Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children

Abstract

Objective To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. Design Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. Setting Five emergency departments in southwest England. Participants 2127 adults and children presenting to the emergency department with acute elbow injury. Intervention Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. Main outcome measures Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. Results Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. Conclusion The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

Does preservation of active range of motion after acute elbow injury rule out the need for the radiography?

“…However, the addition of point tenderness at the olecranon, epicondyles and radial head did not improve the sensitivity or specificity of the active ROM maneuvers in the detection of elbow fractures. [10][11][12] In our study, patients with partial limitation in one or two movements had no sign of fractures on the Xray. However, almost all patients with fracture had limited range in all movements.…”

“…Several studies have shown the sensitivity of elbow ROM in detecting fracture (92% in the study of Lamprakis et al, [13] 96.8% in the large study by Appelboam [12] and 100% in the study of Darracq [10] ).…”

“…In the literature, linear fracture of the head of the radius [1,[10][11][12] and fracture of the olecranon [10][11][12] were two injuries observed in patients with normal ROM. However, the addition of point tenderness at the olecranon, epicondyles and radial head did not improve the sensitivity or specificity of the active ROM maneuvers in the detection of elbow fractures.…”

“…[1,10] Studies which relied only on full extension had lower specificity (69.4% and 48.5% in the studies of Docherty and Appelboam, respectively). [12,14] The active ROM is an easy test to perform in the ED and has been proven to be sensitive. Thus, the elbow clinical examination could help clinicians to efficiently use radiography for injured patients.…”

“…[1,[11][12][13] In several studies, the patient's ability to fully extend the elbow was suggested as a sensitive clinical screening test for patients with elbow injuries or in situations in which radiology facilities were lacking. [1,[11][12][13][14] In this study, we evaluated the role of a normal elbow active ROM following acute trauma as the predictor of low risk fracture with no need for further radiography. We hypothesized that maintaining full ROM of elbow in all movements (flexion, extension, supination, pronation) after trauma demonstrated low fracture risk in patients and that X-ray radiographs for every patient may not be required.…”