Extension test and ossal point tenderness cannot accurately exclude significant injury in acute elbow trauma

Abstract

Study objective: Elbow injury is a common presentation at the emergency department (ED). There are no guidelines indicating which of these patients require radiography, whereas clinical decision rules for other limb injuries are widely accepted and resulted in less radiography and reduced waiting times. We aim to identify clinical signs that can be used to predict the need for radiography in elbow injury.

Methods: A prospective observational study at 2 ED locations in the Netherlands was performed. For every eligible patient with acute elbow injury, elbow extension and addition of point tenderness at the olecranon, epicondyles, and radial head were evaluated for predicting the need for radiography (primary endpoint). A subgroup of patients was assessed by a blinded second investigator to analyze interobserver variability (secondary endpoint). All patients received anterior-posterior and lateral elbow radiographs. Fractures were treated according to current guidelines and patients were followed at outpatient clinics.

Results: In total, 587 patients were included. Normal extension was observed in 174 patients (30%). Normal extension predicted absence of a fracture or isolated fat pad with 88% sensitivity and 55% specificity. Five patients with normal extension had a fracture that required surgery. Absence of point tenderness in patients with normal extension was observed in only 24 patients, of whom 3 showed a fracture and 1 required surgery. Addition of point tenderness to the extension test to predict absence of a fracture or isolated fat pad resulted in 98% sensitivity and 11% specificity. Interobserver analysis for extension and palpation of olecranon, epicondyles, and radial head resulted in κ values between 0.6 and 0.7.

Conclusion: In contrast with previous studies, ours shows that in acute elbow injury, the extension test alone or in combination with point tenderness assessment does not safely rule out clinically significant injury. Interobserver variability was substantial. We would not recommend the use of the extension test (+/- point tenderness assessment) as a clinical decision rule to guide radiologic diagnostics in acute elbow trauma.