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Three Part Question

In [adults with elbow injuries] does [ability to fully extend the injured limb] exclude the possibility of [significant injury]?

Clinical Scenario

A 35 year old man presents to the emergency department complaining of pain in his left elbow, having fallen onto his outstretched hand. On examination he can fully extend the elbow on the affected side. You have heard that full elbow extension can be used as a 'rule-out' tool for significant injury and you wonder whether there is any value in obtaining an x-ray.

Search Strategy

Ovid MEDLINE from 1950 to July week 2 2010.


((elbow adj3 injur$).mp OR (elbow adj3 fracture$).mp OR (olecranon adj3 fracture$).mp OR (trochlea$ adj3 fracture$).mp OR (radi$ adj3 fracture$).mp) AND (extension.mp OR extend.mp). LIMIT to English language and humans.

Search Outcome

Three hundred and seventy papers were obtained, of which five were relevant to the three-part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hawksworth CR, Freeland P, 1991, Scotland	100 Patients with acute elbow injuries who the attending doctor felt to require an x-ray	Prospective / observational	Ability to extend elbow fully. Gold standard was x-rays reported by a consultant radiologist blind to the clinical findings	54 Patients were felt to have a significant injury on x-ray assessment (fracture or effusion or both). Sensitivity of the extension test was 90.7% and specificity was 69.5%	Gold standard provided by single radiologist
Docherty MA et al, 2002, USA	114 adults (>14 years) with acute elbow injuries. Four did not have x-rays and thus were excluded from the analysis	Prospective / observational	Ability to extend elbow fully. Gold standard consisted of a radiologist's opinion while blinded to clinical findings	38 Patients were felt to have a bone/joint injury on the x-ray. The sensitivity of the extension test was 97.3% with a specificity of 69.4%	Gold standard provided by on-call radiologist
Lennon RI et al, 2007, UK	407 Patients attending a single hospital with acute elbow injuries. All patients felt to require an x-ray by the attending practitioner were included (n=331)	Prospective observational study	Ability to fully extend elbow was assessed, as was the ability to full flex, supinate and pronate the elbow. Gold standard was the radiology report, not clear if blinded	183 Patients had an abnormal x-ray. Sensitivity of the extension test was 91.6% and specificity was 47.8%. (Reported the opposite way round as authors have defined a normal test as a positive finding)	Gold standard of radiology report. Possible selection bias
Lamprakis et al, 2007, Greece	70 Patients attending an emergency department with an acute elbow injury were included	Prospective observational study	Ability to extend elbow fully with the arm in a supine position. Gold standard was the x-ray report by a consultant radiologist blinded to the clinical findings	24 Patients had an abnormal x-ray. The sensitivity of the elbow extension test was 92% and the specificity was 61%	Gold standard of radiologist report
Darracq et al, 2008, USA	113 Patients aged ≥5 years presenting within 24 h of an elbow injury were included. Exclusion criteria included obvious deformities suggesting fracture or dislocation. Convenience sample	Observational study	Ability to extend elbow fully. Gold standard was the presence of fracture or effusion on x-ray as reported by blinded radiologist. Patients followed up for 3 months post-recruitment	53 Patients had a fracture or effusion on x-ray. Sensitivity and specificity for full elbow extension were both 100%	Convenience sampling may lead to selection bias
Appelboam et al, 2008, UK	1740 Patients aged ≥3 years presenting within 72 h of elbow injury were included. (Four lost to follow up)	Validation study in adult patients (>15 years) and observational study in children (3–15 years). Adults who could fully extend their elbow did not receive an x-ray, children received an x-ray at the discretion of the treating practitioner	Reference standard consisted of final discharge diagnosis from orthopaedic clinic, formal blinded radiology report and 7–10 day telephone interview for patients not followed up	538 Patients had a fracture on x-ray. Sensitivity for full extension was 96.8% and sensitivity was 48.5%. For fracture or effusion sensitivity of the test was 95.8% and specificity 54.6%	Variable reference standard

Comment(s)

There are now several studies incorporating over 2500 patients examining the role of the extension test as a method of ruling out fracture in elbow injuries. The sensitivity values range from 92% to 100% and certainly suggest that this technique could be applied with only a small risk of missing a fracture. The injuries missed by this examination technique also tended to be minor ones that would usually be managed conservatively. On the other hand, the risks to the patient from the radiation exposure from an elbow x-ray are minimal, so the main savings by reducing the number of x-rays for this condition are time and money rather than any clinical benefit. Given the high sensitivity and specificity of x-rays as a diagnostic tool and the fact that it is rapidly accessible, safe and reasonably cheap, a clinical test to avoid x-ray is only acceptable if the sensitivity is very close to 100%.

Editor Comment

This BET report was written by the authors before they published their own paper on the subject.

Clinical Bottom Line

It would be reasonable to incorporate an attempt at full extension as part of the examination of a patient with an acute elbow injury, and the high sensitivity of this component should be borne in mind when deciding whether or not to send the patient for x-ray. However, it cannot be recommended as an isolated method for ruling out fractures by clinical examination.

References

1. Hawksworth CR, Freeland P. Inability to fully extend the injured elbow: an indicator of significant injury. Arch Emerg Med 1991;8(4):253-256.
2. Docherty MA, Schwab RA, John O. Can elbow extension be used as a test of a clinically significant elbow injury? South Med J 2002;95(5):539-541.
3. Lennon RI, Riyat MS, Hilliam R, et al. Can a normal range of elbow movement predict a normal elbow x ray? Emerg Med J 2007;24:86–8.
4. Lamprakis A, Vlasis K, Siampou E, et al. Can elbow-extension test be used as an alternative to radiographs in primary care?. Eur J Gen Pract 2007;13:221–4.
5. Darracq MA, Vinson DR, Panacek EA. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture. Am Emerg Med 2008;26:779–82.
6. Appelboam A, Reuben AD, Benger JR, et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ 2008;337:a2428.