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19:474 https://doi.org/10.1186/s12909-019-1916-0 Background “Ultrasound is an extension of the stethoscope” is an oft-cited catchphrase that is rapidly becoming more accurate as point of care ultrasound (POCUS) becomes more readily accessible in the world of medicine. Historically an imaging modality limited to radiology departments and daylight hours, the recent evolution of ultrasound has led to its usage in operating rooms, in emergency departments, on wards and in offices by a vast spectrum of clinicians [1]. Arguably the least invasive imaging modality currently available, with significant portability, relative ease of use and relevance to almost any medical specialty, it’s no wonder ultrasound has become a mainstay of bedside diagnosis and procedural guidance [2]. In addition to being a useful adjunct to a physical exam and procedural skills for generalist medical practitioners, there are also numerous, more specific POCUS skills that can be readily applied in specialist and subspecialist settings. One such modality is that of musculoskeletal ultrasound (MSK POCUS). Sonography enables the diagnosis of many musculoskeletal pathologies including muscle sprains and tears, ligament injuries, tendon inflammation and ruptures and fractures [3–5]. From a treatment perspective, ultrasound helps to guide joint injections and aspirations, and confirm adequate reduction of fractures and dislocations immediately post-reduction [4, 6]. When used to guide forearm fracture reduction in comparison to the traditional blind method, MSK POCUS has been shown to increase the certainty [7] and success rate of closed reductions [7, 8], decrease the number of attempts and decrease the need for operative intervention [8, 9]. A further benefit of MSK POCUS is its ability to decrease the more expensive, time-consuming use of MRI for diagnostic purposes. In addition to not being subject to any contraindications, ultrasound allows immediate bilateral comparisons, differentiates fluids from solids more accurately than MRI and allows for real-time dynamic examination [10]. In the hands of a competent orthopaedic surgeon, an office-based ultrasound of the shoulder can provide a definitive diagnosis of a rotator cuff tear. When surgeons use POCUS plus physical exam, the diagnosis is more accurate than radiologist-read MRI, when intra-operative findings are used as the gold standard [11]. Thus office-based shoulder ultrasound allows definitive diagnosis of rotator cuff injury to happen with less delay and in a single setting, and MRI to be preserved for evaluation of more complex injuries [12]. Given ultrasound’s numerous advantages, it has become commonplace for medical schools to introduce learners to POCUS and many residency programs, such as emergency medicine, general surgery and anesthesia now involve extensive POCUS training. In orthopaedic surgery residencies in Canada, however, ultrasound skills are not a requirement for board certification by the Royal College of Physicians and Surgeons of Canada [13]. Furthermore, no published evidence of MSK POCUS being required in other orthopaedic surgery training programs elsewhere could be found. As a result, MSK POCUS has yet to become a skill commonly acquired by orthopaedic residents. Similar gaps in ultrasound training have also been noted in family medicine [14] and internal medicine [15]. In reviewing the literature surrounding point of care ultrasound education, it is noted that simulation and web-based learning are gaining ground as excellent, evidence-based adjuncts to clinical POCUS training and hands-on sessions [16]. By allowing learners to improve ultrasound skills and knowledge prior to attempting to use the modality in the clinical setting, patient safety and comfort is notably improved [17] and procedural complications are reduced [18]. In the orthopedics world specifically, Piposar et al. [19] found that orthopedics residents significantly improved their ability to assess ankle tendons with ultrasound after a multimedia tutorial alone. Building upon these concepts, a blended learning model has been described as one that combines multimedia-based learning tools, such as online modules, with simulation and hands on sessions with real or standardized patients [16]. This blended approach is thought to improve overall learner proficiency when compared to more traditional apprenticeship models [20]. Further reinforcing this approach is a publication by Finnoff et al. [21], in which a group of physical medicine and rehabilitation residents (PM&R) completed a blended learning MSK POCUS course and demonstrated marked improvement in ultrasound-related general knowledge image acquisition and injury assessment. Given the many procedural, diagnostic and cost-saving benefits alluded to previously, it stands to reason that in the future, MSK POCUS will become a cornerstone of managing orthopedics patients, both in the acute setting and in the office. To better understand how these skills can best be acquired by orthopedics residents, a study was designed with the purpose of assessing the utility of administering a general MSK POCUS curriculum to orthopedics residents using a blended learning model. The hypothesis was that a brief MSK POCUS course using a blended learning model would improve orthopaedic surgery residents’ performance in ultrasound guided
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