Description of the Posterolateral Rotatory Drawer Maneuver for the Identification of Posterolateral Corner Injury Fábio Janson Angelini, M.D., M.Sc., Marcelo Batista Bonadio, M.D., Camilo Partezani Helito, M.D., Roberto Freire da Mota e Albuquerque, M.D., Ph.D., José Ricardo Pécora, M.D., Ph.D., and Gilberto Luis Camanho, M.D., Ph.D.
Abstract: Injury to the posterolateral corner (PLC) is difficult to diagnose; most lesions of this type are included within the context of complex knee injuries. Study of the posterolateral complex is growing in importance because of the complex instability generated by these injuries. Although various physical examination tests are described for the diagnosis of PLC lesions, in 72% of cases these lesions are not identified at their initial presentation, which shows the difficulty in both performing these tests and interpreting the results. The maneuver described in this report is performed by executing external rotation of the leg. With the thumb of the proximally positioned hand, the examiner evaluates the positioning of the lateral tibial plateau in relation to the femoral condyle. With this maneuver, in lesions of the PLC and particularly lesions of its external rotationerestricting structures, we observe external rotation of the tibia and posterior subluxation of the lateral tibial plateau that cause the anterior edge of the tibial plateau to be posteriorized in relation to the anterior edge of the lateral femoral condyle. The idea behind this maneuver is not to eliminate the use of other tests but, rather, to add it to a diagnostic arsenal that still has interpretation flaws.
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njury to the posterolateral corner (PLC) is difficult to diagnose,1,2 and it is a very rare isolated lesion, occurring in fewer than 2% of cases. Most lesions of this type are included within the context of complex knee injuries, specifically in association with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries.2-5 Study of the posterolateral complex is growing in importance because of the complex instability generated by these injuries, as well as the higher failure rates in reconstructions of the ACL and PCL in the presence of unidentified PLC lesions.3,6-11 Clinical evaluation to identify PLC injury begins during the examination. If the lesion is severe, the patient may have joint effusion and abrasions from swelling of the anteromedial
From the Department of Orthopaedics and Traumatology, Institute of Orthopedics and TraumatologyeHospital and Clinics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received December 4, 2013; accepted January 8, 2014. Address correspondence to Marcelo Batista Bonadio, M.D., Rua Dr Ovidio Pires de Campos, 333, São Paulo, SP, CEP 05403-010, Brazil. E-mail:
[email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/13849/$36.00 http://dx.doi.org/10.1016/j.eats.2014.01.008
compartment of the knee. In chronic lesions, asymmetric genu varum associated with a gait with lateral laxity of the knee may be present.12,13 Some specific physical examination tests described by Hughston and Norwood14 for the evaluation of the PLC are recurvatum and external rotation, in which lifting the leg by the great toe shows hyperextension associated with external rotation of the injured knee. Another maneuver described by the same authors is the posterolateral drawer test, in which the knee is kept at 90 of flexion and the foot at 15 of external rotation. In this position a posteriorizing force is applied to the proximal tibia, causing greater posteriorization of the lateral compartment compared with that of the undamaged limb. Jakob et al.15 described the reverse pivot-shift test, in which the knee is placed in 70 of flexion and the foot is rotated externally. This leads to posterior subluxation of the lateral compartment of the PLC-injured knee. The knee is then slowly extended to about 20 of flexion, at which point the force vector of the iliotibial band changes and the tibia is pulled forward, reducing the subluxation. For investigation of PLC lesions, one can also perform the posterolateral rotation, or dial, test, in whichdwith the patient in the ventral decubitus position and the knees at 30 of flexiondboth ankles are externally
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Fig 1. Positioning of patient in horizontal dorsal decubitus position with hips flexed at 45 and knee flexed at 90 with heel resting on stretcher.
Fig 2. Lateral view of right knee with external rotation of leg with examiner’s distal hand positioned on ankle.
rotated simultaneously. An increase in external rotation of 10 to 15 is considered a positive test result for PLC injury.14,16,17 Although various physical examination tests are described for the diagnosis of PLC lesions, in 72% of cases these lesions are not identified at their initial presentation, which shows the difficulty in both performing these tests and interpreting the results. The difficulty increases significantly when central pivot and medial collateral ligament injuries are involved.18 Thus the objective of this study is to describe a physical examination maneuver for better evaluation of PLC lesions, attempting to isolate their instability from that of other associated injuries.
One need only pay attention to several details of the maneuver outlined in Table 1.
Maneuver The described maneuver was developed by the senior author (F.J.A.) for the identification of PLC lesions. The maneuver is performed by placing the patient in the horizontal dorsal decubitus position with the hips flexed at 45 and the knee flexed at 90 with the heel resting on the stretcher (Fig 1). The examiner places his or her opposite hand beside the patient’s injured knee on the posterior proximal part of the calf and pushes forward to reduce posteriorization of the tibia caused by a possible PCL lesion. With the other hand, the examiner holds the patient’s ankle and performs external rotation of the leg (Fig 2). With the thumb of the proximally positioned hand, the examiner evaluates the positioning of the lateral tibial plateau in relation to the femoral condyle (Fig 3). With this maneuver, in lesions of the PLC and particularly lesions of its external rotationerestricting structures, we observe external rotation of the tibia and posterior subluxation of the lateral tibial plateau that cause the anterior edge of the tibial plateau to be posteriorized in relation to the anterior edge of the lateral femoral condyle (Video 1). The maneuver is simple to perform, without the need for equipment or calculation of exact measurements.
Discussion The PLC of the knee is a complex structure comprising a series of dynamic and static restrictors.19,20 Terry and LaPrade,19 in a prospective study, show some associations between clinical signs and specific anatomic injuries in the PLC. Despite this, however, 50% of these injuries are not properly diagnosed until the patients are referred to a knee specialist.18 The previously mentioned findings are corroborated by several articles showing the difficulty of diagnosis by physical examination. Veltri et al.21 suggest a lack of accuracy in the external rotation test at 30 of knee flexion for diagnosing PLC and ACL injuries. LaPrade et al.12 show that the findings of the recurvatum and external rotation tests are only positive in association with ACL injuries.
Fig 3. Front view of right knee showing examiner’s thumb evaluating positioning of lateral tibial plateau in relation to femoral condyle.
POSTEROLATERAL ROTATORY DRAWER MANEUVER Table 1. Details of Maneuver Advantage The maneuver avoids diagnostic errors in patients with knee rotatory instabilities. Indications Knee sprains with possible PLC tears Contraindications None Tips and advice Keep the knee at 90 of flexion and the foot free for external rotation. Reduce the knee in the sagittal plane. Keep the finger on the joint line to feel tibial rotation. Do not worry about degrees of rotation. Pitfalls and risks None Key points The tibial lateral plateau must move posterior to the lateral femoral condyle. Always perform all tests to confirm the diagnosis.
The common association with injuries of other kneestabilizing structures2-5 also makes clinical evaluation difficult because the absence of different structures can generate similar instabilities. An example of this is increased external rotation of the tibia, which can occur in both PLC injuries and injuries of the anteromedial structures, possibly leading to false-positive results in the dial test maneuver.22 The maneuver described in this report aims to cover all possibilities for assessment of the knee, thereby achieving greater accuracy in the diagnosis of PLC injuries. For this purpose, the maneuver involves anteriorization of the tibia with the hand positioned proximally to increase external rotation during the maneuver, specifically when associated with a possible PCL injury. Non-reduction of the knee in the sagittal plane can block external rotation of the tibia.23,24 Another advantage, as well as critical detail, of the maneuver for evaluation of the PLC lesion is the use of the position of the anterior edge of the lateral plateau in relation to the lateral femoral condyle and not only external rotation of the tibia, which can be caused by other deviations. Noyes et al.22 show that injuries of the anteromedial complex can cause external rotation during the dial test, whichdif compared with the uninjured sidedmay be erroneously interpreted as a PLC lesion. In our opinion, this reference parameter, which has not yet been highlighted in the literature, is critical for avoiding misdiagnosis of rotatory instability. Despite the similarities between the described test and the dial test,25 our maneuver does not use any rotational degrees, and sometimes, in cases with subtle changes of rotation related to the contralateral side, this can lead to diagnostic doubt. Only the position of the lateral plateau in relation to the lateral condyle, as felt by the examiner’s finger on the articular interline of the affected knee, is important.
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The idea behind the proposed maneuver is not to eliminate the use of other tests but, rather, to add it to a diagnostic arsenal that still has interpretation flaws. The maneuver does not require measurement tools, has no contraindications, and helps avoid confusion with other injuries, especially those involving the anteromedial complex.
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