Elbow extension test

The Elbow Extension Test is a simple clinical tool used to assess the presence of bony fractures or joint effusion in the elbow [1][2].It is especially valuable in acute care and emergency settings, helping clinicians decide whether a patient requires radiographic evaluation after trauma.

• Particularly reliable for adults, though less specific in children due to subtle fracture presentation [3].

• Acts primarily as a rule-out test due to its high sensitivity and negative predictive value [3][5].

• Elbow injuries account for 2–3% of all emergency visits, making this test highly relevant in primary care [3].

Test Procedure

Patient positioning

• Patient seated or standing with arms exposed.

Execution

1. Patient flexes shoulders to 90°.

2. Both elbows are fully extended simultaneously.

Comparison

• Injured elbow is compared with the uninjured side.

Interpretation

• Negative test (full painless extension): Low likelihood of fracture.

• Positive test (restricted extension): High likelihood of fracture or effusion → radiographs recommended [3].

Diagnostic Validity

Reliability

• Inter-rater ICC: 0.53–0.97 (moderate to excellent).

• Intra-rater ICC: 0.45–0.99 (good to excellent).

Adults

• Sensitivity: 96.8%

• NPV: 98.4%

• Specificity: 48.5–69.4%

Children

• Sensitivity: 94.6%

• NPV: 95.8%

High sensitivity and NPV make it excellent for ruling out fractures, but moderate specificity means positive tests still require imaging.

Likelihood Ratios

Population	Sensitivity	Specificity	LR+	LR-
Adults (fracture)	98.4%	47.7%	1.88	0.03
Adults (fracture+eff.)	97.3%	54.3%	2.13	0.05
Children (fracture)	94.6%	49.5%	1.87	0.11
Children (fracture+eff.)	93.7%	54.8%	2.07	0.11

Clinical Relevance

• Quick screening test in emergency and primary care.

• Effective for ruling out fractures without immediate X-ray.

• Positive tests should be followed by radiological assessment.

• Not sufficient as a stand-alone diagnostic tool.

Conclusion

The Elbow Extension Test is a fast, reliable, and non-invasive tool for detecting elbow fractures or effusion. With its high sensitivity and negative predictive value, it is ideal as a rule-out test, but limited specificity means imaging remains necessary for confirmation.

Sources:

1. 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.

2. 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.  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.

4. 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. 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.

6. Flynn TW, Cleland JA, Whitman JM. Users' guide to the musculoskeletal examination. United States; Evidence in motion:2008.

7. 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.