Fremerey R, Bosch U
Unfallchirurgische Klinik, Medizinische Hochschule Hannover.
Zentralbl Chir. 2001 Mar;126(3):184-91. doi: 10.1055/s-2001-12507.
Chronic instabilities may be traumatic or atraumatic, unidirectional or multidirectional. It is important to distinguish between symptomatic instability and asymptomatic hyperlaxity. Posttraumatic, unidirectional anterior instability without hyperlaxity is the most common form of instability. The patient presents apprehension, the sulcus-sign is negative. Posttraumatic, unidirectional instability with hyperlaxity is due to an adequate trauma, both the apprehension test and the sulcus sign are positive. The treatment of traumatic instability is surgically with respect to the underlying pathology of the ligaments, labrum and capsule. The "golden standard" is the reconstruction of the capsulolabral complex. The repetitive microtraumatic instability is seen in overhead athletes with elongation or disruption of the capsule. The typical patient presents with painful subluxations, the instability may be unidirectional or multidirectional. The treatment is conservatively. Multidirectional instability with hyperlaxity is defined as symptomatic instability in at least two directions of instability with multidimensional hyperlaxity. These individuals will also report on pain rather than instability. The apprehension test is positive in at least two directions, the sulcus sign is positive as well. The patients are responsive to an intensive rehabilitation program for 6-12 months. Open capsular shift or thermal capsular shrinkage may be successful after failed conservative treatment. Multidirectional instability without hyperlaxity is extremely rare and is due to more than one adequate trauma with traumatic instability in different directions. The apprehension test is positive, the sulcus sign negative. The treatment is surgically. The fixed dislocation is posterior in most of the cases and frequently being missed primarily. It is seen in unconscious, multiple-injured patients or after grand mal or electroshock seizures. The reduction may be either closed or open depending on the interval between trauma and diagnosis. Voluntary instability represents a subset of individuals with atraumatic instability. The patients can dislocate and reduce their shoulder, have no pain and do not develop arthritis. They do not require a special therapy.
慢性不稳定可能是创伤性或非创伤性的，单向或多向的。区分症状性不稳定和无症状性关节过度松弛很重要。创伤后单向无关节过度松弛的前向不稳定是最常见的不稳定形式。患者表现出恐惧，沟槽征为阴性。创伤后伴有关节过度松弛的单向不稳定是由于足够的创伤，恐惧试验和沟槽征均为阳性。创伤性不稳定的治疗针对韧带、盂唇和关节囊的潜在病理进行手术。“金标准”是关节囊盂唇复合体的重建。重复性微创伤性不稳定见于上肢过顶运动的运动员，表现为关节囊拉长或断裂。典型患者表现为疼痛性半脱位，不稳定可能是单向或多向的。治疗以保守为主。伴有关节过度松弛的多向不稳定定义为至少在两个不稳定方向上有症状性不稳定且伴有多维度关节过度松弛。这些个体也会诉说疼痛而非不稳定。恐惧试验至少在两个方向上为阳性，沟槽征也为阳性。患者对6至12个月的强化康复计划有反应。保守治疗失败后，开放性关节囊移位或热关节囊收缩可能成功。无关节过度松弛的多向不稳定极为罕见，是由于在不同方向上有不止一次足够的创伤导致创伤性不稳定。恐惧试验为阳性，沟槽征为阴性。治疗采用手术。在大多数情况下，固定性脱位是后脱位，最初常被漏诊。见于无意识的多发伤患者或癫痫大发作或电击惊厥后。复位可根据创伤与诊断之间的时间间隔采用闭合或开放方式。自愿性不稳定是无创伤性不稳定个体的一个子集。患者能够自行脱位和复位肩关节，无疼痛且不会发展为关节炎。他们不需要特殊治疗。
