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Diagnostik und Therapie der posterioren Schulterinstabilität

Diagnostics and treatment of posterior shoulder instability

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Zusammenfassung

Die posteriore Schulterinstabilität besitzt eine deutlich geringe Inzidenz als die anteriore Schulterinstabilität. Sie weist ein weites Spektrum an klinischer Symptomausprägung auf. Zudem fehlt bei der Mehrheit der Patienten anamnestisch eine traumatische Erstluxation. Neben der ausführlichen Anamnese ist zur Diagnosefindung die gezielte klinische Untersuchung mithilfe standardisierter Provokationstests wichtig. Zum Nachweis einer strukturellen posterioren Kapsel-Labrum-Läsion sollte bei chronischen Verläufen eine Magnetresonanztomographie mit intraartikulär appliziertem Kontrastmittel durchgeführt werden. Relevante knöcherne Defekte am Humeruskopf (reverse Hill-Sachs-Läsion) sind häufig, während kritische posteriore Defekte des Glenoids relativ selten sind. Beide Läsionen sollten mithilfe der 3D-Computertomographie quantifiziert werden. Die Wahl des therapeutischen Vorgehens orientiert sich am zugrunde liegenden Defekt. Die konservative Therapie ist bei Patienten mit Skapuladyskinesie, willkürlichen Luxationen und pathologischem „muscle patterning“ als sinnvoll zu betrachten. Bei isolierten Weichteilpathologien werden als Standardtherapie die arthroskopische Labrumrefixation und Kapselraffung angewandt. Bei insuffizienten Weichteilverhältnissen oder kritischem posteriorem Glenoiddefekt ist der knöcherne Glenoidaufbau mithilfe des Beckenkammspans die Therapie der Wahl.

Abstract

Posterior shoulder instability has a markedly lower incidence than anterior shoulder instability. It has a wide spectrum of clinical symptom manifestations and the overwhelming number of patients lack a traumatic primary dislocation. In addition to a detailed medical history, a specific clinical examination with the help of standardized provocation tests is essential for the diagnostics. For the detection of structural posterior capsule and labral lesions in cases of chronic courses, magnetic resonance imaging (MRI) should be used with an intra-articular contrast agent. Relevant bony defects of the humeral head (reverse Sachs-Hill lesion) are frequent, whereas critical posterior defects of glenoid cavity are relatively rare. Both lesions should be quantified using 3D computed tomography. The choice of therapeutic procedure should be based on the underlying pathology of the defect. Conservative therapy is useful in patients with scapular dyskinesis, voluntary dislocation and pathological muscle patterning. In isolated soft tissue pathologies, arthroscopic labrum fixation and capsule plication are the standard treatment. In the case of insufficient soft tissue relations or critical posterior glenoid defects, bony stabilization of the glenoid using an iliac crest bone graft is the recommended therapy.

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  1. Diakovere Annastift, Orthopädische Klinik, Medizinische Hochschule Hannover, Anna-von-Borries-Str. 1–7, 30625, Hannover, Deutschland

    M. Wellmann, M.-F. Pastor &  T. Smith

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Wellmann, M., Pastor, MF. & Smith, T. Diagnostik und Therapie der posterioren Schulterinstabilität. Unfallchirurg 121, 134–141 (2018). https://doi.org/10.1007/s00113-017-0430-2

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