Elbow fracture diagnosis, without an x-ray

Via Medscape (subscribe at www.medscape.com), reporting on a study in the December 9th Online First issue of the BMJ: The Elbow Extension Test can help practitioners determine the need to refer for radiography.  If a patient cannot fully extend the elbow after an injury, there is almost a 50% chance of a fracture.  From Medscape: “ “Elbow injuries are common in primary and secondary care, accounting for 2-3% of emergency department attendances,” write A. Appelboam, from the Emergency Department, Royal Devon and Exeter Foundation NHS Trust in Exeter, United Kingdom, and colleagues. “Only a minority of patients with such injuries have a fracture, but although clinical decision rules for other limb injuries are well recognised, no guidelines have been established to indicate which patients with an elbow injury require radiography. An effective clinical decision rule to exclude fracture in acute elbow injury would prevent unnecessary radiography, and could reduce expenditure”…

“For detecting elbow fracture, the elbow extension test had sensitivity of 96.8% (95% confidence interval [CI], 95.0 – 98.2) and specificity of 48.5% (95% CI, 45.6 – 51.4). Negative predictive value for fracture of full elbow extension was 98.4% (95% CI, 96.3 – 99.5) in adults and 95.8% [95% CI, 92.6 – 97.8] in children, and negative likelihood ratios were 0.03 [95% CI, 0.01 – 0.08] and 0.11 (95% CI, 0.06 – 0.19), respectively.  “The elbow extension test can be used in routine practice to inform clinical decision making,” the study authors write. “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.”  However, the study authors caution that patients who do not undergo radiography should return for reevaluation if symptoms have not resolved within 7 to 10 days.”

While there are limitations to the study, this interests me for several reasons.  1) This test is one way to possibly reduce healthcare expenditures (and radiation exposure); 2) as PT’s truly gain direct access, and as PT’s become more involved in ED’s they can both be informed and help inform the physicians of what PT’s can do and how we can help reduce expenditures (at my recent outpatient internship I worked one day a week there and had a great experience, learned a lot, and gained confidence – more on that later).


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