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

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

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2428 (Published 09 December 2008) Cite this as: BMJ 2008;337:a2428
  1. A Appelboam, consultant emergency physician1,
  2. A D Reuben, consultant emergency physician1,
  3. J R Benger, consultant emergency physician2,
  4. F Beech, specialist registrar3,
  5. J Dutson, specialist registrar4,
  6. S Haig, specialist registrar3,
  7. I Higginson, consultant emergency physician2,
  8. J A Klein, specialist registrar5,
  9. S Le Roux, specialist registrar6,
  10. S S M Saranga, specialist registrar6,
  11. R Taylor, consultant emergency physician1,
  12. J Vickery, emergency nurse practitioner1,
  13. R J Powell, statistician7,
  14. G Lloyd, consultant emergency physician1
  1. 1Emergency Department, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW
  2. 2Emergency Department, United Bristol Healthcare NHS Trust, Bristol BS2 8HW
  3. 3Emergency Department, Bath Royal United Hospital NHS Trust, Bath BA1 3NG
  4. 4Emergency Department, Bristol Royal Infirmary, United Bristol Healthcare NHS Trust, Bristol BS1
  5. 5Emergency Department, Musgrove Park Hospital, Taunton and Somerset NHS Trust, Taunton TA1 5DA
  6. 6Emergency Department, Bristol Children’s Hospital, United Bristol Healthcare NHS Trust, Bristol BS3 8BJ
  7. 7Research and Development Support Unit, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW
  1. Correspondence to: G Lloyd gavin.lloyd{at}rdeft.nhs.uk
  • Accepted 15 September 2008

Abstract

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.

Footnotes

  • We thank Beth Newstead, Charlotte Pagram, Julie Small and the reception and clinical staff of participating hospitals for their assistance and support of this study.

  • Contributors: AA and ADR co-wrote the manuscript. AA, ADR, JRB, and GL formed the SWEET research committee, which designed and implemented the study, and reviewed the manuscript. GL is the guarantor. FB, JD, SH, IH, JAK, SLeR, SSMS, RT, and JV reviewed the manuscript and co-ordinated the trial at their respective centres.

  • Funding: Research grant from the College of Emergency Medicine. The research was independent of the funders.

  • Competing interests: None declared.

  • Ethical approval: Each site obtained approval from local ethics committee. All eligible patients were recruited after written informed consent had been obtained.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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