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Three Part Question

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

Clinical Scenario

A 7 year old girl presents to the emergency department complaining of pain in her left elbow, having fallen onto her outstretched hand. On examination she 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

Medline 1966-02/11 using the OVID interface
{(exp elbow joint OR elbow.mp) AND (fracture.mp) AND (exp Movement/ OR range of movement.mp. OR exp "Range of Motion, Articular"/ OR extension.mp) AND (diagno$.mp OR Examin$.mp)} LIMIT to humans and English Language

Search Outcome

109 papers found of which 3 relevant to the 3 part question and of sufficient quality.

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	145 patients with acute elbow injuries	Prospective / observational	Ability to fully extend the injured elbow in the absence of a significant injury	Sensitivity 90.7% specificity 69.5% 5 false negatives	No breakdown of results by age groups (adults Vs Children). Wide confidence intervals. No standardisation of criteria for x-ray during study period
Darracq MA et al, 2008, USA	113 patients aged 5 and above presenting to one of four emergency departments with traumatic elbow pain (those with deformity excluded) 42 aged 5-18	Diagnostic	Sensitivity	100%	Small numbers of patients particularly as recruitment over 10 months with total 150000 patients pa.
			Specificity	100%
Appelboam A et al, 2008, UK	780 Children aged 3-15 (and 960 adults) presenting with acute elbow injury to five Emergency Departments.	Prospective diagnostic	Sensitivity for fracture in children	94.6% (95% CI 90.7-97.2)
			Specificity for fracture in children	49.5% (95% CI 45.2- 53.7%)

Comment(s)

Of the three papers relevant to the three part question only the smallest shows a sensitivity high enough to qualify as a SnOut. Given the results of the larger trials it appears that an ability to extend the elbow is not good enough to rule out a fracture in children but should reduce suspicion. None of the studies describe the likely outcomes of the missed fractures using this rule.

Editor Comment

ST

Clinical Bottom Line

Ability to fully extend an injured elbow cannot reliably be used to exclude the possibility of significant injury in children following trauma.

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. Darracq MA. Vinson DR. Panacek EA. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture American Journal of Emergency Medicine. 26(7):779-82, 2008 Sep.
3. 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 337:a2428, 2008.