Reverse Pivot Shift

With the patient supine and the knee flexed 90 degrees, the foot is externally rotated and the knee extended with an applied

Box 53-2 Classification of Posterior Cruciate Ligament Injuries16

• Time frame

Acute (<2 weeks)

Subacute (2-8 weeks)

Chronic (>8 weeks)

• Instability

Level 1: Posterior drawer < grade II

Level 2: Posterior drawer > grade II; stable to varus and

valgus

stress at 0 degrees

Level 3: Posterior drawer > grade II; unstable to varus and

valgus

stress at 0 degrees or pathologic hyperextension

Level 4: Knee dislocation

Figure 53-7 Classification of posterior cruciate ligament injury, as assessed with the posterior drawer test. In a normal knee, the anterior edge of the medial tibial plateau is palpated 1 to 1.5 cm anterior to the medial femoral condyle. In grade I injury, 0 to 5 mm of posterior tibial displacement is possible. In grade II injury, the tibia can be displaced flush with the femur (5 to 10 mm of displacement), and in grade III injury (>10mm), the tibia can be displaced posterior to the condyle. (From Petrie RS, Harner CD: Evaluation and management of the posterior cruciate injured knee. Oper Tech Sports Med 1999;7:93-103.)

valgus stress. A positive test occurs with palpable reduction of the displaced tibia at 20 to 30 degrees of knee flexion. It is important to examine the opposite knee, as a positive reverse pivot can be a normal variant in some patients.1

Dial (Tibia External Rotation) Test

This is considered the most important test for posterolateral instability and is most easily performed with the patient prone.

The tibiae are externally rotated, and the thigh-foot angle measured and compared between sides. A pathologic examination is indicated by more than 10 to 15 degrees of asymmetry. The test should be performed with the knees at both 30 and 90 degrees of flexion. If asymmetry exists only at 30 degrees, this most likely indicates an isolated PLCC injury, but if asymmetry exists at both 30 and 90 degrees, combined PLCC and PCL injury should be suspected.

Figure 53-8 In the quadriceps active test, quadriceps contraction will reduce the posteriorly displaced tibia. (From Giffin JR, Annunziata CC, Harner CD: Posterior cruciate ligament injuries in the adult. In DeLee JC, Drez D Jr, Miller MD [eds]: Orthopaedic Sports Medicine, 2nd ed. Philadelphia, WB Saunders, 2003, pp 2083-2106.)

Figure 53-8 In the quadriceps active test, quadriceps contraction will reduce the posteriorly displaced tibia. (From Giffin JR, Annunziata CC, Harner CD: Posterior cruciate ligament injuries in the adult. In DeLee JC, Drez D Jr, Miller MD [eds]: Orthopaedic Sports Medicine, 2nd ed. Philadelphia, WB Saunders, 2003, pp 2083-2106.)

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