The relationship between the clinical symptoms and radiography results of patients with isolated blunt elbow trauma
More details
Hide details
Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
Equally First Author, Mashhad University of Medical Sciences, Mashhad, Iran
Online publish date: 2018-04-20
Publish date: 2018-04-20
Electron J Gen Med 2018;15(4):em53
Elbow injuries are amongst the most common complaints reported by the adults and children referring to the trauma emergency units and they account for 2% to 3% of the referrals to the emergency units. The majority of these patients are referred to radiography for an examination of fracture, whereas about 30% to 40% of these individuals are found having no clear need for radiography in clinical examinations. The present study aims at investigating the relationship between the clinical and fractures’ examinations scales and their usability for predicting the elbow bone injuries in patients with blunt elbow joint trauma.

Patient and Method:
The study sample volume included the entire patients with blunt elbow joint trauma who had referred to Hasheminejad and Imam Reza (Peace be upon him) Hospitals during the time span from 2014 to 2015 and also had no past records of elbow joint fracture, surgery and deformity. After performing a preliminary examination of the patients’ elbow joints which was conducted in the form of extension, supination, pronation, topical tenderness evaluations in such regions as ulnar head, radial head and humerus epicondyle as well as investigation for the existence of ecchymosis and hematoma in the elbow joint region, the patients were subjected to standard lateral and anterior-posterior (AP) radiography; the results of the examinations were recorded in a checklist that had been prepared beforehand. Then, the results of the radiographies were studied based on which the proper treatments were figured out. Afterwards, the results of the radiographies were matched with the preliminary examinations and finally they were all exposed to evaluations so as to come up with a conclusion.

The study sample volume included 188 patients. Based on the fracture type, the logistic regression analysis data indicated that there is a significant relationship between radial head fracture with restriction in supination of the forearm, sensitivity to palpation on the radius bone head, tenderness to topical touching of the ulnar head bone and sensitivity to topical touch of epicondyle of the humerus and that the former can be applied as a predictor for all of the latter signs (P<0.05). Also, the analyses were indicative of the existence of a significant relationship between the ulnar bone head fracture with pronation and supination limitations, sensitivity to palpation of the ulnar head bone (P<0.05). In distal humerus fractures, the clinical sings are predictable in the form of extension restrictions and tenderness to palpation on the radius head (P<0.05). Logistic regression analysis data were also indicative of a significant relationship between the proximal radial fracture only with supination limitations in elbow joint position (P<0.05) and the combined humerus fractures can be predicted by supination limitations and hematoma in elbow joint (P>0.05). Also, the data analyses showed that there is no significant relationship between the proximal ulnar fracture and any of the clinical signs so the clinical symptoms were found incapable of properly predicting the proximal ulnar fractures (P>0.05).

Based on the data analysis, it seems that some of the clinical scales can be used as parts of acceptable instruments for predicting the elbow joint fractures so that the unnecessary diagnostic radiographies could be prevented.

1. Chen NC. Elbow Fractures with Instability: Evaluation and Treatment Strategies. Hand Clin. 2018;34(1):75-83. https://doi.org/10.1016/j.hcl.... PMid:29169599.
2. Nanno M, Sawaizumi T, Ito H. Transverse divergent dislocation of the elbow with ipsilateral distal radius fracture in a child. J Orthop Trauma. 2007;21(2):145-9. https://doi.org/10.1097/BOT.0b... PMid:17304072.
3. Siebenlist S, Braun KF. Elbow dislocation fractures. Unfallchirurg. 2017;120(7):595-610. https://doi.org/10.1007/s00113... PMid:28664232.
4. Ahmad R, Ahmed SM, Annamalai S, Case R. Open dislocation of the elbow with ipsilateral fracture of the radial head and distal radius: a rare combination without vascular injury. BMJ Case Rep. 2009;2009:bcr2006044016.
5. Sakata J, Nakamura E, Suzuki T, Suzukawa M, Akaike A, Shimizu K, Hirose N. Efficacy of a Prevention Program for Medial Elbow Injuries in Youth Baseball Players. Am J Sports Med. 2017:363546517738003.
6. Sato R, Hamada Y, Hibino N, Nishisho T, Tonogai I, Endo K, et al. Restoration of the Active Forearm Rotation Using Vascularized Free Fibular Graft and Radial Head Arthroplasty for a Wide Defect of the Proximal Radius. J Hand Surg Asian Pac Vol. 2017;22(4):531-534. https://doi.org/10.1142/S02188... PMid:29117845.
7. Yoshida M, Goto H, Takenaga T, Tsuchiya A, Sugimoto K, Musahl V, et al. Anterior and posterior bands of the anterior bundle in the elbow ulnar collateral ligament: ultrasound anatomy. J Shoulder Elbow Surg. 2017;26(10):1803-1809. https://doi.org/10.1016/j.jse.... PMid:28735845.
8. Bazzocchi A, Aparisi Gómez MP, Bartoloni A, Guglielmi G. Erratum: Emergency and Trauma of the Elbow. Semin Musculoskelet Radiol. 2017;21(5):649-650. https://doi.org/10.1055/s-0037... PMid:29025193.
9. Dwek JR. A Segmental Approach to Imaging of Sports-Related Injuries of the Pediatric Elbow. Sports Health. 2012;4(5): 442–452. https://doi.org/10.1177/194173... PMid:23016119 PMCid:PMC3435948.
10. Capo JT, Shamian B, Francisco R, Tan V, Preston JS, Uko L, et al. Fracture pattern characteristics and associated injuries of high-energy, large fragment, partial articular radial head fractures: a preliminary imaging analysis. J Orthop Traumatol. 2015;16(2):125-31. https://doi.org/10.1007/s10195... PMid:25542062 PMCid:PMC4441642.
11. Russell DW, Janz DR, Emerson WL, May AK, Bernard GR, Zhao Z, et al. Early exposure to hyperoxia and mortality in critically ill patients with severe traumatic injuries. BMC Pulm Med. 2017;17(1):29. https://doi.org/10.1186/s12890... PMid:28158980 PMCid:PMC5291954.
12. Freed HA, Shields NN. Most frequently overlooked radiographically apparent fractures in a teaching hospital emergency department. Annals of emergency medicine. 1984;13(10):900-4. https://doi.org/10.1016/S0196-....
13. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Annals of emergency medicine. 1992;21(4):384-90. https://doi.org/10.1016/S0196-....
14. Shell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA. 1993;269(9):1127-32. https://doi.org/10.1001/jama.1....
15. Stiell IG, Greenberg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. Jama. 1996;275(8):611-5. https://doi.org/10.1001/jama.1... PMid:8594242.
16. Emparanza JI, Aginaga JR. Validation of the Ottawa knee rules. Annals of emergency medicine. 2001;38(4):364-8. https://doi.org/10.1067/mem.20... PMid:11574791.
17. Stiell IG, Greenberg GH, McKnlght RD, Nalr RС, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. health care. 1993;13:15.
18. Bulloch B, Neto G, Plint A, Lim R, Lidman P, Reed M, et al. Validation of the Ottawa Knee Rule in children: a multicenter study. Annals of emergency medicine. 2003;42(1):48-55. https://doi.org/10.1067/mem.20... PMid:12827123.
19. Hawksworth C, Freeland P. Inability to fully extend the injured elbow: an indicator of significant injury. Archives of emergency medicine. 1991;8(4):253-6. https://doi.org/10.1136/emj.8.... PMid:1772537 PMCid:PMC1285793.
20. Lennon RI, Riyat MS, Hilliam R, Anathkrishnan G, Alderson G. Can a normal range of elbow movement predict a normal elbow x ray? Emergency medicine journal. 2007;24(2):86-8. https://doi.org/10.1136/emj.20... PMid:17251609 PMCid:PMC2658213.
21. Appelboam A, Reuben A, Benger J, Beech F, Dutson J, Haig S, 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. https://doi.org/10.1136/bmj.a2... PMid:19066257 PMCid:PMC2600962.
22. Baker M, Borland M. Range of elbow movement as a predictor of bony injury in children. Emerg Med J. 2011;28(8):666-9. https://doi.org/10.1136/emj.20... PMid:20713361.