Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment.

We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our hospital and performed a further 3 month review to detect resulting changes in practice.

In the initial study period, 121 children presented with upper limb fractures. 10 (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients. However, information on nerves examined was only recorded in 5 (5%) with the majority (85%) documented as ‘neurovascuarly intact’. None of the nerve injuries were detected on initial assessment.

Following guideline introduction, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (Fisher's Exact Test, p=0.02) with details of nerves examined increasing to 69%. Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination.

The recent British Orthopaedic Association Standards for Trauma (BOAST) guideline on peripheral nerve injuries emphasises the importance of clearly recorded neurological assessment in trauma patients. Our study shows that introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries.

A retrospective analysis was carried out to determine the influence of pre-existing spinal pathology on the outcome of Total Knee Replacement surgery. Data was collected from 345 patients who had undergone Total Knee Replacement, at four centres in the UK, between 2000 and 2007. Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 questionnaires were recorded prospectively. Data was collected pre-operatively and then post-operatively at 3 months, 1 year and 2 years. Patients were divided into those with (n=40) and without a history of low back pain (n=305). In addition to determining the influence of low back pain on outcome after Total Knee Replacement we also examined the influence of concomitant hip and ankle pathology in the same cohort of patients.

OKS scores were significantly worse for patients with symptomatic low back pain at 3 (p=0.05), 12 (p=0.009) and 24 months (p=0.039) following surgery. SF-12 physical scores followed a comparable pattern with significance demonstrated at 3 (p=0.038), 12 (p=0.0002) and 24 months (p=0.016). AKSS followed a similar pattern, but significance was only reached at 1 year (p=0.013). The mental component of the SF-12 measure demonstrated a significant improvement in patients' mental health post-operatively for patients with no history of low back pain. In contrast patients with low back pain showed no improvement in mental health scores post-operatively.

In contrast to low back pain, hip and ankle pathology had no statistically significant detrimental effect on the outcome of Total Knee Replacement surgery.

This study demonstrates that low back pain significantly affects the functional outcome after Total Knee Replacement surgery and that patients with low back pain show no improvement in mental health post-operatively.

Neurological examination is essential in patients with upper limb injuries and should be clearly documented. We aimed to assess the quality and documentation of neurological examination performed for children presenting with upper limb fractures to the emergency department.

Clinical notes of all children admitted with upper limb fractures over a three month period were reviewed. Documentation of initial neurological assessment was analysed and clinical suspicion of any nerve injury noted. In parallel, we conducted an anonymous survey of emergency doctors evaluating their upper limb neurological examination in children.

The casenotes of 121 children with upper limb fractures were reviewed. 10 children (8%) had a nerve injury (median = 4, ulnar = 2, radial = 2, anterior interosseous = 2). Neurological examination was documented in 107 (88%) of patients. However, none of the nerve injuries were detected on initial examination. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’, 2 (20%) as ‘CSM normal’, 1 (10%) as ‘moving fingers’ and 2 (20%) had no documented neurological examination.

30 emergency doctors completed the questionnaires (5 consultants, 9 registrars, 16 foundation doctors). All doctors stated that they routinely performed an upper limb neurological examination and assessed median, ulnar and radial nerves. However, 30% of doctors described incomplete examination of median nerve function, 30% inadequate ulnar nerve assessment and 50% incomplete radial nerve examination. In addition, 75% of doctors failed to identify the need for assessment of anterior interosseous nerve function.

While emergency doctors recognise the importance of neurological assessment in children with upper limb injuries, it is often performed inadequately. This in part may be due to difficulties performing neurological examination in paediatric patients. As a result of this study, we have introduced local guidelines to assist neurological assessment in children.