Performance of the 4-way range of motion test for radiographic injuries after blunt elbow trauma

Am J Emerg Med. 2016 Feb;34(2):235-9. doi: 10.1016/j.ajem.2015.10.031. Epub 2015 Oct 24.


Objectives: 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.

Publication types

  • Multicenter Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Child
  • Child, Preschool
  • Elbow Joint / diagnostic imaging*
  • Elbow Joint / injuries*
  • Emergency Service, Hospital
  • Female
  • Humans
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Prospective Studies
  • Radiography
  • Range of Motion, Articular / physiology*
  • Sensitivity and Specificity
  • Wounds, Nonpenetrating / diagnostic imaging*
  • Wounds, Nonpenetrating / physiopathology*