January 2017

Harry Potter is flying fast on his Nimbus 2000 while being chased by a rogue bludger. After an endless pursuit, the rogue bludger slams into Harry’s arm, and an audible pop is heard. Harry then reaches out, catches the snitch and falls to the ground. You’re able to examine Harry before Gilderoy Lockhart is able to get there. Harry is unable to extend his arm fully, and he is tender to palpation at the proximal radial head.

What is the best answer choice?

A. Harry should be referred for radiographs due to the audible pop that was heard when the rogue bludger hit his arm.

B. Harry should be placed in a sling and referred for radiographs if not better within 72 hours.

C. Harry should be referred for radiographs because he is unable to extend his elbow.

D. Harry should be referred for radiographs based on the American College of Radiology Appropriateness Criteria due to the tenderness to palpation at the proximal radial head.

SCROLL DOWN TO SEE ASNWER AND EXPLANATION

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What is the best answer choice?

A. Harry should be referred for radiographs due to the audible pop that was heard when the rogue bludger hit his arm.

B. Harry should be placed in a sling and referred for radiographs if not better within 72 hours.

C. Harry should be referred for radiographs because he is unable to extend his elbow.

D. Harry should be referred for radiographs based on the American College of Radiology Appropriateness Criteria due to the tenderness to palpation at the proximal radial head.

Explanation: Answer choice C is correct because the inability to extend the elbow is a clinically useful test, and an extremely sensitive test.  If you cannot fully extend your elbow, a radiograph should be ordered to rule out a fracture.

See some links below to some great articles with short summaries:

Boyles, R. (2013). Posterior Dislocation of the Elbow. Journal of Orthopaedic & Sports Physical Therapy, 43(9), 673-673.

  • This is a great article that describes a 23 year old with severe left elbow pain after falling on an outstretched hand, and highlights the importance of referring for imaging when a patient cannot extend elbow fully.

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. BMJ. 2008;337:a2428.

  • Methods
    • 5 EDs in Southwest England
    • 2127 adults presented with acute elbow pain
    • 1740 met inclusion criteria
    • 602 able to extend elbow
    • 17 had fracture
    • 1138 without full elbow extension
    • 521 fractures identified
  • Results
    • SN 8% SP 48.5%
    • CI 95%
    • Negative Predictive value 4% (adults) 95.8% (children)
    • Negative LR .03 (adults) .11 (children)
  • Conclusions
    • Those who cannot extend elbow should be referred for radiography
    • Nearly 50% increase in chance of fracture
    • Able to fully extend elbow; confident no olecranon fx
    • Defer radiograph
    • Return if symptoms do not resolve in 7-10 days

Docherty, M. A., Schwab, R. A., & John, O. (2002). Can elbow extension be used as a test of clinically significant injury?. Southern medical journal, 95(5), 539-542.

  • 114 patients with acute elbow injury
  • 110 underwent radiographic injury
  • Unable to extend elbow
    • Bone injury
      • 37 of 38
    • Able to extend
      • Bone Injury
        • 1 of 54
      • SN 97% SP 69%

Jie KE, van Dam LF, Verhagen TF, Hammacher ER. Extension test and ossal point tenderness cannot accurately exclude significant injury in acute elbow trauma. Ann Emerg Med. 2014 Jul;64(1):74-8. doi: 10.1016/j.annemergmed.2014.01.022. PubMed PMID: 24530106.

  • 2 EDs in Netherlands
  • Passive Extension + point tenderness
  • 587 patients included
  • Normal extension in 174 pt.s
    • Normal ext. predicted absence of fx with SN 88% SP 55%
  • Absence of point tenderness with normal extension
    • 24 patients
    • 3 had fracture
    • 1 required surgery
    • SN 98% SP 11%

Hoppes, C. W., & Jonson, S. R. (2015). Fracture Through an Enthesophyte on the Olecranon Process. Journal of Orthopaedic & Sports Physical Therapy, 45(2), 143-143.

A short case again highlighting the importance of referring for imaging.

  • 54 y.o. man currently serving in the military
  • Evaluated by PT in direct access capacity
  • Chief complain of left elbow pain
  • Onset: 3 weeks prior
  • MOI: Forcefully hyperextending elbow while playing volleyball

Fat Pad Sign

  • Click on the link and you will see a normal radiograph of an elbow without the fat pad sign where the anterior fat pad is just anterior to the coronoid and radial fossae, and the posterior fat pad is located deep within the concavity of the olecranon fossa.
  • In the scenario where the radial head is fractured, fluid will fill the synovial cavity, which will elevate the fat pads within the coronoid and olecranon fossa. See the other picture highlighted in the link.
  • The fat pad sign is useful to look for because a radial head fracture may not be well visualized on imaging.

What else can cause limited elbow extension?

  • Heterotrophic ossification
  • Edema
  • Osteophytes
  • Medial elbow tightness

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