Elbow extension as a ‘rule-out’ tool for significant injury in children
Date First Published:
April 23, 2004
Last Updated:
April 7, 2011
Report by:
Adam Reuben and Beth Newstead, Consultant Emergency Physicians (Royal Devon and Exeter Hospital)
Search checked by:
Gavin Lloyd, Royal Devon and Exeter Hospital
Three-Part Question:
In [children with elbow injuries] does [ability to fully extend the injured limb] exclude the possibility of [significant injury]?
Clinical Scenario:
A 7 year old girl presents to the emergency department complaining of pain in her left elbow, having fallen onto her outstretched hand. On examination she can fully extend the elbow on the affected side. You have heard that full elbow extension can be used as a 'rule-out' tool for significant injury and you wonder whether there is any value in obtaining an x-ray.
Search Strategy:
Medline 1966-02/11 using the OVID interface
Search Details:
{(exp elbow joint OR elbow.mp) AND (fracture.mp) AND (exp Movement/ OR range of movement.mp. OR exp "Range of Motion, Articular"/ OR extension.mp) AND (diagno$.mp OR Examin$.mp)} LIMIT to humans and English Language
Outcome:
109 papers found of which 3 relevant to the 3 part question and of sufficient quality.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Inability to fully extend the injured elbow: an indicator of significant injury. Hawksworth CR, Freeland P. 1991, Scotland | 145 patients with acute elbow injuries | Prospective / observational | Ability to fully extend the injured elbow in the absence of a significant injury | Sensitivity 90.7% specificity 69.5% 5 false negatives | No breakdown of results by age groups (adults Vs Children). Wide confidence intervals. No standardisation of criteria for x-ray during study period |
| Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture Darracq MA. Vinson DR. Panacek EA. 2008, USA | 113 patients aged 5 and above presenting to one of four emergency departments with traumatic elbow pain (those with deformity excluded) 42 aged 5-18 | Diagnostic | Sensitivity | 100% | Small numbers of patients particularly as recruitment over 10 months with total 150000 patients pa. |
| Specificity | 100% | ||||
| Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. Appelboam A. Reuben AD. Benger JR. et al. 2008, UK | 780 Children aged 3-15 (and 960 adults) presenting with acute elbow injury to five Emergency Departments. | Prospective diagnostic | Sensitivity for fracture in children | 94.6% (95% CI 90.7-97.2) | |
| Specificity for fracture in children | 49.5% (95% CI 45.2- 53.7%) |
Author Commentary:
Of the three papers relevant to the three part question only the smallest shows a sensitivity high enough to qualify as a SnOut. Given the results of the larger trials it appears that an ability to extend the elbow is not good enough to rule out a fracture in children but should reduce suspicion. None of the studies describe the likely outcomes of the missed fractures using this rule.
Bottom Line:
Ability to fully extend an injured elbow cannot reliably be used to exclude the possibility of significant injury in children following trauma.
References:
- Hawksworth CR, Freeland P.. Inability to fully extend the injured elbow: an indicator of significant injury.
- Darracq MA. Vinson DR. Panacek EA.. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture
- Appelboam A. Reuben AD. Benger JR. et al.. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children.