions and the decision-making process in a case involving polytrauma, remained separate categories. The references provided for each question in the musculoskeletal trauma section were also recorded.
Two authors (M.B.C. and D.C.O.) classified the musculoskeletal trauma questions according to a previously described taxonomy classification5-10. Taxonomy 1 (T1) questions involved memory or recall of knowledge. Taxonomy 2 (T2) questions either required the examiner to make a diagnosis or to interpret a radiograph or intraoperative problem. Taxonomy 3 (T3) questions were management, decision-making, and/or treatment questions.
Further, the authors reviewed the radiographic modalities used in each musculoskeletal trauma question, and placed each question into the following nine categories: (i) none, (ii) radiograph(s), (iii) magnetic resonance imaging (MRI), (iv) radiograph(s) and computed tomography (CT), (v) radiograph(s) and MRI, (vi) CT and MRI, (vii) photograph, (viii) radiograph(s) and photograph, and (ix) radiograph(s) and nuclear-medicine study. The specific treatments tested by each question were also recorded. This classification included questions to provide a treatment decision for a presented problem, as well as questions about a specific surgical procedure.
Statistical Methods
Ratios of the average score in the musculoskeletal trauma section divided by the number of individuals in each YIT category who took the OITE were calculated (i.e., rate ratios), as were their 95% confidence intervals. Comparisons were made between the rate ratio in YIT-1 and YIT-4/5 for each year.
Multivariate regression analysis was also performed to determine the effect of the number of T3 questions and the year in training on the average score in the musculoskeletal trauma section. The independent variable of T3 questions asked and year in training were force-entered into the model11. The number of T3 questions asked was evaluated as a continuous variable and year in training was assessed with use of dummy variables, with the reference group being YIT-511.
Performance on the Orthopaedic In-Training Examination has been correlated with achieving a passing score on the ABOS Part-I written examination3,4. Similar to the objective in prior published and unpublished analyses of sections on the OITE5-8,11,12, the objective of our paper was to provide an in-depth analysis of the musculoskeletal trauma section of the OITE in order to aid in improving trainee performance.
After analyzing the national performance data, we found that, in general, residents gain the majority of their knowledge from YIT-1 to YIT-2, and then this knowledge levels out over the remaining years of their residency. In fact, there is no statistical difference in the scores between YIT-4/5 and YIT-1. Thus, it appears that attending surgeons should continually ask questions of senior residents in conference settings in order to improve their knowledge base. Although numerous orthopaedic journals exist, when studying for the OITE, residents should focus their time on articles written in The Journal of Bone and Joint Surgery (American volume) and the Journal of Orthopaedic Trauma, while also reading Clinical Orthopaedics and Related Research and the Journal of the American Academy of Orthopaedic Surgeons. Additionally, residents should choose either Skeletal Trauma (Browner et al., Saunders) or Rockwood and Green's Fractures in Adults (Bucholz et al., Lippincott Williams & Wilkins) as a reference book, but they likely do not need to read both. Based on our analysis, these references would expose residents to enough information to correctly answer the majority of questions in the musculoskeletal trauma section. Although the examinee is infrequently required to make a treatment decision, when one does have to make a treatment decision, it is most commonly with regard to open reduction and internal fixation. In particular, residents should focus on the use of femoral and tibial nails, management of nonunions, and the use of locked plating in treating a particular fracture type. In addition, a common question stem was the management of the polytraumatized patient; thus, the orthopaedic resident should have a firm understanding of emergency-room management of these patients, when to perform "damage control" orthopaedics, and when to definitively treat the polytraumatized patient.
The limitations of our analysis of the trauma section are the same as the limitations of prior published analyses5-8,11,12. Undoubtedly, there are some musculoskeletal trauma questions that were categorized in other sections, such as the hand section and the foot and ankle section. However, in order to be consistent in our analysis, we elected to include only those questions in the "musculoskeletal trauma" section as determined by the authors of the OITE. In addition, we only examined the questions asked over the last five years. However, this time period is consistent with past publications on the OITE5-8. Finally, although it has been shown that there is greater than 85% correlation between test authors and residents when classifying questions10, there may be some error or bias in how we classified each question.
Similar to what is true when taking other standardized tests, having an awareness of the most commonly tested topics and having the knowledge of how to study for the examination will improve the examinee's performance on the OITE. We believe that orthopaedic residents can focus their studies on the most heavily referenced journals and that educators can focus their teaching on the most commonly tested topics in the trauma section, and that both of these strategies may result in improved performance on the OITE.