title: Introduction of a simple guideline to improve neurological assessment in paediatric patients presenting with upper limb fractures.
abstract: BACKGROUND
  Neurological examination in children presenting with upper limb fractures is often poorly performed in the Emergency Department (ED). We aimed to assess the improvement in documented neurological examination for children presenting with upper limb fractures following introduction of a simple guideline.
  
  
  METHODS
  We developed and introduced a simple guideline for upper limb neurological assessment in children ('rock, paper, scissors, OK'). We compared documentation of neurological examination and nerve injury detection at our hospital before and after introduction of this guideline, as well as for children admitted from external hospitals (where the guideline had not been introduced).
  
  
  RESULTS
  In the period following guideline introduction, 97 children with upper limb fractures were admitted (46% presenting directly to our ED and 54% admitted from external hospitals). This cohort was similar in number and distribution to the cohort reviewed prior to the guideline. Documentation of neurological examination in our ED increased from 92% to 98% after guideline introduction. Documented information on nerves examined also increased from 2% to 68% (p<0.01). Prior to the guideline, there were six nerve injuries, all of which were missed in our ED. After guideline introduction, there were four nerve injuries, all of which were detected in our ED. Documentation and nerve injury detection at external hospitals over the same time period showed no improvement.
  
  
  CONCLUSIONS
  A simple guideline to assist neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and nerve injury detection.
authors.affiliation: Orthopaedic Department, Royal Hospital for Sick Children, Yorkhill, Glasgow, Scotland.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Marsh
authors.affiliation: Orthopaedic Department, Royal Hospital for Sick Children, Yorkhill, Glasgow, Scotland.
authors.forename: James S
authors.initials: JS
authors.lastname: Robertson
authors.affiliation: Orthopaedic Department, Royal Hospital for Sick Children, Yorkhill, Glasgow, Scotland.
authors.forename: Anna
authors.initials: A
authors.lastname: Godman
authors.affiliation: Orthopaedic Department, Royal Hospital for Sick Children, Yorkhill, Glasgow, Scotland.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Boyle
authors.affiliation: Orthopaedic Department, Royal Hospital for Sick Children, Yorkhill, Glasgow, Scotland Department of Surgery, Sidra Medical and Research Centre, Doha, Qatar.
authors.forename: James S
authors.initials: JS
authors.lastname: Huntley
mesh_terms: D001134:Arm Injuries / Q000150:complications*; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence / Q000592:standards; D004282:Documentation / Q000592:standards; D004636:Emergency Service, Hospital; D005260:Female; D050723:Fractures, Bone / Q000150:complications*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D008297:Male; D009460:Neurologic Examination / Q000592:standards*; D010808:Physical Examination / Q000379:methods / Q000592:standards; D017410:Practice Guidelines as Topic; D020196:Trauma, Nervous System / Q000175:diagnosis* / Q000209:etiology
keywords: Trauma, extremity; clinical assessment, education; musculo-skeletal, fractures and dislocations; neurology, peripheral; paediatric injury