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Rapid Responses: Rapid Responses published:
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Extensor mechanism integrity does not exclude fracture
- Quamar Bismil, MSK Bismil (19 December 2008)
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Elbow extension Rule
- Sreejib Das (4 January 2009)
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Risk of misdiagnosis of fracture if examined immediately after injury
- Paul D Moynagh (8 January 2009)
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Medical Radiation Benefit
- Milind M Deshpande, Poornima Deshpande (15 January 2009)
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The elbow extension test
- Stephen H Boyce, ML2 0DP. (29 January 2009)
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Quamar Bismil, SpR Trauma and Orthopaedics ExpertOrthopaedics.com, MSK Bismil
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Sir, We read with interest the level 1 study on the diagnosis elbow fracture by Appelboam et al. In our experience of managing patients with and operating upon elbow fractures: we have seen many patients with fractures about the elbow and an intact extensor mechanism. It is widely accepted that an in the knee an intact extensor mechanism (and straight leg raise) is entirely possible in the presence of fracture- why should the elbow be different? Almost 3% of patients in this study with an intact extensor mechanism have a fracture: we suggest the decision not to x-ray on the basis of elbow extension is not defencible. We suggest any patient with an injured elbow and bony tenderness or reduced range-of-motion must be x-rayed. Q Bismil MBChB Hons MRCS DipSEM MFSEM FRCS (Tr and Orth) MSK Bismil MBBS MS FRCS Competing interests: None declared |
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Sreejib Das, EM trainee (ST3) Ipswich hospital, Heath Road, Ipswich, IP4 5PD
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There has been series of articles on elbow extension as a reliable test to rule out clinically significant elbow injuries. Most article demonstrated sensivity ranging from 90%-97%, but specificity varied from 48% to 69%. Most studies are happy to use it a primary assesment tool. Your multicentric trail demonstrates similar results. A meta analysis might have been more useful. The conclusion of your study cautions us of missing olecranon fractures and advises reassessment in 7- 10 days. I think if we add bony tendeness over the olecranon to elbow extension test, we should be able to improve the sensivity and specificity of test, thereby reduce the number of elbow xrays. 1.Can elbow-extension test be used as an alternate to radiographs in primary care. Eur J Gen Pract. 2007;13(4):221-4 2.Can a normal range of elbow movement predict a normal elbow x ray?Emerg Med J. 2007 Feb;24(2):86-8 3.Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture.Am J Emerg Med. 2008 Sep;26(7):779-82 4.Can elbow extension be used as a test of clinically significant injury?Southern medical journal, May 2002, vol./is. 95/5(539-41), 0038- 4348 Competing interests: None declared |
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Paul D Moynagh, Retired Consultant Orthopaedic Surgeon Kingswear, Devon, TQ6 0DX (home)
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Congratulations. What an excellent study. It would be interesting to know how soon after injury the five missed adult fractures were examined. In my experience assessment of any trauma made by physical examination within an hour or so of injury can be misleading and should remain suspect until a later full re-examination. This is standard teaching for serious multiple injuries, but that I am aware of, not for simple limb trauma. I have personal recall of a number of similar missed diagnoses and I used to teach my juniors to be wary if they happen to see a patient so soon. Off duty doctors circumstantially at the scene of accidents can also fall into this trap. There may be some advantage from a long wait in the Accident & Emergency Department! But my interest in this study has a more personal twist. 8 years ago my 59 year old wife fell injuring her elbow. I, then a recently retired orthopaedic surgeon, was there to pick her up. I immediately examined the joint, finding limited tenderness, minimal bruising and a negative elbow extension test. So with the full weight of 30 years of managing such injuries I reassured her and advised expectant symptomatic management. I made her suffer another 3 days before properly re-examining her and taking her to be x-rayed. Surgical fixation followed the diagnosis of a displaced olecranon fracture. The shame and guilt of my misdiagnosis has dogged me ever since. Was I more concerned about who would now do all the housework? Or was it not practising what I had taught my juniors: always re-examine if you happen to see an injury within two hours. What a relief to now read that, whether due to too early assessment, or to a limitation of the elbow extension test in this injury, I am not alone in making such an error. One query: if the authors cannot quote an earlier study than 1991 (1), where did I learn this test which I have used since at least the early 1970s ? Reference: (1) Hawksworth CR, Freeland P. Inability to fully extend the injured elbow: an indicator of significant injury. Arch Emerg Med 1991;8:253-6. Competing interests: Personal - author misdiagnosed wife's olecranon fracture |
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Milind M Deshpande, consulting orthosurgeon vivekanand hospital,hubli,karnataka,India,580029, Poornima Deshpande
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Sir Congrats! The test is indeed useful but in this era of consumerlaws,it is better to err on the side of radiation putting aside the theoretical risk predicted by the "linear no threshhold"theory. Regards Milind,Poornima. Competing interests: None declared |
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Stephen H Boyce, Consultant Emergency Medicine Wishaw General Hospital, ML2 0DP.
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The elbow extension test has been applied by many EM clinicians as part of their clinical practice when assessing elbow injuries in adults and children. A block to full extension is normally mechanical due to the presence of an elbow joint effusion. This paper confirms that is is highly unlikely that an intra-articular fracture will be present if a patient can straighten the elbow fully. It also raises the awareness of the isolated undisplaced olecranon fracture which can be missed if applying this test exclusively. This test can be used as a teaching aid to help decrease the amount of X-rays ordered by ENP's and junior doctors when examining elbow injuries. Competing interests: None declared |
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