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Inability to Extend the Elbow After Acute Injury Predicts Fracture

Full extension of the elbow can help rule out fracture and avoid unnecessary radiography.

The elbow extension test compares a patient’s ability to extend elbows on both sides while the arms are supinated and the shoulders are flexed to 90 degrees. Investigators prospectively examined the utility of the test for predicting fracture in 960 adults (age range, 16–94) and 780 children (age range, 3–15 years) who presented to five emergency departments in England with acute, isolated elbow injuries.

Adult patients with full extension did not undergo radiography; children underwent radiography at the discretion of the treating physician regardless of test results. Patients who did not undergo radiography were followed up by telephone assessment at 7 to 10 days, and those who met predefined criteria were recalled for radiography. Among 311 adults and 287 children with full extension, 17 fractures were detected: 5 in adults (2 undisplaced radial head, 1 undisplaced radial neck, and 2 olecranon fractures) and 12 in children (4 undisplaced radial head, 5 undisplaced radial neck, and 3 undisplaced supracondylar fractures). The two adult patients with olecranon fractures underwent surgical repair. Among patients with incomplete elbow extension, fractures were detected in 48% of adults and 43% of children. Overall, the elbow extension test had a sensitivity of 97% and a specificity of 49% for detecting elbow fracture. Full elbow extension had a negative predictive value for fracture of 98% in adults and 96% in children. An editorialist opines, "We should start to view emergency medical practice more as a means of managing risk rather than of making a diagnosis."

Comment: Although decision rules can help to avoid unnecessary resource use, no algorithm is 100% accurate. Clinical judgment is not infallible either, and we can’t obtain x-rays for every patient. The elbow extension test performs well, and its use as a decision maker in the ED makes sense. However, we must carefully manage expectations of patients and parents by communicating that a single test result cannot eliminate the chance of fracture and that failure of symptoms to improve or resolve within a few days should prompt follow-up evaluation.

— Kristi L. Koenig, MD, FACEP

Published in Journal Watch Emergency Medicine January 23, 2009

Citation(s):

Appelboam A 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 Dec 9; 337:a2428. (http://dx.doi.org/10.1136/bmj.a2428)

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Mackway-Jones K. The rational clinical examination in emergency care. BMJ 2008 Dec 15; 337:a2374. (http://dx.doi.org/10.1136/bmj.a2374)

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