Elbow Extension Sign
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Purpose
The elbow extension test is used to determine the presence of either a bony fracture or elbow joint effusion.[1][2] It a reliable method for assessing the presence of elbow fractures in adults, provided an olecranon fracture is not suspected. However, Appelboam A et al. caution against using it as the sole diagnostic diagnostic tool in children.[3]
This test is particularly valuable in primary care settings, where it can help predict severe elbow injuries, especially in practices without access to radiology. As a simple, non-invasive clinical tool, it aids clinicians in determining the necessity of radiographic imaging for patients with acute trauma.[4] Given that elbow injuries account for 2–3% of emergency department visits, the ability to rule out fractures without imaging is valuable. Studies have shown that full elbow extension strongly correlates with the absence of significant bony injury.[3]
Technique
The elbow extension test is performed as follows:
- Patient Positioning: The patient is seated with the arms fully exposed.
- Test Execution: The patient is asked to flex their shoulders to 90 degrees and then fully extend both elbows to achieve full terminal extension.
- Comparison: The injured side is compared to the uninjured side. The test is considered negative if both elbows can extend fully without pain.
- Interpretation: Negative Test (Full Extension Achieved) suggests a low likelihood of fracture while Positive Test (Incomplete Extension) indicates a higher probability of fracture, necessitating further radiographic investigation.[3] This test is often combined with patient history and clinical examination for improved diagnostic accuracy.[5]
The patient extends his/her elbow as far as possible while either in supine or standing position. The examiner will evaluate whether the patient is able to achieve full extension.
A positive test is if the patient is unable to fully extend the elbow.[6]
Evidence
Reliability
The elbow extension test demonstrates strong intra- and inter-rater reliability, especially when performed by skilled clinicians. Inter-rater reliability falls between 0.53 and 0.97, signifying moderate to excellent agreement, while intra-rater reliability ranges from 0.45 to 0.99, reflecting strong reproducibility. The accuracy of results is influenced by factors such as the examiner’s expertise, adherence to standardized protocols, and patient cooperation.[7]
Validity
This test is highly effective in identifying fractures, particularly as a rule-out tool. A multicenter study conducted by Appelboam et al. (2008) found that in adults, the test exhibited a sensitivity of 96.8% and a negative predictive value (NPV) of 98.4%, reinforcing its reliability in excluding fractures. Among pediatric patients, the sensitivity was reported at 94.6%, with an NPV of 95.8%. However, specificity ranges from 48.5% to 69.4%, suggesting that while a positive result may indicate the presence of a fracture, imaging is required for definitive diagnosis. Despite its moderate specificity, this test remains a valuable screening tool in clinical settings.[5][3]
Table 1. Elbow extension test characteristics [3]
| Adults | Children | Combined |
| Fx | Fx+Effusion | Fx | Fx+Effusion |
Fx | Fx+Effusion | |
| Sensitivity |
98.4 | 97.3 | 94.6 | 93.7 | 96.8 | 95.8 |
| Specificity |
47.7 | 54.3 | 49.5 | 54.8 | 48.5 | 54.6 |
| LR+ | 1.88 | 2.13 | 1.87 | 2.07 | 1.88 | 2.11 |
| LR- | 0.03 | 0.05 | 0.11 | 0.11 | 0.06 | 0.08 |
References
- ↑ Hawksworth CR, Freeland P. Inability to fully extend the injured elbow: an indicator of significant injury. Emergency Medicine Journal. 1991 Dec 1;8(4):253-6.
- ↑ Docherty MA, Schwab RA, John O. Can elbow extension be used as a test of clinically significant injury?. Southern medical journal. 2002 May 1;95(5):539-42.
- ↑ 3.0 3.1 3.2 3.3 3.4 Appelboam A, Reuben AD, Benger JR, Beech F, Dutson J, Haig S, Higginson I, Klein JA, Le Roux S, Saranga SS, Taylor R. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. Bmj. 2008 Dec 9;337.
- ↑ Lamprakis A, Vlasis K, Siampou E, Grammatikopoulos I, Lionis C. Can elbow-extension test be used as an alternative to radiographs in primary care?. European Journal of General Practice. 2007 Jan 1;13(4):221-4.
- ↑ 5.0 5.1 Breda G, De Marco G, Cesaraccio P, Pillastrini P. Diagnostic accuracy of clinical tests to rule out elbow fracture: a systematic review. Clinics in Shoulder and Elbow. 2023 Jun;26(2):182.
- ↑ Flynn TW, Cleland JA, Whitman JM. Users' guide to the musculoskeletal examination. United States; Evidence in motion:2008.
- ↑ Van Rijn SF, Zwerus EL, Koenraadt KL, Jacobs WC, van den Bekerom MP, Eygendaal D. The reliability and validity of goniometric elbow measurements in adults: A systematic review of the literature. Shoulder & elbow. 2018 Oct;10(4):274-84.