title: Performance of the 4-way range of motion test for radiographic injuries after blunt elbow trauma.
abstract: OBJECTIVE
  Acute elbow injuries are common in the acute care setting. A previous study observed that limited active range of motion (ROM) was highly sensitive for radiographic injuries after blunt trauma. Our aim was to validate these findings in patients ≥5 years old with an acute (<24 hours) nonpenetrating elbow injury.
  
  
  METHODS
  This prospective study included a convenience sample of patients undergoing plain radiographs of an injured elbow in 3 emergency departments. Before imaging, treating clinicians completed a standardized data collection sheet including mechanism of injury and 4-way ROM findings (full extension, flexion to 90°, full pronation and supination). Radiographic interpretation by a staff radiologist was used to ascertain the presence of fracture or joint effusion.
  
  
  RESULTS
  The median age of the 251 patients was 24 years. Ninety-two patients (36.7%) had active 4-way ROM, and 159 patients (63.3%) demonstrated limited ROM. Negative radiographs were present in 152 patients (60.6%), whereas 99 patients (39.4%) had abnormal radiographs: 75 with explicit fractures and 24 with only joint effusions. The 4-way ROM elbow test had a sensitivity of 0.99 (95% confidence interval [CI], 0.94-1.00), specificity of 0.60 (95% CI, 0.52-0.68), positive predictive value of 0.62 (95% CI, 0.54-0.69), and negative predictive value of 0.99 (95% CI, 0.94-1.00).
  
  
  CONCLUSIONS
  Active 4-way ROM test is 99% sensitive for all radiographic injures following blunt elbow trauma and 100% sensitive for injuries requiring surgical intervention. Caution should be used in relying on this test in the pediatric population until it is validated in a larger cohort.
authors.affiliation: The Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, CA. Electronic address: drvinson@ucdavis.edu.
authors.forename: David R
authors.initials: DR
authors.lastname: Vinson
authors.affiliation: The Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Kann
authors.affiliation: Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA.
authors.forename: Samuel D
authors.initials: SD
authors.lastname: Gaona
authors.affiliation: Department of Emergency Medicine, University of South Alabama Medical Center, Mobile, AL.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Panacek
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D004551:Elbow Joint / Q000000981:diagnostic imaging*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011859:Radiography; D016059:Range of Motion, Articular / Q000502:physiology*; D012680:Sensitivity and Specificity; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D000092464:Elbow Injuries