Neurological examination in children presenting with upper limb fractures is often poorly performed. 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 own hospital and performed a further 3 month clinical review to detect any resulting change in practice.

In the initial study period, 121 patients presented with upper limb fractures. 10 children (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients, however, none of the nerve injuries were detected on initial assessment. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’ and 2 (20%) had no documented examination.

Following introduction of the guideline, 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 (p=0.02). Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination.

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.

There is substantial concern about the state of musculoskeletal knowledge of junior doctors. There are also marked differences in the locomotor curricula of medical schools, raising the possibility that students may be selectively disadvantaged from gaining appropriate knowledge and/or attaining a musculoskeletal career path. The aims of this study were to assess the musculoskeletal knowledge of newly qualified doctors in the south of Scotland, and to compare this between the two medical schools (Glasgow and Edinburgh) that have different locomotor teaching programmes.

All final year medical students, from Glasgow and Edinburgh Universities (n=158 and 221, respectively), attending the compulsory ‘Preparation for Practice’ lecture course immediately after (Glasgow) or before (Edinburgh) final exams, were assessed by the Freedman and Bernstein musculoskeletal examination, previously validated with two different pass-standards: (i) 73.1% (by orthopaedic surgeons), and (ii) 70% (by physicians).

There was a significant difference (Wilcoxon two sample test; p<0.5×10⁻⁹) in the marks obtained at the two institutions, the median being 59% (IQR 50–67%) and 68% (IQR 60–76%) at Glasgow and Edinburgh respectively. The pass-rates for the two institutions (Glasgow vs. Edinburgh) were markedly different, being 17.1% vs. 32.6% for the higher pass-mark, and 21.5% vs. 48% for the lower.

The majority of newly qualified doctors in the south of Scotland have inadequate musculoskeletal knowledge. There is a substantial and statistically significant difference in the scores attained by students from two neighbouring medical schools (Glasgow and Edinburgh). The striking difference in the pass-rates can be best explained by differences in respective musculoskeletal courses. These explicit and comparative deficits raise substantial questions for musculoskeletal curriculum planning, teaching, assessment and quality assurance.