Lateral Pivot Shift Test Elbow

Lateral Pivot Shift test elbow or as called (Posterolateral Apprehension Test) is used for Lateral Ulnar Collateral Ligament Injury (PLRI) which causes posterolateral instability of the elbow.

This test was first described by described by O’Driscoll in 1991¹.

How do you perform the Lateral Pivot Shift Test Elbow?

• With the patient supine, the examiner stands at the patient’s head and grasps around the patient’s wrist with one hand and the slightly flexed elbow with the other.
• The examiner supinates the forearm and applies a mild valgus force.
• From this position, the patient’s elbow is further flexed and axial pressure is applied to the elbow.
• This test is often more reliable on anesthetized patient.

What does a positive Lateral Pivot Shift Test Elbow mean?

Lateral Pivot Shift test elbow is considered positive when:

• A posterolateral subluxation of the elbow occurs at 20 to 30° of flexion, accompanied by pain and an evasive movement by the patient.
• With continued flexion of the elbow to 40 to 70°, the joint reduces with a palpable and audible “snap.

Sensitivity & Specificity

• Sensitivity: 100 % (In anesthetized patients)
• Sensitivity: 38 % (In awake patients) ^{2 3}

Notes

• Because of the anatomical fact that the arm normally has a valgus orientation and load, mild varus instabilities remain unnoticed clinically. Mild valgus instabilities are more likely to be present.
• Reproducing the actual subluxation, and the clunk that occurs with reduction, usually can only be accomplished with the patient under general anesthesia or occasionally after injecting local anesthetic into the elbow.

• Varus instability of the elbow is acutely due to rupture of the lateral collateral ligament from subluxation of the elbow or from instability due to a lateral collateral ligament injury that has failed to heal properly.
• Rarely, one sees instability in people who are chronically dependent on walking sticks or in patients in the context of surgery for lateral epicondylitis or surgical repair of a radial head fracture.
• Posterolateral instability occurs with rupture of the lateral collateral ligament. Because of the anatomical fact that the arm normally has a valgus orientation and load, mild varus instabilities remain unnoticed clinically. Mild valgus instabilities are more likely to be present.

Reference

1. O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991 Mar; 73(3):440-6. PMID: 2002081
2. William Regan, Peter C Lapner: Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the elbow. J Shoulder Elbow Surg . May-Jun 2006;15(3):344-6. doi: 10.1016/j.jse.2005.03.009. PMID: 16679236
3. Lauren E. Karbach, MD and John Elfar, MD: Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and Testing. J Hand Surg Am. 2017 Feb; 42(2): 118–126. PMID: 28160902
4. Musculoskeletalkey
5. Clinical Tests for the Musculoskeletal System 3rd Edition.
6. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.