Rockwood Adults CH34

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SECTION TWO • Upper Extremity

Authors’ Preferred Treatment for Posterior Glenohumeral Instability (Algorithm 34-3)

Posterior shoulder instability é trauma

High demand patient/athlete

Low demand

Symptoms < 6 months

Symptoms > 6 months

Physical therapy conservative management

Recurrent posterior instability or pain

MR é arthrogram

Posterior labral tear é increased axial capsular volume > 300 mm

No posterior labral tear (posterior axial capsular volume > 300 mm)

Surgery

No concern for posterior glenoid bone loss

Concern for posterior glenoid bone loss (CT with 3D reconstruction)

Posterior bone loss

Glenoid retroversion

> 20 degrees

< 20 degrees

< 20%

> 20%

Posterior glenoid bone grafting é arthroscopic or open repair

Arthroscopic or open repair é glenoid osteotomy or bone grafting

Arthroscopic or open posterior repair

Algorithm 34-3.  Authors’ preferred treatment for anterior shoulder instability with or without trauma.

Patients who present with symptoms of posterior shoul- der instability should be grouped into either low demand/ nonathletes or high demand/athletes. It is important for the physician to differentiate between symptoms of posterior apprehension, instability, or pain as these can help guide treatment options. In the low-demand group, symptoms less than 6 months should be addressed with conservative management with physical therapy focusing on ROM exer- cises and rotator cuff and deltoid musculature strengthen- ing. For patients who present with longer than 6 months of duration of symptoms, advanced imaging should be

obtained to evaluate for intra-articular injuries. If no pos- terior labral tear is detected on the MRI (with or without arthrogram), then physical therapy and conservative man- agement is initiated. If there is no posterior labral tear but the posterior axial capsular volume is greater than 300 mm, or in patients with discrete posterior labral tear, surgery should be recommended. In patients who present with glenoid retroversion or bone loss on CT images, the decision between arthroscopic repair and posterior bone block procedure is based on the critical amount for both retroversion and bone loss.