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Three Part Question

In [patients with traumatic elbow effusions] is [aspiration of the joint better than conservative treatment] in [reducing symptoms and time to healing]?

Clinical Scenario

A 17 year old female presents to the Emergency Department following a fall onto the right forearm. She complains of elbow pain and has a limited range of movement of that joint. X-ray reveals a moderate elbow effusion and an undisplaced fracture of the radial head (Manson type 1). You wonder whether aspirating the joint is worthwhile.

Search Strategy

Medline 1966-03/99 using the OVID interface.
[{exp elbow OR exp elbow joint OR elbow$.mp OR exp radius OR exp radius fractures OR radial head$.mp} AND {exp aspiration OR aspiration.mp OR aspirate$.mp}] LIMIT to human and english language.

Search Outcome

47 papers found of which 45 were irrelevant to the study question or of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Holdsworth BJ et al 1987 UK	80 adult patients with radial head fractures. Aspiration, bupivicaine injection and early mobilisation vs early mobilisation alone.	PRCT	Range of movement	no difference	Unblinded. Randomisation method not explicit. 14 patients lost to follow up. Measurements were taken at 2,6,12,26,and 52 weeks; it is unclear which period the results presented apply to. Grip strength data is not reported.
			Grip strength	no results reported
			Aspiration success	3/41 could not be aspirated
			Pain after aspiration	improvement reported
Dooley JF and Angus PD 1991 UK	28 adult patients with type 1 or 2 radial head fractures. Aspiration (13) vs no aspiration	PRCT	Pain	Better immediately after aspiration and at 3, and 6 months	Unblinded. Randomisation method not explicit. Small numbers. No statistical analysis. Non standard methods for measurement of outcomes.
			Range of movement	Better immediately after aspiration and at 3, and 6 months

Comment(s)

The studies relevant to this question are very poor in design and execution. A properly designed PRCT looking at pain, mobility, time to healing and harm (infection rate) is necessary to investigate this further.

Clinical Bottom Line

While aspiration may benefit patients with traumatic elbow effusions the evidence is too poor to recommend it as a routine procedure.

References

1. Holdsworth BJ, Clements DA, Rothwell PN. Fractures of the radial head - the benefit of aspiration: a prospective controlled trial. Injury 1987;18:44-47.
2. Dooley JF and Angus PD. The importance of elbow aspiration when treating radial head fractures. Arch Emerg Med 1991;8:117-121.