Optimizing Radiology Resident Competency in Pediatric Musculoskeletal Radiograph Interpretation

Innovative, evidence-based, and feasible educational interventions to teach pediatric musculoskeletal (pMSK) radiograph interpretation to radiology post-graduate trainees (R-PGT) are currently lacking.

We evaluated the effectiveness of a pMSK radiograph education intervention in improving the identification and risk stratification of fractures and dislocations. We also determined cases most at risk of diagnostic error.

This was a multicenter prospective cross-sectional study in a convenience sample of R-PGT practicing in the United States and Canada. The web-based education intervention included 1609 pMSK extremity radiographs organized into six anatomic regions. R-PGT deliberately practiced identifying if there was a fracture/dislocation present or absent, and if present, they located and risk-stratified the fracture. Participants completed cases until they achieved a performance standard.

We enrolled 100 R-PGT and derived 48,166 unique case interpretations. From the initial to final 25 case completions, there were learning gains in diagnostic sensitivity (14.9%; 95% CI 13.4, 16.4), fracture location accuracy (14.1%; 95% 12.6, 15.5), and risk stratification (23.6%; 95% CI 21.5, 25.7). Of the 100 R-PGT, 77.5% (95% CI 71.1; 83.1) achieved the performance standard in at least one anatomic region in a median of 173 cases (IQR 94, 315) or a median of 41.5 min (IQR 22.6, 76.6). There was a higher odds of correctness in older versus younger children (OR=1.3; 95% 1.2, 1.4) and those without versus with a suspicion for non-accidental injury (OR=2.0; 95% CI 1.6, 2.4). The most frequent locations among the 171 high-risk false negative cases were the elbow (n=48 [28.1%]), pelvis (n=39 [22.8%]), and ankle (n=27 [15.8%]).

This study demonstrates that a web-based and competency-focused intervention can improve pMSK radiograph interpretation among R-PGTs and identifies cases prone to diagnostic error. These findings align with prior work showing the value of deliberate practice in radiology education.