Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children.

OBJECTIVE: To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. DESIGN: Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. SETTING: Five emergency departments in southwest England. PARTICIPANTS: 2127 adults and children presenting to the emergency department with acute elbow injury. INTERVENTION: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. MAIN OUTCOME MEASURES: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. RESULTS: Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. CONCLUSION: The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

High intensity exercise conditioning increases accumulated oxygen deficit of horses.

High intensity exercise is associated with production of energy by both aerobic and anaerobic metabolism. Conditioning by repeated exercise increases the maximal rate of aerobic metabolism, aerobic capacity, of horses, but whether the maximal amount of energy provided by anaerobic metabolism, anaerobic capacity, can be increased by conditioning of horses is unknown. We, therefore, examined the effects of 10 weeks of regular (4-5 days/week) high intensity (92+/-3 % VO2max) exercise on accumulated oxygen deficit of 8 Standardbred horses that had been confined to box stalls for 12 weeks. Exercise conditioning resulted in increases of 17% in VO2max (P<0.001), 11% in the speed at which VO2max was achieved (P = 0.019) and 9% in the speed at 115% of VO2max (P = 0.003). During a high speed exercise test at 115% VO2max, sprint duration was 25% longer (P = 0.047), oxygen demand was 36% greater (P<0.001), oxygen consumption was 38% greater (P<0.001) and accumulated oxygen deficit was 27% higher (P = 0.040) than values before conditioning. VLa4 was 33% higher (P<0.05) after conditioning. There was no effect of conditioning on blood lactate concentration at the speed producing VO2max or at the end of the high speed exercise test. The rate of increase in muscle lactate concentration was greater (P = 0.006) in horses before conditioning. Muscle glycogen concentrations before exercise were 17% higher (P<0.05) after conditioning. Exercise resulted in nearly identical (P = 0.938) reductions in muscle glycogen concentrations before and after conditioning. There was no detectable effect of conditioning on muscle buffering capacity. These results are consistent with a conditioning-induced increase in both aerobic and anaerobic capacity of horses demonstrating that anaerobic capacity of horses can be increased by an appropriate conditioning programme that includes regular, high intensity exercise. Furthermore, increases in anaerobic capacity are not reflected in blood lactate concentrations measured during intense, exhaustive exercise or during recovery from such exercise.