Diagnostic accuracy of clinical tests to rule out elbow fracture: a systematic review

Abstract

Background: Elbow traumas represent a relatively common condition in clinical practice. However, there is a lack of evidence regarding the most accurate tests for screening these potentially serious conditions and excluding elbow fractures. The purpose of this investigation was to analyze the literature concerning the diagnostic accuracy of clinical tests for the detection or exclusion of suspected elbow fractures.Methods: A systematic review was performed using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines. Literature databases including PubMed, Cumulative Index to Nursing and Allied Health Literature, Diagnostic Test Accuracy, Cochrane, the Web of Science, and ScienceDirect were searched for diagnostic accuracy studies of subjects with suspected traumatic elbow fracture investigating clinical tests compared to imaging reference tests. The risk of bias in each study was assessed independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies 2 checklist.Results: Twelve studies (n=4,485 patients) were included. Three different types of index tests were extracted. In adults, these tests were very sensitive, with values up to 98.6% (95% confidence interval [CI], 95.0–99.8). The specificity was very variable, ranging from 24.0% (95% CI, 19.0–30.0) to 69.4% (95% CI, 57.3–79.5). The applicability of these tests was very high, while overall studies showed a medium risk of bias.Conclusions: Elbow full rom test, elbow extension test, and elbow extension and point tenderness test appear to be useful in the presence of a negative test to exclude fracture in a majority of cases. The specificity of all tests, however, does not allow us to draw useful conclusions because there was a great variability of results obtained.

Clinical tests to evaluate for elbow fracture

“…This systematic review 8 found several clinical tests for the evaluation of elbow fracture to be useful. The studies included in the systematic review were performed in the emergency department setting, and all tests are easy to perform and reproducible, making them important components of the evaluation particularly in settings where imaging is not readily available.…”

“…Five studies evaluated diagnostic accuracy of index tests in patients > 16 years, and seven in patients < 14–16 years. Physicians or nurses performed tests in all studies, and most studies did not provide training on how to perform the clinical tests 8 . The quality of the included trials was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS‐2) checklist.…”

“…Fracture was defined as a bony tissue disruption of the radius proximal epiphysis, ulna proximal epiphysis, or humerus distal epiphysis after a trauma. Studies reported diagnostic accuracy including sensitivity, specificity, and likelihood ratios (LR–, LR+) 8 …”

“…4,5 Recent studies, however, have evaluated several physical examination findings that may assist in determining the need for any imaging among patients with suspected elbow fracture. 6,7 This systematic review discussed here 8 included studies enrolling patients presenting with a suspected elbow fracture and comparing one or more clinical tests to x-ray. The systematic review excluded studies that used complex technological equipment not available for everyday clinical use (e.g., dynamometers); those performing the index test on a cadaver, during or after surgery, or under anesthesia; and studies including patients with severe polytrauma and/or temporary loss of consciousness that did not allow investigators to perform the index test.…”

“…Studies reported diagnostic accuracy including sensitivity, specificity, and likelihood ratios (LR-, LR+). 8 The systematic review identified 12 relevant studies (n = 4485).…”