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diagnosis of musculoskeletal injury, improve confidence in reduction of fractures, and improve ability to perform difficult joint injections and aspirations. Methods Curriculum development An MSK ultrasound curriculum was developed by a multidisciplinary team, which was comprised of a Royal Larrivée et al. BMC Medical Education (2019) 19:474 Page 2 of 9 College trained attending physician in emergency medicine with a fellowship in point of care ultrasound, an attending pediatric orthopaedic surgeon, an orthopaedic surgery resident and an emergency medicine resident. The course drew inspiration by the one developed by Finnoff, Smith [21], but was heavily modified to target ultrasound skills deemed relevant to orthopaedic surgery based on a literature review and the combined clinical experience of the team. Given the busyness of the teaching curriculum in the orthopaedic surgery residency, it was decided that the online portion of the course should be short, and the practical portion should be done in one half-day of teaching. The final curriculum consisted of: A two-hour online course completed independently by the learners prior to the practical session. Content included a review of ultrasonography basics (physics, knobology), followed by an overview of sonographic appearance of normal MSK tissues (bone, tendon, ligament, muscle and large joints) as well as ultrasound technique for generating the relevant images. The course concluded with an overview of sonographic appearance of pathological MSK tissues (long bone fractures, ligament and tendon tears, bursitis, rotator cuff tears) and common pitfalls in point of care MSK ultrasound. A four-hour practical session administered by the attending emergency medicine physician with ultrasound fellowship training and an orthopaedic surgery resident and emergency medicine resident. This session covered practical demonstrations of the examination of the shoulder (including rotator cuff), elbow and ankle joints and included ample hands-on practice time for participants. There was also training time dedicated to ultrasoundguided musculoskeletal injections and aspirations and ultrasound-guided fracture reductions, both of which were taught using models. (See Additional file 1) Study design Approval was obtained from the appropriate ethics board. Given the small size of the orthopaedic surgery residency program being studied, a quasi-experimental study design was selected, and a pre-test post-test approach was utilized. It was determined that all orthopaedic surgery residents would benefit from MSK ultrasound training and should be exposed to the proposed curriculum, therefore no control group was used. Inclusion criteria included being an orthopaedic surgery resident completing their residency training at the study site. Any resident in poor standing with the program, having less than 6 months left before graduation, or on extended leave was to be excluded. Recruitment of participants was done by adding the MSK POCUS curriculum to program-scheduled academic days with the support of the local program directors. All of the orthopaedic surgery residents were required to attend as a component of their residency education, but they were given the option of declining participation in pre and post testing. Informed consent was provided by all participants. Participants were provided with a monetary compensation of twenty dollars per assessment. Outcome measures Prior to the intervention (ultrasound course), all participants completed a pre-test via password-protected online survey examining theoretical knowledge of MSK ultrasound, including identifying pathology and using ultrasound technology (See Additional file 2). An online survey assessing previous exposure to ultrasound (in hours), setting of the exposure, number of times used in the last 6 months and comfort performing the different aspects of the MSK POCUS exam was also administered at this time. After completing both the online and practical components of the curriculum, the initial post-test was administered to all participants. Post-testing entailed completion of the previously detailed online exam administered as the pre-test, as well as a practical exam component. These assessments were completed immediately after the practical session. The practical exam included basic ultrasound usage and a complete shoulder assessment, including the rotator cuff and was designed to be used as a benchmark for ultrasound competence both initially and over time (See Additional file 3 for practical exam marking scheme). Satisfaction with different aspects of the course was also assessed with an online survey. Six months post intervention, both the online and the practical exam were administered by the same members of the research team. Participants were allowed to review the online material and steps of the practical examination at their leisure before the assessment. The survey on participants use and comfort performing MSK POCUS in the previous 6 months was also readministered at that time. (See Additional file 4 for clinical use survey). Data analysis All statistical analyses were tested with a 0.05 threshold for significance and performed on SPSS statistics v22.0 ed. 64 bits for Windows (IBM, Armonk). Descriptive statistics including frequencies and means
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