Diagnostic accuracy of clinical tests to rule out elbow fracture: a systematic review

Elbow traumas represent a relatively common condition in clinical practice. However, there is a lack of evidence regarding the most accurate tests for screening these potentially serious conditions and excluding elbow fractures. The purpose of this investigation was to analyze the literature concerning the diagnostic accuracy of clinical tests for the detection or exclusion of suspected elbow fractures. A systematic review was performed using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines. Literature databases including PubMed, Cumulative Index to Nursing and Allied Health Literature, Diagnostic Test Accuracy, Cochrane Library, the Web of Science, and ScienceDirect were searched for diagnostic accuracy studies of subjects with suspected traumatic elbow fracture investigating clinical tests compared to imaging reference tests. The risk of bias in each study was assessed independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies 2 checklist. Twelve studies (4,485 patients) were included. Three different types of index tests were extracted. In adults, these tests were very sensitive, with values up to 98.6% (95% confidence interval [CI], 95.0%-99.8%). The specificity was very variable, ranging from 24.0% (95% CI, 19.0%-30.0%) to 69.4% (95% CI, 57.3%-79.5%). The applicability of these tests was very high, while overall studies showed a medium risk of bias. Elbow full range of motion test, elbow extension test, and elbow extension and point tenderness test appear to be useful in the presence of a negative test to exclude fracture in a majority of cases. The specificity of all tests, however, does not allow us to draw useful conclusions because there was a great variability of results obtained.