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Tabletop relocation test: A new clinical test for posterolateral rotatory instability of the elbow
Tabletop relocation test: A new clinical test for posterolateral rotatory instability of the elbow Chinnakonda H. V. Arvind, FRCS(Tr&Orth), and David G. Hargreaves, FRCS(Tr&Orth), Southampton, United Kingdom
We describe a new clinical test for the assessment of posterolateral rotatory instability. This has been assessed in 8 patients who have been diagnosed with posterolateral rotatory instability. Of these, 6 have undergone surgical reconstruction of the lateral ulnar collateral ligament, and the clinical test has subsequently been negative with resolution of their symptoms. (J Shoulder Elbow Surg 2006;15:707-708.)
P osterolateral
rotatory instability of the elbow is thought to be the most common form of recurrent instability of the elbow.4 It most commonly occurs after primary traumatic dislocations of the elbow but can occur after iatrogenic injuries. Cadaveric studies have shown that incompetence of both the lateral collateral ligament and the lateral ulnar collateral ligament is necessary in order for posterolateral rotatory instability to be present.1,6 Posterolateral rotatory instability is a poorly understood cause of elbow pain and is under-diagnosed. Assessment for posterolateral rotatory instability is often difficult, and the condition is diagnosed by the O’Driscoll pivot shift test.4 This test is difficult to perform and usually only gives a feeling of apprehension, unless the patient is anesthetized.3 O’Driscoll4 has previously commented that many patients with posterolateral rotatory instability complain of weakness and pain on pushing up from a chair. We advocate the use of a new simple clinical test that aids in the diagnosis of posterolateral rotatory instability. MATERIALS AND METHODS The patient is asked to stand in front of a table. The hand of the symptomatic arm is placed over the lateral edge of the table. The test involves 3 parts. The patient is initially asked to perform a press-up maneuver with the elbow From Southampton General Hospital. Reprint requests: David G. Hargreaves, FRCS(Tr&Orth), Orthopaedic Department, F Level, East Wing, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom. Copyright © 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2006.01.005
pointing laterally. This maintains the forearm in supination. Pressure is pushed down through the hand onto the table, as the elbow is allowed to flex (bringing the chest toward the table). In the presence of posterolateral rotatory instability, positive apprehension and a reproduction of pain occur as the elbow reaches approximately 40° of flexion. The maneuver is then repeated but with the examiner placing his or her thumb over the radial head, giving support and preventing posterior subluxation, while the press-up maneuver is performed (Figure 1). Patients with posterolateral rotatory instability find that their symptoms of pain and instability are relieved by this second maneuver, which is similar to Jobe’s relocation test of the shoulder.2 Finally, removal of the examiner’s supporting thumb from the weight-bearing, partially flexed elbow reproduces the pain and apprehension again. The relief and recurrence of pain during the second and third maneuvers help to exclude articular pathology as the cause of pain and reinforce the diagnosis of instability.
RESULTS Between 2000 and 2003, we have diagnosed 8 cases of posterolateral rotatory instability. These patients were confirmed to have posterolateral rotatory instability by a positive pivot shift test. All of these patients also had a positive tabletop relocation test. Six patients have undergone surgical reconstruction of the lateral ulnar collateral ligament complex. At 6 months after surgery, all 6 patients had a negative pivot shift test and a negative tabletop relocation test. DISCUSSION Posterolateral rotatory instability of the elbow was first described by O’Driscoll et al in 1991.5 It is caused by disruption of the lateral ulnar collateral ligament. There is almost always a history of significant trauma to the elbow as the initiating cause of symptoms. Occasionally, surgical disruption of the lateral ligament complex can occur, particularly after overenthusiastic release of the lateral epicondyle for tennis elbow or an operative approach to the lateral condyle. Assessment for posterolateral rotatory instability can be difficult and requires specific knowledge of the pivot shift test. Findings from investigations with computed tomography and magnetic resonance imaging
707
708
Arvind and Hargreaves
J Shoulder Elbow Surg November/December 2006
therefore, has a low sensitivity. We have found that a press-up test is sensitive but not specific, as radiocapitellar articular pathology will often also cause pain. The tabletop relocation test is a useful modification, which is quick, easy test to perform, and improves the specificity of the press-up test. In our small group of patients, we have found this test to be reliable and consistent and have noted that a positive relocation test is no longer present in treated cases of posterolateral rotatory instability. We believe that this simple test is likely to help clinicians to diagnose this specific type of elbow instability. REFERENCES
Figure 1 Press-up maneuver.
scans are often normal, unless performed under dynamic stress conditions. Stress radiographs, in forced maximal supination of the forearm, often show subluxation of the radial head posteriorly. This is usually best performed in the anesthetized patient. Many surgeons find that the pivot shift test, as described by O’Driscoll,5 is difficult to perform and,
1. Dunning CE, Zarzour ZD, Patterson SD, Johnson JA, King GJ. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 2001;83:1823-8. 2. Kvitne RS, Jobe FW. The diagnosis and treatment of anterior shoulder instability in the throwing athlete. Clin Orthop 1993;291: 107. 3. Lee BP, Teo LH. Surgical reconstruction for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg 2003;12:476-9. 4. O’Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res 2000;370:34-43. 5. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-6. 6. Olsen BS, Sojbjerg JO, Nielsen KK, Vaesel MT, Dalstra M, Sneppen O. Posterolateral elbow joint instability: the basic kinematics. J Shoulder Elbow Surg 1998;7:19-29.
We describe a new clinical test for the assessment of posterolateral rotatory instability. This has been assessed in 8 patients who have been diagnosed with posterolateral rotatory instability. Of these, 6 have undergone surgical reconstruction of the lateral ulnar collateral ligament, and the clinical test has subsequently been negative with resolution of their symptoms. (J Shoulder Elbow Surg 2006;15:707-708.)
P osterolateral
rotatory instability of the elbow is thought to be the most common form of recurrent instability of the elbow.4 It most commonly occurs after primary traumatic dislocations of the elbow but can occur after iatrogenic injuries. Cadaveric studies have shown that incompetence of both the lateral collateral ligament and the lateral ulnar collateral ligament is necessary in order for posterolateral rotatory instability to be present.1,6 Posterolateral rotatory instability is a poorly understood cause of elbow pain and is under-diagnosed. Assessment for posterolateral rotatory instability is often difficult, and the condition is diagnosed by the O’Driscoll pivot shift test.4 This test is difficult to perform and usually only gives a feeling of apprehension, unless the patient is anesthetized.3 O’Driscoll4 has previously commented that many patients with posterolateral rotatory instability complain of weakness and pain on pushing up from a chair. We advocate the use of a new simple clinical test that aids in the diagnosis of posterolateral rotatory instability. MATERIALS AND METHODS The patient is asked to stand in front of a table. The hand of the symptomatic arm is placed over the lateral edge of the table. The test involves 3 parts. The patient is initially asked to perform a press-up maneuver with the elbow From Southampton General Hospital. Reprint requests: David G. Hargreaves, FRCS(Tr&Orth), Orthopaedic Department, F Level, East Wing, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom. Copyright © 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2006.01.005
pointing laterally. This maintains the forearm in supination. Pressure is pushed down through the hand onto the table, as the elbow is allowed to flex (bringing the chest toward the table). In the presence of posterolateral rotatory instability, positive apprehension and a reproduction of pain occur as the elbow reaches approximately 40° of flexion. The maneuver is then repeated but with the examiner placing his or her thumb over the radial head, giving support and preventing posterior subluxation, while the press-up maneuver is performed (Figure 1). Patients with posterolateral rotatory instability find that their symptoms of pain and instability are relieved by this second maneuver, which is similar to Jobe’s relocation test of the shoulder.2 Finally, removal of the examiner’s supporting thumb from the weight-bearing, partially flexed elbow reproduces the pain and apprehension again. The relief and recurrence of pain during the second and third maneuvers help to exclude articular pathology as the cause of pain and reinforce the diagnosis of instability.
RESULTS Between 2000 and 2003, we have diagnosed 8 cases of posterolateral rotatory instability. These patients were confirmed to have posterolateral rotatory instability by a positive pivot shift test. All of these patients also had a positive tabletop relocation test. Six patients have undergone surgical reconstruction of the lateral ulnar collateral ligament complex. At 6 months after surgery, all 6 patients had a negative pivot shift test and a negative tabletop relocation test. DISCUSSION Posterolateral rotatory instability of the elbow was first described by O’Driscoll et al in 1991.5 It is caused by disruption of the lateral ulnar collateral ligament. There is almost always a history of significant trauma to the elbow as the initiating cause of symptoms. Occasionally, surgical disruption of the lateral ligament complex can occur, particularly after overenthusiastic release of the lateral epicondyle for tennis elbow or an operative approach to the lateral condyle. Assessment for posterolateral rotatory instability can be difficult and requires specific knowledge of the pivot shift test. Findings from investigations with computed tomography and magnetic resonance imaging
707
708
Arvind and Hargreaves
J Shoulder Elbow Surg November/December 2006
therefore, has a low sensitivity. We have found that a press-up test is sensitive but not specific, as radiocapitellar articular pathology will often also cause pain. The tabletop relocation test is a useful modification, which is quick, easy test to perform, and improves the specificity of the press-up test. In our small group of patients, we have found this test to be reliable and consistent and have noted that a positive relocation test is no longer present in treated cases of posterolateral rotatory instability. We believe that this simple test is likely to help clinicians to diagnose this specific type of elbow instability. REFERENCES
Figure 1 Press-up maneuver.
scans are often normal, unless performed under dynamic stress conditions. Stress radiographs, in forced maximal supination of the forearm, often show subluxation of the radial head posteriorly. This is usually best performed in the anesthetized patient. Many surgeons find that the pivot shift test, as described by O’Driscoll,5 is difficult to perform and,
1. Dunning CE, Zarzour ZD, Patterson SD, Johnson JA, King GJ. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 2001;83:1823-8. 2. Kvitne RS, Jobe FW. The diagnosis and treatment of anterior shoulder instability in the throwing athlete. Clin Orthop 1993;291: 107. 3. Lee BP, Teo LH. Surgical reconstruction for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg 2003;12:476-9. 4. O’Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res 2000;370:34-43. 5. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-6. 6. Olsen BS, Sojbjerg JO, Nielsen KK, Vaesel MT, Dalstra M, Sneppen O. Posterolateral elbow joint instability: the basic kinematics. J Shoulder Elbow Surg 1998;7:19-29.