Abstract
Background
Trauma orthopedics is a key component of orthopedic clinical education, but its teaching is often limited by complex fracture patterns, high demands for spatial understanding, and insufficient opportunities for hands-on practice. Although problem-based learning (PBL) and virtual simulation have each shown educational value, evidence regarding their combined use in trauma orthopedic teaching remains limited. This study aimed to evaluate the effectiveness of an integrated PBL and virtual simulation teaching model in trauma orthopedic education.
Methods
This assessor-blinded randomized controlled study included 50 clinical medical students undertaking internships at the First Affiliated Hospital of Wannan Medical University between July 2024 and June 2025. Participants were randomly assigned to a control group (n = 25), which received traditional lecture-based teaching, or an experimental group (n = 25), which received PBL combined with virtual simulation. Outcomes included theoretical knowledge, clinical skills, critical thinking ability, student evaluation of teaching effectiveness, and teaching satisfaction. Data were analyzed using t tests and chi-square tests.
Results
No significant between-group differences were observed in baseline theoretical knowledge or clinical skills scores before teaching. After the intervention, the experimental group achieved significantly higher written examination scores than the control group (88.48 ± 4.02 vs. 77.04 ± 5.31,mean difference = 11.44,95% CI: 8.76 − 14.12, p < 0.01) and significantly higher practical operation scores (86.28 ± 3.18 vs. 76.52 ± 3.39,mean difference = 9.76,95% CI :7.89 − 11.63,p < 0.01). The experimental group also showed higher total critical thinking scores (314.12 ± 10.68 vs. 270.28 ± 19.76,mean difference = 43.84,95% CI: 34.70 − 52.98, p < 0.05), overall teaching effectiveness scores (17.72 ± 1.24 vs. 12.72 ± 1.02,mean difference = 5.00,95% CI: 4.35 to 5.65,p < 0.01), and total teaching satisfaction scores (86.96 ± 6.46 vs. 70.24 ± 8.71,mean difference = 16.72,95% CI:12.35 − 21.09,p < 0.05).
Conclusions
The integration of PBL with virtual simulation improved theoretical performance, clinical skills, critical thinking, and learning satisfaction in trauma orthopedic teaching, and may represent an effective strategy for clinical education reform in this field.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-026-09558-0.
Keywords: Trauma orthopedics, Problem-based learning, Virtual simulation, Medical education, Clinical skills, Critical thinking
Introduction
Trauma orthopedics is a core component of surgical education and an important part of orthopedic clinical training [1]. Because it involves a complex knowledge system, strong practical demands, and high requirements for clinical decision-making, it presents substantial learning challenges for medical students [2, 3]. Compared with other teaching modules, trauma orthopedics requires students to integrate fracture pattern recognition, three-dimensional anatomical understanding, imaging interpretation, and surgical planning [4, 5]. However, due to the diversity of fracture types, the complexity of injury mechanisms, and marked individual variation, students often find it difficult to build a systematic and three-dimensional understanding of the subject within a limited training period [6]. This difficulty is particularly evident when they are required to interpret complex fractures, periarticular injuries, and internal fixation strategies, as many students struggle to translate two-dimensional imaging findings into accurate spatial understanding [4, 6].
Traditional trauma orthopedic teaching mainly relies on lectures, two-dimensional imaging materials, and printed atlases [7, 8]. Although these approaches are useful for delivering theoretical knowledge such as fracture classification and surgical indications, they are limited in fostering spatial cognition and practical competence. In addition, cadaveric specimens and authentic clinical cases are often insufficient for repeated teaching, especially for rare injuries, complex deformities, and high-risk procedures [9]. Owing to concerns related to medical ethics, patient safety, and limited clinical teaching opportunities, students also have relatively few chances to perform hands-on procedures in real clinical settings [10, 11]. As a result, trauma orthopedic teaching often emphasizes theoretical learning more than practical application, which may hinder students’ ability to transfer knowledge into clinical problem-solving [12].
Problem-based learning (PBL) has been widely used in medical education in recent years [13, 14]. By using clinical problems and case-based discussion to guide learning, PBL encourages students to actively search for information, analyze clinical situations, and propose solutions. Previous studies have shown that PBL can improve learning motivation, classroom engagement, knowledge integration, and clinical reasoning. In trauma orthopedic teaching, PBL may help students connect abstract concepts with specific clinical cases and gradually develop a more structured clinical thinking process.
At the same time, advances in virtual simulation technology have created new opportunities for practical teaching in medicine [15, 16]. Through virtual simulation platforms, VR/AR-based systems, and surgical simulators, educators can provide three-dimensional visualization, immersive experiences, and repeated skills training in a controllable environment. These tools may help overcome some of the limitations of traditional teaching by improving students’ spatial understanding and procedural skills. In orthopedic education, virtual simulation has shown value in anatomical learning, fracture classification, fracture reduction, internal fixation planning, and basic surgical skills training [17, 18].
Although both PBL and virtual simulation have demonstrated educational benefits [19], most existing studies have focused on either approach alone, and evidence on their combined use in trauma orthopedic teaching remains limited. Because trauma orthopedic education requires both clinical reasoning and spatial-operational competence, a single teaching method may be insufficient to meet these learning needs. Therefore, this study aimed to develop and evaluate a combined teaching model integrating PBL with virtual simulation in trauma orthopedic education, and to examine its effects on students’ theoretical performance, clinical reasoning, practical skills, and learning satisfaction.We hypothesized that, compared with traditional teaching, the combined PBL and virtual simulation model would lead to better educational outcomes in trauma orthopedics, including improved theoretical performance, clinical skills, clinical reasoning, and higher learning satisfaction.
Materials
A total of 50 clinical medical students who completed their internship at the First Affiliated Hospital of Wannan Medical University between July 2024 and June 2025 were enrolled in this study. A single-blind randomized controlled design was adopted, and the participants were randomly assigned to either a control group or an experimental group, with 25 students in each group. For sequence generation, an independent researcher who was not involved in teaching or outcome evaluation generated the random allocation sequence using a computer-generated random number sequence. For allocation concealment, sequentially numbered, sealed, opaque envelopes were prepared according to the allocation sequence. For implementation, after participant enrollment, the envelopes were opened sequentially, and students were assigned to the corresponding group.Outcome assessors were blinded to group allocation until completion of data collection.Instructors were aware of group allocation because they delivered different teaching interventions, whereas students were not informed of their group assignment or the study hypothesis.The control group received traditional lecture-based teaching, whereas the experimental group received a teaching model integrating problem-based learning (PBL) with virtual simulation technology.
In the control group, there were 14 male and 11 female students, with a mean age of 25.04 ± 1.02 years. In the experimental group, there were 16 male and 9 female students, with a mean age of 25.12 ± 1.01years. The two groups received the same teaching content and class hours, and all sessions were delivered by the same instructor. The core learning content was identical in both groups and focused on common trauma orthopedic conditions, including femoral neck fractures, distal radius fractures, and complex pelvic fractures. The learning objectives included understanding trauma-related anatomy and injury mechanisms, recognizing fracture morphology and classification, interpreting plain radiographs and CT images, formulating diagnosis and treatment principles, designing surgical plans, understanding fracture reduction procedures, selecting internal fixation strategies, choosing appropriate surgical approaches, and preventing and managing common complications. In the experimental group, these contents were delivered through case-based PBL discussion combined with three-dimensional virtual simulation training. In the control group, the same core content was delivered through lecture-based teaching, two-dimensional imaging materials, anatomical atlases, and bedside teaching.All students had completed the theoretical coursework in trauma orthopedics and relevant clinical clerkships before the study, The theoretical coursework included basic orthopedic anatomy, fracture classification, fracture healing, principles of fracture management, radiographic interpretation, common trauma orthopedic conditions, and prevention and management of complications. The relevant clinical clerkship mainly consisted of ward rounds, outpatient or emergency observation, case discussion, imaging review, and observation of common trauma orthopedic procedures. During the clerkship, students were exposed to typical trauma orthopedic cases, but they did not independently perform trauma orthopedic procedures or make clinical decisions. Therefore, all participants had comparable basic exposure to trauma orthopedic education before randomization, but none had previous independent clinical work experience in trauma orthopedics.
Teaching methods
Experimental group
The experimental group received a teaching model integrating problem-based learning (PBL) with virtual simulation technology.In this study, the term “teaching model” was used to describe the structured instructional approach integrating PBL with virtual simulation, rather than a fully established theoretical pedagogical framework.Teaching was delivered through a virtual simulation platform and its supporting simulation software. The virtual simulation training was conducted using a computer-based three-dimensional virtual simulation platform. The hardware included a desktop workstation, a high-resolution display, keyboard and mouse input devices, and multimedia projection equipment for group teaching. High-resolution CT imaging data of fracture cases were retrieved from the hospital’s picture archiving and communication system (PACS) in DICOM format. These data were imported into Mimics software (Materialise, Belgium), where bone tissue was segmented using threshold-based segmentation followed by region-growing and manual refinement to ensure accurate extraction of fracture fragments. The segmented masks were then converted into three-dimensional surface models using the “Calculate 3D” function, and smoothing algorithms were applied to improve anatomical clarity. The generated three-dimensional models were exported in STL format and imported into 3D Slicer. In this environment, students could perform multi-angle rotation, zooming, slicing, transparency adjustment, model clipping, and simulated fracture reduction using the “Transforms” and “Model Clipping” modules. In addition, students completed relevant virtual simulation learning modules through the National Virtual Simulation Experiment Teaching Course Sharing Platform, i.e., ilab-x (https://www.ilab-x.com), which provides shared virtual simulation experimental teaching resources for online learning and training. This workflow enabled students to observe fracture morphology, spatial anatomical relationships, and reduction strategies in an interactive and reproducible virtual teaching environment.The workflow of the virtual simulation-based training is shown in Fig. 1. A representative procedure-based virtual simulation platform for surgical training is illustrated in Fig. 2. The instructional modules included three-dimensional anatomical visualization, fracture morphology observation, fracture reduction simulation, internal fixation placement, and demonstration of surgical approaches.Representative implant models used in simulation-based teaching are shown in Fig. 3.
Fig. 1.
Workflow of virtual simulation-based training for distal radius fracture reduction. Using a virtual simulation platform, students completed stepwise training in history taking, physical examination, clinical assessment, and fracture reduction and fixation in a simulated clinical scenario. A Virtual history taking. B, C Physical examination and clinical assessment of the injured upper limb. D Simulation-based training in fracture reduction and external fixation
Fig. 2.
Procedure-based virtual simulation platform for total hip arthroplasty training. The platform integrates three-dimensional anatomical simulation, procedural training, dynamic interaction, and assessment to provide a progressive learning environment for total hip arthroplasty. A Anatomical modeling and surgical planning, including selection of patient positioning and surgical incision. B, C Interactive simulation of key operative steps, including osteotomy and femoral head removal. D Intraoperative measurement and spatial assessment. E–H Component selection, implantation, and assembly, followed by final verification of implant position and alignment
Fig. 3.
Representative internal fixation and implant models used in simulation-based orthopedic training. These virtual models were used to support simulation-based teaching in orthopedics, including fracture reduction, implant recognition, fixation strategy selection, and internal fixation planning. A intramedullary nail model for intertrochanteric femoral fracture. B Spinal rod-and-screw fixation model. C Cervical plate-and-screw fixation model. D Total knee arthroplasty prosthesis model
Typical trauma orthopedic cases, including femoral neck fractures, distal radius fractures, and complex pelvic fractures, were used to construct problem-based scenarios based on patients’ medical history, physical examination findings, and imaging data. Students worked in small groups to analyze diagnosis, treatment principles, and surgical planning, and then entered the virtual simulation environment to observe three-dimensional fracture morphology and adjacent anatomy and to perform simulated fracture reduction, internal fixation placement, and surgical approach selection. After the simulation, each group discussed the diagnostic basis, treatment strategies, and key surgical considerations. The instructor acted mainly as a facilitator, providing guidance only when necessary. At the end of the session, each group presented its conclusions, and the instructor summarized the key knowledge points and clinical reasoning involved.
Control group
The control group received lecture-based learning (LBL). Teaching was primarily delivered through PowerPoint presentations, plain radiographs, two-dimensional CT images, and anatomical atlases. The instructor systematically explained the anatomical structures, injury mechanisms, clinical manifestations, and treatment principles of common trauma orthopedic conditions.
The teaching activities mainly consisted of topic-based mini-lectures and bedside teaching rounds. During the mini-lectures, theoretical content was delivered primarily through PowerPoint presentations. During the teaching rounds, students first presented the medical history, after which the instructor supplemented the history information and demonstrated the specialized physical examination. The instructor then used specific cases to explain the diagnostic approach, treatment principles, and clinical management of typical trauma orthopedic conditions. Throughout the teaching process, instruction was mainly teacher-centered, supplemented by question-and-answer interaction, while students participated primarily through listening, note-taking, and responding to questions.
Outcome measures and effectiveness evaluation
Clinical assessment
Clinical assessment included both theoretical knowledge and clinical skills.For the theoretical knowledge assessment, students in both groups completed a closed-book examination covering anatomical structures, fracture classification, treatment principles, and prevention and management of complications. Detailed information regarding the theoretical knowledge examination, including the examination content, question format, scoring criteria, and topic distribution, is provided in Supplementary File 3.The maximum score was 100 points.For the clinical skills assessment, students were evaluated on case analysis, radiographic interpretation, and surgical planning. These components were scored independently by two instructors who were blinded to group allocation.Detailed information regarding the clinical skills assessment, including the OSCE stations, assessment tasks, scoring items, scoring criteria, and score distribution, is provided in Supplementary File 4.
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2.
Student evaluation of teaching methods
An anonymous self-administered questionnaire on orthopedic teaching effectiveness was distributed to students in both groups.(see Supplementary File 1 ). In this study, “teaching effectiveness” referred to students’ perceived evaluation of the instructional approach as measured by the self-administered questionnaire.The questionnaire was developed by the research team and included five domains: knowledge acquisition, development of clinical thinking, improvement of practical skills, stimulation of self-directed learning, and enhancement of teamwork ability. Each item was rated on a 4-point scale: 1 = none, 2 = moderate, 3 = obvious, and 4 = very obvious. A 4-point forced-choice Likert-type response format was used to reduce central tendency bias and encourage students to make a clearer judgment regarding the perceived degree of teaching effectiveness.The total score ranged from 5 to 20 points, with higher scores indicating better perceived teaching effectiveness.The internal consistency reliability of this questionnaire was confirmed by Cronbach’s α = 0.87, indicating good reliability. Content validity was established through expert review by three senior orthopaedic educators prior to implementation.The design of this self-developed questionnaire was informed by previously validated educational evaluation frameworks [20, 21]. Its structure and scoring dimensions were adapted from established studies on medical education assessment and active learning outcomes.These references guided the domain selection and item phrasing to ensure theoretical consistency and content relevance.
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3.
Teaching satisfaction evaluation
An anonymous survey was conducted to assess teaching satisfaction.(see Supplementary File 2 ). A self-designed trauma orthopedic teaching satisfaction scale was used, including five domains: 1.teaching effectiveness, 2.learning interest, 3.teaching content, 4.self-value, 5.humanistic competence and teamwork. Each domain was assigned 20 points, with a total score of 100 points. A total score of ≥ 90 was defined as very satisfied, 60–89 as basically satisfied, and < 60 as dissatisfied. Satisfaction rate was calculated as follows: (very satisfied + basically satisfied) / total number of students × 100%.The questionnaire demonstrated good internal consistency (Cronbach’s α = 0.91). Content validity was reviewed by two medical education specialists and three clinical teaching experts to ensure appropriateness and clarity of the items.Similarly, this satisfaction questionnaire was developed with reference to established educational evaluation methodologies [22], incorporating validated constructs from prior studies in health professions education to enhance reproducibility and comparability.
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4.
Assessment of critical thinking ability
An anonymous questionnaire was used to assess students’ critical thinking ability in both groups. The scale consisted of seven dimensions: truth-seeking, open-mindedness, analytical ability, systematicity, critical thinking self-confidence, curiosity, and cognitive maturity. Each dimension contained 10 items and was rated using a 6-point Likert scale. The total score ranged from 70 to 420 points, with higher scores indicating stronger critical thinking ability.
Statistical analysis
All statistical analyses were performed using SPSS version 19.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation, and categorical variables were presented as frequencies and percentages. The Shapiro–Wilk test was used to assess the normality of data distribution, and Levene’s test was used to examine the homogeneity of variances. Baseline characteristics, including age and gender, were compared between the two groups using the independent-samples t test or chi-square test, as appropriate. For theoretical knowledge and clinical skills scores, within-group comparisons before and after teaching were performed using the paired-samples t test, and between-group comparisons were conducted using the independent-samples t test. Scores for teaching effectiveness, critical thinking, and teaching satisfaction were compared between groups using the independent-samples t test. No formal adjustment for multiple comparisons was applied because theoretical knowledge and clinical skills scores were prespecified as the main academic outcomes, whereas questionnaire-based outcomes were considered secondary and exploratory. Therefore, the results of secondary outcomes should be interpreted cautiously.Satisfaction rates were compared using the chi-square test. Effect sizes (Cohen’s d) were calculated to estimate the magnitude of between-group differences. A two-sided p value of < 0.05 was considered statistically significant.A post hoc power analysis was conducted based on the difference in post-teaching written examination scores between the two groups. The observed effect size was large, with Cohen’s d = 2.38. The calculated statistical power was > 0.99 at a two-sided α level of 0.05, indicating that the sample size of 25 students per group was sufficient to detect the observed between-group difference in the primary academic performance outcome.
Results
Clinical assessment
No significant between-group differences were observed in baseline written examination or practical operation scores before teaching. The written examination scores before teaching were 66.24 ± 3.21 in the experimental group and 66.40 ± 3.05 in the control group (P = 0.856). The practical operation scores before teaching were 64.48 ± 3.01 and 64.40 ± 3.00, respectively (P = 0.925).
After teaching, written examination and practical operation scores were higher in the experimental group than in the control group, and the between-group differences were statistically significant. The written examination scores after teaching were 88.48 ± 4.02 in the experimental group and 77.04 ± 5.31 in the control group ( mean difference 11.44, 95% CI 8.76 to 14.12, P < 0.01). The practical operation scores after teaching were 86.28 ± 3.18 and 76.52 ± 3.39, respectively (mean difference 9.76, 95% CI : 7.89 to 11.63, P < 0.01).
Greater improvements were observed in the experimental group than in the control group after teaching. The gain in written examination scores was 22.24 ± 5.20 in the experimental group and 10.64 ± 5.96 in the control group (mean difference 11.60, 95% CI 8.42 to 14.78, P < 0.01). The gain in practical operation scores was 21.80 ± 4.71 and 12.12 ± 4.79, respectively ( mean difference 9.68, 95% CI 6.98 to 12.38, P < 0.01) (outlined in Table 1; Fig. 4). The effect sizes were large for both post-teaching written examination scores (Cohen’s d = 2.43) and practical operation scores (Cohen’s d = 2.97). Large effect sizes were also observed for gains in written examination scores (Cohen’s d = 2.07) and practical operation scores (Cohen’s d = 2.04).
Table 1.
Comparison of clinical assessment outcomes between the experimental and control groups before and after teaching
| Assessment | Timepoint | Experimental group (mean ± SD) | Control group (mean ± SD) | P value |
|---|---|---|---|---|
| Written examination (score) | Before teaching | 66.24 ± 3.21 | 66.40 ± 3.05 | 0.856 |
| Practical operation (score) | Before teaching | 64.48 ± 3.01 | 64.40 ± 3.00 | 0.925 |
| Written examination (score) | After teaching | 88.48 ± 4.02 | 77.04 ± 5.31 | < 0.01 |
| Practical operation (score) | After teaching | 86.28 ± 3.18 | 76.52 ± 3.39 | < 0.01 |
| Written examination gain (score) | After-before | 22.24 ± 5.20 | 10.64 ± 5.96 | < 0.01 |
| Practical operation gain (score) | After-before | 21.80 ± 4.71 | 12.12 ± 4.79 | < 0.01 |
Gain = score after teaching minus score before teaching
Fig. 4.
Clinical assessment outcomes in the experimental and control groups. The lower segment of each bar represents the baseline score before teaching, and the upper segment represents the gain score after teaching. The total bar height indicates the post-teaching score. Greater improvements in both written examination and practical operation scores were observed in the experimental group than in the control group
Critical thinking ability
The experimental group had higher scores than the control group on all dimensions of critical thinking ability (all P < 0.05). Specifically, higher scores were observed for truth-seeking (46.08 ± 3.42 vs. 38.88 ± 5.71), open-mindedness (44.52 ± 4.07 vs. 38.48 ± 4.39), analyticity (47.36 ± 3.08 vs. 39.16 ± 4.84), systematicity (41.96 ± 4.88 vs. 36.48 ± 5.29), critical thinking self-confidence (46.44 ± 4.37 vs. 40.12 ± 3.48), curiosity (45.56 ± 3.63 vs. 38.84 ± 4.56), and cognitive maturity (42.20 ± 4.43 vs. 38.32 ± 5.66). The total critical thinking score was also significantly higher in the experimental group than in the control group (314.12 ± 10.68 vs. 270.28 ± 19.76,mean difference 43.84, 95% CI 34.70 to 52.98, P < 0.05) (outlined in Table 2; Fig. 5). The effect size for the total critical thinking score was large (Cohen’s d = 2.76).
Table 2.
Comparison of critical thinking dimensions between the experimental and control groups
| Assessment | Experimental group (mean ± SD) | Control group (mean ± SD) | P value |
|---|---|---|---|
| Truth-seeking | 46.08 ± 3.42 | 38.88 ± 5.71 | < 0.05 |
| Open-mindedness | 44.52 ± 4.07 | 38.48 ± 4.39 | < 0.05 |
| Analyticity | 47.36 ± 3.08 | 39.16 ± 4.84 | < 0.05 |
| Systematicity | 41.96 ± 4.88 | 36.48 ± 5.29 | < 0.05 |
| Critical thinking confidence | 46.44 ± 4.37 | 40.12 ± 3.48 | < 0.05 |
| Curiosity | 45.56 ± 3.63 | 38.84 ± 4.56 | < 0.05 |
| Cognitive maturity | 42.20 ± 4.43 | 38.32 ± 5.66 | < 0.05 |
| Total | 314.12 ± 10.68 | 270.28 ± 19.76 | < 0.05 |
Total score mean difference = 43.84, 95% CI 34.70 to 52.98
Fig. 5.
Critical thinking ability in the experimental and control groups. Bars represent mean scores for the seven dimensions of critical thinking ability, and error bars indicate standard deviations. Scores were higher in the experimental group than in the control group across all dimensions (all P < 0.05)
Student evaluation of teaching methods
The overall student evaluation score for the teaching method was higher in the experimental group than in the control group (17.72 ± 1.24 vs. 12.72 ± 1.02, mean difference 5.00, 95% CI 4.35 to 5.65, P < 0.01) (outlined in Table 3). The effect size for the overall student evaluation score was large (Cohen’s d = 4.40).
Table 3.
Comparison of student evaluation of teaching methods between the experimental and control groups
| Assessment | Experimental group (mean ± SD) | Control group (mean ± SD) | P value |
|---|---|---|---|
| Overall score | 17.72 ± 1.24 | 12.72 ± 1.02 | < 0.01 |
Overall score mean difference = 5.00, 95% CI 4.35 to 5.65
Teaching satisfaction evaluation
The experimental group reported higher scores than the control group across all dimensions of teaching satisfaction, including teaching effect (17.52 ± 1.53 vs. 14.08 ± 2.06, P < 0.05), learning interest (17.28 ± 1.59 vs. 13.80 ± 2.02, P < 0.05), teaching content (17.36 ± 1.52 vs. 14.12 ± 2.15, P < 0.05), self-value (17.20 ± 1.83 vs. 13.96 ± 1.84, P < 0.05), and humanistic competence and teamwork (17.60 ± 1.55 vs. 14.28 ± 2.25, P < 0.05). The total teaching satisfaction score was also significantly higher in the experimental group than in the control group (86.96 ± 6.46 vs. 70.24 ± 8.71, mean difference 16.72, 95% CI 12.35 to 21.09, P < 0.05) (outlined in Table 4; Fig. 6). The effect size for the total teaching satisfaction score was large (Cohen’s d = 2.18).
Table 4.
Comparison of teaching satisfaction evaluation between the experimental and control groups
| Assessment | Experimental group (mean ± SD) | Control group (mean ± SD) | P value |
|---|---|---|---|
| Teaching effect | 17.52 ± 1.53 | 14.08 ± 2.06 | < 0.05 |
| Learning interest | 17.28 ± 1.59 | 13.80 ± 2.02 | < 0.05 |
| Teaching content | 17.36 ± 1.52 | 14.12 ± 2.15 | < 0.05 |
| Self-value | 17.20 ± 1.83 | 13.96 ± 1.84 | < 0.05 |
| Humanistic teamwork | 17.60 ± 1.55 | 14.28 ± 2.25 | < 0.05 |
| Total | 86.96 ± 6.46 | 70.24 ± 8.71 | < 0.05 |
Total score mean difference = 16.72, 95% CI 12.35 to 21.09
Fig. 6.
Teaching satisfaction evaluation in the experimental and control groups. Points represent mean scores for the five dimensions of teaching satisfaction, and horizontal error bars indicate standard deviations. Scores were higher in the experimental group than in the control group across all dimensions (all P < 0.05)
Discussion
Trauma orthopedics is an important component of orthopedic education and is characterized by strong complexity, practical relevance, and clinical applicability [1, 15]. However, clinical teaching in this field has long faced multiple challenges. First, the diversity of fracture types, the complexity of injury mechanisms, and marked interindividual variation make it difficult for students to establish a systematic and three-dimensional knowledge framework within a limited training period [23, 24]. Second, opportunities for students to directly participate in clinical procedures are restricted by concerns related to patient safety, ethical requirements, and limited teaching resources, and this problem is particularly pronounced in high-risk or technically demanding procedures. Third, conventional teaching in trauma orthopedics is largely teacher-centered, with students often remaining passive recipients of knowledge [25]. The lack of sufficient situational engagement and problem-driven learning is not conducive to the development of clinical reasoning and comprehensive analytical ability [26]. In the present study, we integrated problem-based learning (PBL) with virtual simulation technology to construct a teaching model that was guided by clinical problems and supported by simulation-based training. Our findings showed that this model was superior to traditional teaching in improving students’ theoretical performance, practical skills, and clinical reasoning.Specifically, after the intervention, the experimental group achieved higher written examination scores (88.48 ± 4.02 vs. 77.04 ± 5.31) and practical operation scores (86.28 ± 3.18 vs. 76.52 ± 3.39), with greater gains in written performance (22.24 ± 5.20 vs. 10.64 ± 5.96) and practical skills (21.80 ± 4.71 vs. 12.12 ± 4.79) than the control group. These findings suggest that the integrated model is an effective approach for trauma orthopedic clinical teaching.
The combined use of PBL and virtual simulation demonstrated clear educational advantages in trauma orthopedic teaching. PBL emphasizes a clinical problem-centered approach and uses typical cases to guide students in self-directed learning, group discussion, and collaborative inquiry, thereby facilitating knowledge integration and strengthening clinical reasoning and problem-solving ability [13]. Virtual simulation, in contrast, provides three-dimensional visualization, immersive experience, and interactive operation, overcoming some of the limitations of traditional teaching in terms of time, space, and practice conditions. It offers students a safe, repeatable, and clinically relevant training environment [27]. In trauma orthopedic education, virtual simulation platforms can be used in multiple stages of teaching, including fracture classification, understanding of anatomical structures, fracture reduction, internal fixation trajectory design, and surgical skills training. As a result, complex and abstract teaching content becomes more intuitive and easier to understand. When combined, PBL and virtual simulation not only enhance student engagement and the heuristic value of teaching, but also promote the integration of theoretical learning with practical training, thereby improving overall teaching effectiveness [28].
From a pedagogical perspective, the combination of PBL and virtual simulation may offer complementary educational advantages [19, 28]. PBL provides a problem-oriented framework that encourages students to identify learning needs, actively seek relevant information, analyze clinical scenarios, and generate potential solutions, thereby facilitating knowledge construction and the development of clinical reasoning [12, 13, 26]. In contrast, virtual simulation provides a visual, interactive, and operational environment in which students can apply their judgments and rehearse procedural strategies in a safe and controllable setting. The integration of these two approaches may therefore support a more iterative learning process involving problem identification, knowledge acquisition, simulation-based practice, and feedback-guided improvement. In this context, virtual simulation appears to enhance the intuitiveness, interactivity, and operability of teaching, whereas PBL may strengthen problem awareness, self-directed learning, and collaborative engagement. Taken together, these complementary features may help reduce the difficulty of understanding complex orthopedic concepts, improve classroom participation and learning effectiveness, and promote the coordinated development of theoretical knowledge, clinical reasoning, and practical skills [25].This interpretation is supported by the higher total critical thinking score in the experimental group than in the control group (314.12 ± 10.68 vs. 270.28 ± 19.76), together with the higher overall teaching effectiveness score (17.72 ± 1.24 vs. 12.72 ± 1.02), indicating that the combined model may have enhanced not only knowledge application but also broader cognitive engagement.
Teaching satisfaction is an important indicator of the acceptability and perceived effectiveness of an educational intervention. In the present study, students receiving the combined PBL and virtual simulation model reported higher overall satisfaction than those receiving traditional teaching, with a higher total teaching satisfaction score (86.96 ± 6.46 vs. 70.24 ± 8.71). Higher scores were also observed across all assessed domains, including teaching effect, learning interest, teaching content, self-value, and humanistic competence and teamwork. This difference may be attributable to several mechanisms. The combined model appeared to promote a more active learning process by increasing students’ involvement in case discussion, problem solving, and simulation-based practice, which may in turn have enhanced learning interest and engagement. In addition, the immersive and feedback-oriented nature of virtual simulation may have facilitated a more intuitive understanding of teaching content and allowed students to recognize and correct performance-related deficiencies in a timely manner, thereby improving learning confidence [29]. Meanwhile, the collaborative features of PBL, including group discussion and increased teacher–student and peer interaction, may have fostered a more supportive learning environment and a stronger sense of participation and achievement. Collectively, these factors may explain the higher satisfaction observed across multiple dimensions of the learning experienc.
The present findings are connected with, but also differ from, previous studies on PBL and virtual simulation in medical education [16, 30]. Previous studies have shown that PBL can promote self-directed learning, knowledge integration, and clinical reasoning, whereas virtual simulation can improve spatial understanding, procedural familiarity, and engagement in surgical education. Our findings are consistent with these reports, as students in the integrated intervention group showed better academic performance, clinical skills, and learning satisfaction. However, unlike most previous studies that evaluated PBL or virtual simulation separately, the present study examined their combined use in trauma orthopedic education. This is particularly relevant because trauma orthopedics requires both clinical reasoning and three-dimensional spatial understanding. Therefore, the current findings extend previous evidence by suggesting that combining PBL with virtual simulation may provide complementary educational benefits for both cognitive and practical learning needs [31].
Comparing the present findings with previous studies further supports the effectiveness of this teaching model. Earlier research has shown that PBL can enhance self-directed learning, knowledge integration, and clinical reasoning in medical education [26], whereas virtual simulation has clear advantages in improving surgical skills training, strengthening spatial cognition, and reducing the risks associated with practical training [16, 19]. Our findings are generally consistent with these previous reports and further support the positive educational value of both approaches. Notably, most earlier studies have focused on PBL alone or virtual simulation alone, whereas systematic research on their combined application remains relatively limited. In the present study, the integration of PBL with virtual simulation showed more pronounced advantages than traditional teaching in terms of both teaching effectiveness and student satisfaction. These findings suggest that in a discipline such as trauma orthopedics, which involves both theoretical complexity and substantial procedural demands, a single teaching approach may be insufficient to address the dual needs of knowledge construction and skills training. In contrast, an integrated teaching model may be better suited to achieving more comprehensive educational outcomes [14, 25]. These results not only extend current thinking on trauma orthopedic teaching, but also provide practical evidence to support further educational reform in this field.
Nevertheless, several limitations should be acknowledged. First, this was a single-center study with a relatively small sample size, and the outcomes were assessed only in the short term. Although the post hoc power analysis suggested that the sample size was sufficient to detect the observed large effect in the main academic performance outcome, the study may still be underpowered to detect smaller effects. The findings may also be influenced by local curriculum structure, instructor experience, student characteristics, and available virtual simulation resources, which may limit generalizability. Second, the two-arm design compared the integrated PBL and virtual simulation approach only with traditional lecture-based teaching. Therefore, this study could not distinguish the independent effects of PBL alone, virtual simulation alone, or their potential synergistic interaction. In addition, traditional lecture-based teaching reflected the routine practice at our institution but may not fully represent contemporary hybrid or blended teaching approaches. Third, instructor blinding was not feasible, and several outcomes were questionnaire-based; therefore, performance bias, response bias, expectation bias, or social desirability bias may have influenced the self-reported results. Finally, the implementation of virtual simulation depends on technical support and financial resources, which may limit wider adoption. Future multicenter studies with larger sample sizes, longer follow-up, four-arm or factorial designs, validated assessment tools, and more objective outcome measures are needed to confirm these findings.
Conclusion
Integrating problem-based learning (PBL) with virtual simulation can effectively improve students’ theoretical learning, clinical reasoning, practical skills, and learning satisfaction in trauma orthopedic teaching. This combined model integrates the advantages of problem-oriented learning and simulation-based training, and may provide a useful approach for the reform and further development of trauma orthopedic clinical education.
Supplementary Information
Acknowledgements
Not applicable.
Abbreviations
- PBL
Problem-Based Learning
Authors’ contributions
Authors GX and XZ designed the study. Authors XZ and SYJ collected the clinical data and conducted the statistical analysis. Author GX wrote the manuscript. Author JQ revised the manuscript. All authors critically read the manuscript to improve intellectual content. The authors read and approved the final manuscript.
Funding
This work was supported by the Quality Assurance and Teaching Reform Project of Wannan Medical University(2025kcsz03), the New Era Education Quality Engineering Project Graduate Mentor Overseas Training Program (2024dshwyx033), the Major Natural Science Research Project of Anhui Provincial Department of Education (2024AH040249), the Talent Introduction Science Foundation of Yijishan Hospital, Wannan Medical University (YR20220214)and The Quality Engineering Project of Wannan Medical University (Grant No. 2025jyxm057).
Data availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of the First Affiliated Hospital of Wannan Medical University.The patients who provided the original imaging data for the model were informed that their image data would be anonymized and used, and their consent were obtained.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Gang Xue and Xin Zhang are co-first authors.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.