Active Recall and Spaced Repetition for Orthopaedic Exams
Active recall and spaced repetition for orthopaedic exams: what the evidence shows, how to write good flashcards, Anki and FSRS settings, and a daily routine.
By OrthoVellum Editorial TeamPublished Updated 9 min read
Educational content for clinicians, not medical advice. Editorial policy
Key points
- Practice testing and distributed practice are the two study techniques rated high utility in the main review of learning methods; re-reading and highlighting were rated low.
- In a randomised trial in residents, repeated testing beat repeated study six months later (39% versus 26% on the final test).
- The best gap between reviews grows with how long you need to remember. A scheduler such as Anki's FSRS works this out card by card.
- Cards fail when they test more than one fact, when you mark a forgotten card as Hard, or when you add new cards faster than you can review them.
- Flashcards drill facts; vivas test reasoning. Pair card review with question banks and spoken answers.
On this page9 sections
Most exam candidates revise by reading: a textbook chapter, a set of notes, a highlighted summary. It feels productive because the material becomes familiar. The evidence says familiarity is the wrong target. Active recall (testing yourself by producing the answer from memory) and spaced repetition (returning to it at lengthening gaps) are the two techniques with the strongest support for long-term retention, and together they suit the fact-dense orthopaedic syllabus better than any amount of re-reading. This guide covers the evidence, how to apply both to orthopaedic material, how to set up Anki or a similar scheduler, and the mistakes that make people give up.
What the evidence shows
The research base is large, and a handful of studies are worth knowing by name.
| Study | What was done | Finding |
|---|---|---|
| Dunlosky et al. 2013 | Review of 10 common study techniques across ages, abilities, materials and outcomes | Practice testing and distributed practice rated high utility; re-reading, highlighting and summarisation rated low |
| Roediger and Karpicke 2006 | Students studied prose passages, then either re-studied or took recall tests | Re-studying won at 5 minutes; testing gave substantially better retention at 2 days and 1 week, even though re-studying made students more confident |
| Larsen et al. 2009 | Randomised trial in paediatric and emergency medicine residents; short-answer tests with feedback versus review sheets, repeated about every 2 weeks | Final test at about 6 months: 39% after testing versus 26% after study |
| Cepeda et al. 2006 | Meta-analysis of 839 assessments of distributed practice from 317 experiments | Spacing beats massing; the gap that gives the best retention increases as the retention interval increases |
| Deng et al. 2015 | Survey of 72 medical students linked to USMLE Step 1 scores | Question-bank volume and unique Anki cards seen were independent predictors of score; about 1,700 unique Anki cards or 445 practice questions per extra point |
Two cautions apply. Most of the laboratory work used students and short texts, not surgeons learning a fellowship syllabus. And Deng's study shows an association in one cohort: students who did more retrieval practice scored higher after adjusting for prior attainment, but that does not prove the cards caused the difference. The Larsen trial is the closest to postgraduate medicine, and it points the same way.
Why re-reading misleads you
Roediger and Karpicke's result explains the trap. Immediately after study, re-reading performs well and feels better; students who re-read were more confident they would remember. The advantage reverses within days. Recognising text on a page is not the same as producing it in a viva or at 3 a.m. on call with nothing in front of you.
The practical test is simple: close the book and try to write or say the answer. If you cannot, you did not know it, however familiar it looked.
The forgetting curve, without the myths
Much revision advice quotes precise figures, such as half of new material lost within an hour or 70 to 80% within a day or a week. Those numbers come loosely from Hermann Ebbinghaus's 19th-century experiments, in which he learned lists of nonsense syllables and measured how much faster he could relearn them later. They describe meaningless syllables, not clinical knowledge you understand and connect to other facts, and they should not be quoted as if they applied to your revision.
What has held up is the shape. Murre and Dros replicated the experiment in 2015: one subject spent 70 hours learning lists and relearning them after 20 minutes, 1 hour, 9 hours, 1 day, 2 days or 31 days, and the results were similar to Ebbinghaus's. Forgetting is steep at first and slows over time. That shape is why reviews should start close together and spread out.
Active recall for orthopaedic material
Different parts of the syllabus need different forms of retrieval.
First understanding, then testing. Read a topic once to build the framework, then close the source. Give yourself five minutes on a blank page to write everything you remember about the condition: anatomy, presentation, investigations, classification, management and complications. Then open the source and mark what you missed in a different colour. The gaps are your next session.
Anatomy and approaches. Draw them from memory: cross-sections, the internervous plane, the structures at risk. For the posterior interosseous nerve, for example, you should be able to draw the deep branch passing beneath the arcade of Frohse into supinator without looking (posterior interosseous nerve anatomy).
Classifications and imaging. Cover the answer on a radiograph or diagram and name the type, mechanism and the management that follows. Classifications are only worth memorising with their consequence attached.
Questions. A question bank is retrieval practice with feedback built in. Deng's study found question volume predicted score independently of flashcards; see how to use a question bank well and learning from your wrong answers.
Spoken answers. For vivas, read only the stem of a scenario and answer aloud as if to an examiner: differential, investigations, decision and justification. Explaining a topic in plain words, as in the Feynman technique, exposes gaps in reasoning that flashcards miss. Passing the orthopaedic viva covers the format.
How to space your reviews
Cepeda's meta-analysis gives the rule: the best gap between study sessions depends on how long you need to remember. If the exam is next week, short gaps are fine. If it is in nine months, the gaps should grow to weeks.
Doing this by hand for thousands of facts is not realistic, which is what scheduling software is for. Anki, a free desktop flashcard program, offers two schedulers. The older SM-2 algorithm adjusts each card's interval with an "ease" multiplier. FSRS (Free Spaced Repetition Scheduler) models each card's stability, difficulty and probability of recall, and schedules the next review for when that probability falls to the level you choose. The Anki manual (opens in a new tab) says FSRS can help you remember more material in the same amount of time by more accurately estimating how much you are likely to forget. OrthoVellum's own flashcards use FSRS with a target retention of 90%.
Setting up Anki
The desktop program and AnkiWeb sync are free; the official iOS app, AnkiMobile, is paid, and AnkiDroid for Android is free (Anki downloads (opens in a new tab)). The settings that matter most, from the Anki manual:
| Setting | What the manual says | What to do |
|---|---|---|
| FSRS | Supported in Anki 23.10, AnkiMobile 23.10, AnkiWeb and AnkiDroid 2.17+ | Turn it on in deck options once every device you use supports it |
| Desired retention | Default 90%; workload rises quickly above 90% and can be overwhelming above 97% | Leave at 90% for most of your preparation |
| Again versus Hard | FSRS treats Hard as a correct but effortful recall; pressing Hard when you forgot makes all intervals too long | Press Again whenever you could not produce the answer |
| Leeches | A card that lapses 8 times is tagged as a leech and suspended by default | Rewrite it, split it or add context; do not just unsuspend it |
| Backlog | If you have a backlog of overdue reviews, stop introducing new cards until you catch up | Treat new cards as the variable you cut first |
| Image occlusion | Built in from Anki 23.10 as its own note type | Use it for anatomy diagrams and labelled radiographs |
Two pieces of older advice no longer apply. "Ease hell", where SM-2 cards pressed Hard repeatedly kept coming back, is described in the manual as a problem FSRS does not have. And the add-on once needed for image occlusion is no longer required.
Writing cards that work
The card is where most people go wrong.
One fact per card. "Tell me about osteosarcoma" is not a card; you will read the answer, half-recognise it and press Good. Split it:
- What is the commonest site of osteosarcoma? Distal femur, then proximal tibia (osteosarcoma).
- Which translocation is characteristic of Ewing sarcoma? t(11;22), EWS-FLI1 (Ewing sarcoma).
- Which translocation defines synovial sarcoma? t(X;18) (synovial sarcoma).
Use cloze deletion for sentences and sequences. Hiding one or two terms in a sentence keeps the context while testing the fact. The posterior interosseous nerve passes beneath the {{c1::arcade of Frohse}} into {{c2::supinator}} gives two cards from one note.
Use image occlusion for anything visual. One diagram of a thigh cross-section or a surgical approach becomes a card for every label you hide.
Put context in the extra field, not the question. A one-line clinical consequence on the back reminds you why the fact matters without making the prompt longer.
Link every classification to its management. A card that asks which type it is should have a sibling that asks what you do about it.
Make your own cards where you can. Shared decks save time, but cards you have never understood become leeches. If you use a shared deck, suspend cards on topics you have not yet studied and unsuspend them after you have.
Mistakes that derail spaced repetition
Flipping too early. If the answer was not clear in your head before you turned the card, mark it Again. "I knew it when I saw it" is recognition.
Adding too many new cards. Each new card generates reviews for months. A large daily intake is easy in a quiet week and becomes an unmanageable queue three weeks later.
Skipping days. Missed reviews do not wait. After several days off, follow the manual's advice: stop new cards and clear the backlog first.
Building instead of reviewing. Hours spent formatting a perfect deck are hours not spent recalling it. Write plain cards quickly and fix the bad ones when they come up.
Losing the clinical picture. Cards isolate facts on purpose. A patient presents with a story, not a classification. Rebuild the context with topic reading, cases and viva practice; see understanding versus memorising in orthopaedic exams.
A routine that survives a rota
- Learn before you card. Read the topic or attend the teaching until it makes sense.
- Test the same day. A blank-page recall or a short set of questions on that topic.
- Make a few cards for the facts you missed, not for everything.
- Clear the due reviews every day, in short blocks: on the commute, between cases, before handover. Little and often matters more than a long weekend session.
- Do questions and spoken answers weekly on mixed topics, so retrieval practice covers reasoning as well as facts.
- Protect the habit when the rota is heavy. Cut new cards first; keep reviews going.
For fitting this into a full revision plan, see building a study schedule that works, and for turning your notes into material you can test yourself on, see making revision notes you'll actually use.
Frequently asked questions
What is the difference between active recall and spaced repetition?
Active recall is how you study: you produce the answer from memory before checking it, instead of re-reading. Spaced repetition is when you study: you return to the same material at gaps that lengthen as the memory strengthens. They work best together. A flashcard app does both, asking you to retrieve each answer and scheduling the next review from how well you did.
Is Anki worth using for orthopaedic exams?
For fact-heavy material such as classifications, numbers, tumour genetics and internervous planes, it is efficient. In one study of 72 medical students, unique Anki cards seen independently predicted licensing exam score after adjusting for prior performance, though the design cannot prove cause. Anki will not teach you to reason through a viva, so use it alongside question banks and spoken practice.
What desired retention should I set in Anki FSRS?
Start with the default of 90%. The Anki manual explains that higher retention means shorter intervals and more reviews, that workload rises quickly above 90%, and that above 97% it can be overwhelming. Raising retention for the last weeks before an exam is reasonable if you have the time; lowering it far below 90% means more forgetting and more relearning.
How many new flashcards should I add each day?
Fewer than you think. Every new card brings future reviews, so a large daily intake builds a backlog weeks later. The Anki manual recommends that if you have a backlog of overdue reviews, you stop introducing new cards until you catch up. Choose a number you can sustain on your busiest clinical week, not your quietest.
References
- Roediger HL, Karpicke JD. Test-enhanced learning: taking memory tests improves long-term retention. Psychol Sci 2006;17(3):249-255. DOI (opens in a new tab)
- Larsen DP, Butler AC, Roediger HL. Repeated testing improves long-term retention relative to repeated study: a randomised controlled trial. Med Educ 2009;43(12):1174-1181. DOI (opens in a new tab)
- Cepeda NJ, Pashler H, Vul E, Wixted JT, Rohrer D. Distributed practice in verbal recall tasks: a review and quantitative synthesis. Psychol Bull 2006;132(3):354-380. DOI (opens in a new tab)
- Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Improving students' learning with effective learning techniques: promising directions from cognitive and educational psychology. Psychol Sci Public Interest 2013;14(1):4-58. DOI (opens in a new tab)
- Murre JMJ, Dros J. Replication and analysis of Ebbinghaus' forgetting curve. PLoS One 2015;10(7):e0120644. DOI (opens in a new tab)
- Deng F, Gluckstein JA, Larsen DP. Student-directed retrieval practice is a predictor of medical licensing examination performance. Perspect Med Educ 2015;4(6):308-313. DOI (opens in a new tab)
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OrthoVellum Editorial Team. Active Recall and Spaced Repetition for Orthopaedic Exams [Internet]. OrthoVellum; 2025 Sep 8 [updated 2026 Oct 2; cited 2026 Nov 11]. Available from: https://www.orthovellum.com/blog/active-recall-for-surgical-exams
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Prepared by the OrthoVellum Editorial Team from cited sources, under our editorial policy.
For education and exam preparation; not medical advice or a substitute for clinical judgement and local guidance.
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