Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial

Abstract

Purpose:

Pediatric supracondylar humerus fractures frequently involve nerve injuries, which can be difficult to assess before and after surgery. This study evaluated a smartphone application that teaches nerve examination to children using a rock–paper–scissors–OK game, and assessed its effects on examination time and satisfaction.

Methods:

In this single-center, prospective randomized controlled study, 102 children aged 4–10 years who underwent surgical treatment were randomized into 2 groups. Group 1 learned nerve examination through the classical method taught by orthopedic residents and a specialist. Group 2 was taught using the smartphone application with the game. Pre- and postoperative nerve examination times were recorded. Child and parent satisfaction were measured with the Child HCAHPS questionnaire.

Results:

Mean preoperative examination time was shorter in group 1 (4.3 ± 1.3 min) (p = 0.036), while postoperative time was shorter in group 2 (12.2 ± 2.4 min; p = 0.041). Although the app-based method took longer preoperatively, children in group 2 adapted better, enabling faster postoperative assessments. Agitation, crying, and noncompliance were less frequent in the game-assisted group. Satisfaction scores were higher in group 2 for “Communication with Doctors” (p = 0.032) and “Keeping You Informed” (p = 0.041), with no differences in other domains. Temporary nerve deficits occurred at similar rates and resolved spontaneously in all cases.

Conclusions:

A smartphone-based rock–paper–scissors–OK game improves postoperative nerve examination efficiency and increases satisfaction, particularly regarding communication and information sharing.

Level of evidence:

Level II.

Trial registration:

ClinicalTrials.gov identifier NCT07480798; retrospectively registered on 16 March 2026, after study initiation on 13 March 2024(Supplemental Material 1).

Introduction

Nerve lesions following supracondylar humerus fractures are common complications that may occur both at the time of injury and during surgical treatment. ¹ The median, radial, ulnar, and anterior interosseous nerves can each be affected through different mechanisms of injury. ² The cornerstone of diagnosing these nerve injuries is a thorough neurovascular examination. However, performing this examination can be challenging in children aged 4–8 years, both preoperatively and postoperatively, due to difficulties in communication and cooperation. ³

To overcome these challenges, non-pharmacological strategies including distraction techniques, play therapy, and behavioral interventions have been increasingly utilized in pediatric care. Several studies have demonstrated that such approaches reduce anxiety, improve cooperation, and enhance the overall quality of pediatric medical examinations and procedures^4,5

Davidson ⁶ first described the use of the rock–paper–scissors game as a tool for neurological assessment of the forearm and hand.

In this game-based framework, the act of making a fist (rock) in pronation evaluates combined function of the median, anterior interosseous, and ulnar nerves; the paper position with wrist extension and finger abduction/extension tests radial and ulnar nerve function; the scissors gesture adduction and abduction of the index and middle fingers with flexion of the ring and little fingers assesses the ulnar nerve; and the “OK” sign tests the anterior interosseous nerve. ⁷ Thus, the entire neurological examination of the hand and forearm for initial assessment can be structured as a playful, child-friendly sequence of rock, paper, scissors, and OK gestures.

Given the communication barriers and anxiety often encountered in pediatric trauma settings, this approach may facilitate cooperation, reduce examination duration, and improve the physician–patient relationship. Among various tools used to assess patient satisfaction, the Child HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) questionnaire is one of the most validated and reliable instruments in pediatric populations. ⁸

We hypothesized that the game-based smartphone approach would facilitate neurological assessment in children compared with the conventional method. The primary aim was to compare neurological examination time, and the secondary aim was to assess child and parent satisfaction with care.

Materials and methods

This prospective, randomized controlled trial was conducted at a single level 1 trauma center between March 2024 and April 2025 and was retrospectively registered at ClinicalTrials.gov (NCT07480798) on 16 March 2026. Randomization was performed using a computer-generated simple random sequence (1:1 allocation) with no blocking or stratification, generated in advance by an independent statistician; allocation was concealed using sequentially numbered, opaque, sealed envelopes. The trial was single-masked with blinding of the outcome assessor. Blinding of participants and clinicians was not feasible because of the nature of the intervention (conventional versus game-based teaching). Outcomes were recorded by a blinded assessor using standardized procedures in both groups. Children aged 4–10 years with supracondylar humerus fractures requiring surgical treatment were eligible. Written informed consent was obtained from a parent/guardian (and assent from the child when appropriate) prior to enrollment. Patients who were unable to follow commands or cooperate sufficiently to perform the rock–paper–scissors–OK maneuvers required for the game-based assessment, or who did not agree to participate, were excluded.

All eligible patients presenting to the emergency department and not suitable for conservative management were invited to participate. Informed consent was obtained from the parents or legal guardians of all participants. Neurological examinations were performed by three orthopedic physicians to minimize interobserver error: an orthopedic resident (PGY-2) in the emergency department, a senior resident (PGY-4) in the operating room during preoperative evaluation, and an orthopedic specialist postoperatively.

Although several external factors may affect examination timing, such as consultation delays, anesthetic recovery times, or transport within the hospital, the primary aim of this study was to determine whether teaching the neurological examination via video and game could reduce total examination time and enhance patient satisfaction, despite these variables.

Preoperative neurological examinations were performed upon the patient’s arrival to the emergency department, and examination duration was measured from initiation to completion of all test movements. Inability to perform specific movements and any neurological deficits were documented.

In the control group, the examination was explained and performed using the classical approach: wrist and finger extension were used to assess the radial nerve, finger adduction and abduction to evaluate the ulnar nerve, fist formation to assess median nerve function, and the OK (ring) sign formed by apposing the thumb and index finger to create a circle to assess anterior interosseous nerve function.

In the experimental group, the neurological examination was conducted using a smartphone application featuring a YouTube-hosted video of the rock–paper–scissors–OK game. Parents were instructed to scan a QR code to access the video (Supplemental Material 3). After viewing, children were guided through the same sequence of gestures, with the “OK” sign indicating completion of the examination. function. Neurological examination instructions were delivered via a publicly available YouTube video (https://www.youtube.com/watch?v=gfcZslLIjAM); none of the authors created, owned, or received any financial benefit from this content.

Preoperative neurological examination time was measured in the emergency department after the diagnosis of supracondylar humerus fracture was established and the patient was evaluated by an orthopedic physician. In group 1 (conventional method), timing started when the examiner began demonstrating and instructing the required movements for neurological assessment and stopped when the examination was completed. In group 2 (game-based method), an instructional video was viewed via a QR code; timing started immediately after the video ended and included brief in-person demonstration/instruction of the movements before playing the rock–paper–scissors–OK game, and stopped when the examination was completed. In both groups, the time spent by the examiner explaining and demonstrating the movements was included in the recorded duration; however, the video-viewing time was excluded.

Postoperative neurological examination time was measured in the recovery room. Timing started when the orthopedic physician initiated the neurological assessment (including brief instruction/demonstration as needed) and stopped upon completion. In group 1, children were asked to repeat the same movements used preoperatively, whereas in group 2, the rock–paper–scissors–OK game was repeated.

All patients subsequently underwent surgical fixation under general anesthesia in the supine position using fluoroscopy. Closed reduction and percutaneous fixation were achieved using two lateral and one medial Kirschner wire. In cases where closed reduction was unsuccessful, open reduction via an anterior approach was performed, followed by similar fixation.

Patient and parent satisfaction were assessed using the Child HCAHPS questionnaire before discharge. This validated survey, developed by the U.S. Agency for Healthcare Research and Quality, evaluates communication, safety, environment, and overall care experience for hospitalized pediatric patients aged 4–10 years.

All data were collected by the same orthopedic resident according to standardized protocols. Statistical analysis was performed using the Shapiro–Wilk test for normality. Continuous variables were expressed as mean ± standard deviation (SD) or median (min–max) as appropriate, and categorical variables as frequency and percentage. Group comparisons were conducted using the independent-sample t-test or Mann–Whitney U test for continuous data and Pearson’s chi-square or Fisher’s exact test for categorical variables. Statistical significance was set at p < 0.05. All analyses were performed according to the intention-to-treat principle, including all randomized participants in the groups to which they were allocated.

An a priori power analysis based on the primary outcome, postoperative neurological examination time (minutes), indicated that a minimum of 45 participants per group was required to detect a moderate standardized effect size (Cohen’s d = 0.5) with 80% power (1 − β = 0.80) and a two-sided α = 0.05.

Results

A total of 102 patients meeting the inclusion criteria were enrolled in the study, with 51 in group 1 (classical method) and 51 in group 2 (video-assisted rock–paper–scissors–OK method; Figure 1).

Figure 1.

Flow diagram.

In group 1, 28 patients (54.9%) were male and 23 (45.1%) female; in group 2, 22 (43.1%) were male and 29 (56.9%) female. The mean age was 6.81 ± 1.45 years (range: 4–10) in group 1 and 7.19 ± 1.54 years (range: 4–10) in group 2, showing no statistically significant difference between groups (p > 0.05). Mechanisms of injury included simple falls, falls from bicycles, and falls from height, with comparable distributions between the groups (Table 1).

Table 1.

Demographic characteristics of the study groups.

Characteristic	Group 1 (classical method, n = 51)	Group 2 (video-assisted, n = 51)
Male, n (%)	28 (54.9)	22 (43.1)
Female, n (%)	23 (45.1)	29 (56.9)
Age (years), mean ± SD	6.81 ± 1.45	7.19 ± 1.54
Age range (years)	4–10	4–10
Nerve injury, n (%)	4 (7.8)	3 (5.8)

SD: standard deviation.

The mean preoperative nerve examination time was 4.30 ± 1.28 min (range: 2–7) in group 1 and 7.28 ± 2.28 min (range: 4–11) in group 2 (p = 0.036). Conversely, the postoperative examination time was 15.14 ± 3.04 min (range: 10–23) in group 1 and 12.19 ± 2.44 min (range: 7–14) in group 2 (p = 0.041). Thus, while preoperative evaluations were significantly shorter in the classical group, postoperative evaluations were significantly shorter in the video-assisted game group (Table 2).

Table 2.

Nerve examination time by group and period (mean ± SD).

Period	Group 1 (classical)	Group 2 (video-assisted)	p-Value
Preoperative	4.30 ± 1.28 (range: 2–7)	7.28 ± 2.28 (range: 4–11)	0.036
Postoperative	15.14 ± 3.04 (range: 10–23)	12.19 ± 2.44 (range: 7–14)	0.041

Values expressed as mean ± SD. p < 0.05 indicates statistical significance. SD: standard deviation.

Patients in the classical examination group demonstrated higher rates of agitation, crying, and non-cooperation, particularly during postoperative evaluations. In contrast, children in the video-assisted group exhibited better engagement and compliance. According to the Child HCAHPS questionnaire, significant improvements were observed in the subcategories of “Communication with Doctors” (p = 0.032) and “Keeping You Informed” (p = 0.041) in Group 2. No significant differences were noted in the other domains, including “Communication with Nurses,” “Attention to Safety and Comfort,” “Hospital Environment,” “Communication about Medicines,” or “Discharge Information” (all p > 0.05). Likewise, overall hospital rating and willingness to recommend did not differ significantly between groups (p = 0.219 and p = 0.408, respectively; Figure 2).

Figure 2.

Box plot comparison of child HCAHPS questionnaire domains between the classical and video-assisted groups. Significant improvements were observed in “Communication with Doctors” (p = 0.032) and “Keeping You Informed” (p = 0.041) in the video-assisted group.

Transient postoperative ulnar nerve deficits were observed in three patients (6.1%) in group 1 and two patients (3.8%) in group 2; in all cases, deficits resolved spontaneously after removal of medial Kirschner wires. Radial nerve deficits were detected preoperatively in one patient from each group (2.0% and 1.9%, respectively), all of which resolved spontaneously during follow-up.

Discussion

This randomized controlled trial evaluated a play-based neurological assessment method (the rock–paper–scissors–OK game) to facilitate nerve examination in pediatric patients undergoing surgical treatment for supracondylar humerus fractures. The primary aim was to determine whether the game-based approach reduces postoperative neurological examination time compared with the conventional method, and the secondary aim was to assess child and parent satisfaction with care. Our findings showed that the game-based approach was associated with shorter postoperative examination times and higher satisfaction scores, particularly in domains related to communication and information sharing.

The neurological examination of young children poses considerable challenges, especially in the perioperative period, due to anxiety, fear, and limited communication abilities. The rock–paper–scissors–OK method offers a simple, standardized, and child-friendly approach that transforms a potentially distressing assessment into an engaging interaction. The combination of visual and motor learning through a smartphone application was effective in improving understanding and participation among pediatric patients.

Previous studies have emphasized that play-based interventions and behavioral engagement techniques can alleviate fear, improve compliance, and increase cooperation during pediatric medical examinations.^9,10 The use of a familiar and universally understood game, such as rock–paper–scissors, facilitates the demonstration of key motor functions corresponding to major upper limb nerves. The addition of the “OK” sign further enhances its diagnostic scope by including the anterior interosseous nerve. The present study reinforces prior findings suggesting that structured play not only enhances clinical communication but also contributes to more accurate and efficient examinations.^11–13

The Child HCAHPS results in our study confirmed that improved communication and patient engagement were reflected in higher satisfaction scores. Prior literature consistently supports that effective physician-family communication is a major determinant of satisfaction in pediatric healthcare settings.^14–16 Integrating playful, interactive methods such as the rock–paper–scissors–OK game appears to bridge communication gaps and foster a more positive doctor-patient relationship.

The introduction of smartphone-based video instruction provided a consistent, repeatable, and accessible training method for both patients and parents. This aligns with current trends in pediatric healthcare emphasizing digital education tools to enhance understanding, reduce procedural anxiety, and standardize patient preparation.^17,18 Mobile-assisted instruction likely contributed to the improved postoperative outcomes observed in our study by reducing uncertainty and promoting familiarity with examination steps before surgery.

Nonetheless, this study has several limitations. Firstly, this method serves as a rapid and straightforward screening tool that provides an initial assessment of potential injuries to the major peripheral nerves of the upper limb, including the median (and anterior interosseous), ulnar, and radial nerves. Although useful as an initial screening test, any abnormal findings should prompt a comprehensive and targeted neurological assessment, since certain wrist and finger flexor muscles receive dual innervation from both the ulnar and anterior interosseous nerves in addition to the median nerve. Being a single-center trial limits generalizability. Variability in factors such as anesthesia recovery time and staff efficiency may have influenced examination duration. Moreover, individual differences in patient temperament, mental status, and socioeconomic background could have affected engagement and satisfaction levels. Despite these constraints, the randomized controlled design and standardized assessment protocol strengthen the validity of the findings. While our findings support the feasibility and acceptability of the game-based smartphone approach and suggest improved postoperative examination efficiency, this trial was not powered to establish measurement validity (e.g., diagnostic accuracy or agreement with a reference standard). Therefore, conclusions should be limited to acceptability and potential workflow benefit, and larger validation studies are needed.

Conclusion

The rock–paper–scissors–OK game, delivered via a smartphone-based instructional video, may be a feasible play-based approach to support neurological examination in pediatric patients with supracondylar humerus fractures. In this trial, the game-based approach was associated with shorter postoperative examination times and higher satisfaction scores in the “Communication with Doctors” and “Keeping You Informed” domains. Larger studies are needed to further evaluate effectiveness and measurement validity.

Supplemental Material

sj-pdf-1-cho-10.1177_18632521261466900 – Supplemental material for Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial

Supplemental material, sj-pdf-1-cho-10.1177_18632521261466900 for Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial by Tahsin Aydin, Fatih Inci, Muhammed Kilic, Nihat Yigit, Yakup Kahve and Erman Ceyhan in Journal of Children's Orthopaedics

Supplemental Material

sj-pdf-2-cho-10.1177_18632521261466900 – Supplemental material for Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial

Supplemental material, sj-pdf-2-cho-10.1177_18632521261466900 for Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial by Tahsin Aydin, Fatih Inci, Muhammed Kilic, Nihat Yigit, Yakup Kahve and Erman Ceyhan in Journal of Children's Orthopaedics

Supplemental Material

sj-pdf-3-cho-10.1177_18632521261466900 – Supplemental material for Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial

Supplemental material, sj-pdf-3-cho-10.1177_18632521261466900 for Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial by Tahsin Aydin, Fatih Inci, Muhammed Kilic, Nihat Yigit, Yakup Kahve and Erman Ceyhan in Journal of Children's Orthopaedics

Supplemental Material

sj-png-1-cho-10.1177_18632521261466900 – Supplemental material for Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial

Supplemental material, sj-png-1-cho-10.1177_18632521261466900 for Rock–paper–scissors–OK game for neurological examination in pediatric supracondylar humerus fractures: A prospective randomized controlled trial by Tahsin Aydin, Fatih Inci, Muhammed Kilic, Nihat Yigit, Yakup Kahve and Erman Ceyhan in Journal of Children's Orthopaedics