Published 9 December 2008, doi:10.1136/bmj.a2428
Cite this as: BMJ 2008;337:a2428

Research

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

A Appelboam, consultant emergency physician1, A D Reuben, consultant emergency physician1, J R Benger, consultant emergency physician2, F Beech, specialist registrar3, J Dutson, specialist registrar4, S Haig, specialist registrar3, I Higginson, consultant emergency physician2, J A Klein, specialist registrar5, S Le Roux, specialist registrar6, S S M Saranga, specialist registrar6, R Taylor, consultant emergency physician1, J Vickery, emergency nurse practitioner1, R J Powell, statistician7, G Lloyd, consultant emergency physician1

1 Emergency Department, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW, 2 Emergency Department, United Bristol Healthcare NHS Trust, Bristol BS2 8HW, 3 Emergency Department, Bath Royal United Hospital NHS Trust, Bath BA1 3NG, 4 Emergency Department, Bristol Royal Infirmary, United Bristol Healthcare NHS Trust, Bristol BS1, 5 Emergency Department, Musgrove Park Hospital, Taunton and Somerset NHS Trust, Taunton TA1 5DA, 6 Emergency Department, Bristol Children’s Hospital, United Bristol Healthcare NHS Trust, Bristol BS3 8BJ, 7 Research and Development Support Unit, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW

Correspondence to: G Lloyd gavin.lloyd{at}rdeft.nhs.uk

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.


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This article has been cited by other articles:

  • (2009). Inability to Extend the Elbow After Acute Injury Predicts Fracture. JWatch Emergency Med. 2009: 2-2 [Full text]  
  • (2009). Elbow-Extension Test Is Useful for Ruling Out Elbow Fracture. JWatch General 2009: 5-5 [Full text]  
  • Mackway-Jones, K. (2008). The rational clinical examination in emergency care. BMJ 337: a2374-a2374 [Full text]  

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