Drew Kelly, Betsy M. Nolan

In their study, Mayne et al. developed and validated a novel simulation model for use in resident education. Junior (postgraduate year [PGY]-1) and senior (PGY-4 and 5) residents performed closed reduction and short-arm cast application on a custom-designed Sawbones (Pacific Research Laboratories) model of a distal radial fracture, and their performance was judged with a task-specific checklist (Objective Structured Assessment of Technical Skills [OSATS]) and a global rating scale (GRS) as well as radiographic measurements. The senior residents performed better than the junior residents in terms of the observed technique, but the final radiographic results, as measured by palmar tilt and three-point index, did not differ significantly. The model was demonstrated to be valid in differentiating between senior and junior residents on the basis of GRS and OSATS scores. The authors appropriately acknowledged limitations of their model, which may provide a basis for a more challenging, clinically relevant fracture model that requires realistic traction and manipulative force for a successful reduction.

In addition to the reduction method selected by the authors, there are many other acceptable methods and adjuncts for reducing and immobilizing a distal radial fracture that were not acknowledged in this study, including the use of finger traps, traction weights, or hematoma block. The immobilization method employed by the authors was a short-arm circumferential plaster cast extending past the metacarpophalangeal joints (MCPJs), but many surgeons prefer sugar-tong splints, long-arm casts, univalved or bivalved casts, fiberglass casts, and splints or casts that allow MCPJ motion. Furthermore, despite the classic admonition by Charnley quoted in the article’s introduction, intraprocedural fluoroscopy is routinely employed at many centers, especially for challenging reductions.

The American Board of Orthopaedic Surgery (ABOS) and the Orthopaedic Surgery Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) recently approved mandates to implement surgical simulation training for all PGY-1 residents in response to much controversy over work-hour restrictions, the increasing use of midlevel providers such as physician assistants and nurse practitioners, and the impact of fellowship training on residency education. Distal radial fractures are among the most common emergency department consultations for orthopaedic surgery residents, and mastery of closed reduction and immobilization for these injuries is an important skill acquired during residency training. The model described in the present study is certainly useful in that it teaches residents to follow a well-defined series of steps for reduction and cast application. Ultimately, the model needs to be validated by comparing performance on the simulated model with the treatment of actual patients and by evaluating performance before and after training.

There is a growing interest in methods of providing low-risk, hands-on skills training to orthopaedic surgeons in training as well as the use of models and simulation as an objective way to evaluate these skills. This study adds to the growing body of literature on the topic. Other notable recent studies used arthroscopic simulation for the purpose of supplementing orthopaedic-surgery education and concluded that technical skills could be improved if surgical trainees participated in simulator-enhanced training, but that initial gains were lost over time if the trainee did not continue to practice with the simulator.

In an era of increasingly limited funding for graduate medical education, the investment required must be justified. Nousiainen et al. performed a cost analysis of implementing a simulation program and concluded that, although the costs in terms of equipment and faculty time were substantial, there was increased learner satisfaction and measurable improvement in learning outcomes.

Mayne et al. point out that “the transfer of skills acquired in a simulated environment to the clinical setting is the end goal of simulation-based education. Previous studies have demonstrated that, regardless of fidelity (the degree to which the simulated experience reflects reality), simulation improves technical clinical skills.” Although proposed models such as the distal radial fracture model described here and the simulation-based learning modules previously described can be useful as adjuncts to residency education and as standardized methods of evaluating motor skills, there is no substitute for the experience residents gain when assuming patient-care responsibilities commensurate with their level of training. Additional research is needed to determine at what time point and with what frequency these models and simulations should be employed in a trainee’s education in order to maximize their benefit.