Hill Sachs Lesion
Original Editors - Lien Hennebel
- 1 Definition/Description
- 2 Clinically relevant anatomy
- 3 Epidemiology/Etiology
- 4 Characteristics/Clinical presentation
- 5 Differential diagnosis
- 6 Diagnostic Procedures
- 7 Medical management
- 8 Physiotherapy management
- 9 Resources
- 10 Clinical bottom line
- 11 References
A Hill-Sachs lesion is a compression fracture or "dent" of the posterosuperolateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint. It was first described by two radiologists by the name HA Hill and MD Sachs in 1940. This lesion is caused by an anterior shoulder dislocation which causes a humeral head impression fracture. The posterolateral aspect of the humeral head impacts on the anterior glenoid in the dislocated position, causing instability at the glenohumeral joint.
Clinically relevant anatomy
The glenohumeral joint is a synovial ball-and-socket diarthroidal joint. It is the articulation between the glenoid of the scapula and the head of the humerus. It is commonly known that the shoulder joint has a loose capsule, making it the most commonly dislocated joint in the human body, of which 90% of these dislocations are anterior. This is a result of the scapular orientation of about 30° anterior to the frontal plane of the body. The humerus is thus anteriorly orientated to the glenoid in the glenohumeral joint.
This is a brief overview of the relevant anatomy. See the page for the glenohumeral joint for detailed information.
The labrum, a fibrocartilaginous structure, surrounds the glenoid to ensure that there is enough contact between the surface of the glenoid and the humeral head. There is a concavity compression mechanism which plays an important role in the stability of the shoulder. The less contact there is, the higher the risk for dislocations.
- Glenohumeral ligaments (pars superior, media and inferior): Assists in strengthening of the capsule
- Coracohumeral ligament: Assists in strengthening of the capsule
- Transversal humeral ligament: Functions with the Biceps Brachii muscle
- Internal Rotators:
- External Rotators:
There are eight bursae in the shoulder complex as a result of the high amount of muscles surrounding the shoulder. They ensure a smooth contact between the muscle and the underlying structures. The subacromial bursa is the biggest in the body.
The incidence of Hill-Sachs lesions are approximately 40%-90% of all anterior shoulder instability cases, and even as high as 100% in patients with recurrent anterior instability. A study looking at this found Hill-Sachs lesions in 65% of acute dislocations and 93% in patients with recurrent instability.
A Hill-Sachs lesion occurs in about 50% of the first-time shoulder dislocations. For people with a shoulder dislocations history (i.e. shoulder instability) humeral head compression fractures are present in most cases.
- Anterior shoulder instability:
- Approximately 47% of the lesions are associated with the initial shoulder instability according to research studies
- Bankart lesion
- 2.5 times more likely to for someone with either of those lesions to have the other as well
- Anterior glenoid bone loss (in cases of recurrent instability)
Classification systems are used to describe the amount of damage to the anterior capsule and the labrum, reflected by the depth of the lesion. Higher grade lesions are associated with increased risk of recurrent dislocation.
- Grade 1: Defect in the articular surface down to (but not including) the subchondral bone
- Grade 2: Lesion includes the subchondral bone
- Grade 3: Lesion causes large defect in the subchondral bone.
Further classification can be done by looking at the percentage of the defect of humeral head involvement in the compression fracture. The size of the lesion correlates in most cases to the number of previous dislocations.
- Minor: <20%
- Moderate: 20%-45%
- Severe: >45%
Shoulder dislocation rarely occur isolated. It causes damage to different tissues surrounding the glenohumeral joint, such as ligaments, rotator cuff tendons, joint capsule as well as the bone and cartilage of the humeral head. This occurs when the round humeral head is forcibly impacted on the edge of the glenoid, which causes compression fractures in the humeral head. This forms a dimple structure on the articular surface of the humerus - a Hill-Sachs lesion. This is always caused by dislocation, not only sublaxation.
According to the page on shoulder dislocations, the following indicates an acute anterior glenohumeral dislocation:
- Arm held in abduction and external rotation
- Loss of normal contour of the deltoid and acromion prominent posteriorly and laterally
- Humeral head palpable anteriorly
- All movements limited and painful
- Coracoid process: Palpable fullness and positioned towards the axilla
- Bankart lesion:
- Pseudo-Hill-Sachs lesion:
- It is normal that below the level of the coracoid, the humeral head normally flattens out, and should not be mistaken as a Hill-Sachs lesion
- Humeral avulsion fractures
- Mid capsular tears
- Floating anterior capsule
- Reverse Hill-Sachs lesion:
- Bony apprehension test:
- Positive test: Pain/reflex muscle contraction (in case of sublaxation)
- Jobe relocation test:
- Positive test: Apprehension
- Crepitus and catching may be felt during active and passive abduction and external rotation
- Possible lesion indicated by audible/palpable clunk in active/passive abduction and external rotation or an unstable feeling during mid-range
- Grashey view (AP) in internal and external rotation; transcapular view (X-ray beam caudally from standard AP view); axillary views with exaggerated external rotation and West Pont views (if pain allows)
- Important first step at effectively evaluating the glenohumeral relationship as well as osseous pathology of the humerus and the glenoid
- Can detect bony lesions related to shoulder instability in the acute phase
- Difficult to see Hill-Sachs lesion
- Detect and localize a compression fracture
- Cost-effective, minimal exposure to excessive radiation, comfortable for patient
- Hill-Sachs lesions: Apparent triangular depression in the contour of the humerus
- CT scan: Reliably asses the location and depth of the humeral lesion
- MRI: Detect pathology of the soft tissue; determine the amount of humeral and glenoid bone loss
- Disabilities of the arm, shoulder and hand (DASH)
- Shoulder Pain and Disability Index (SPADI)
- Numeric Pain Rating Scale (NPRS)
Several studies have shown that when the number of dislocations increases, the incidence and size of Hill-Sachs lesion also increases. It can be a cause of instability and in this case, surgical treatment is considered. Frequently, authors consider that surgical treatment of recurrent shoulder dislocation is indicated when someone had more than five shoulder dislocations. With minimum glenoid bone loss and without significant involvement of the humeral head (<20%), surgical management is not indicated. This instability can be managed conservatively in a mastersling for immobilization for 2-6 weeks, before starting with rehabilitation (see "Physiotherapy management" later on).
Management of humeral bone loss (as in Hill-Sachs lesion) can be directed at the restoration of the glenohumeral articular arc with either glenoid-based bone augmentation techniques (most commonly used), humeral-based strategies, or a combination. These strategies include open as well as arthroscopic procedures, depending on the extent of the pathology. . Treating the glenoid defects is often the solution to the glenohumeral instability. CT scans make it possible to reliably asses the location and depth of the humeral lesion. Based on the this, a surgical decision is made.
- Remplissage procedure: Defect is filled with soft tissue, usually from the infraspinatus tendon
- Second arthroplasty method: Percutaneous humeroplasty
- Lesion is filled by using a bone tamp brought into a drilled osseus window 180° from the lesion
- Advantage: Rotational osteotomy of the humeral head is not needed and the humeral head can be restored without transpositioning the soft tissue
- Limitations: Limited to moderate-sized defects; lack of management of osteochondral defects
- Other procedures: Techniques that use various small bone plugs
- Laterjet procedure: Most frequently done
- Most commonly, bone from the coracoid process is used as an augment to the antero-inferior glenoid bone loss. By reforming the concavity and width of the glenoid, a Hill-Sachs lesion does not influence the anterior glenoid rim of unstable shoulders.
- Successful in preventing instability over time
- Negative consequences associated with the Laterjet are shoulder arthrosis and loss of function
- Autologous bone plugs
- Size-matched osteo-articular allografts
- Rotational humeral osteotomy:
- Osteotomy of the surgical neck to rotate the humeral head for 25°
- Currently not method of choice, given the related risks and the success rates of more recent procedures.
- The osseus humeral allograft bone plug technique:
- A size-matched humeral bone plug of a donor is used
- Approach: Delto-pectoral or deltoid-splitting
- Advantages: Minimal exposure; humeral head remains in the capsule.
- Disadvantage: Limited to small and moderate lesions; risks of using cadaveric tissue
Aim: Prevent reoccurrence of dislocations
The non-operative rehabilitation of the unstable shoulder consists about seven key factors. It is important to consider this in the rehabilitation program of the shoulder after a Hill-Sachs lesion.
- The onset of pathology
- The degree of instability
- The frequency of dislocation
- The direction of instability
- Concomitant pathologies
- Neuromuscular control
- Activity level
Physiotherapy interventions include:
- 2-6 weeks of immobilization in a mastersling:
- Scapula stabilization exercises
- Hand, wrist and elbow exercises
- Teach patient on functional adaptions (e.g. personal hygiene, dressing and undressing)
- No driving while still in sling
- When use of sling is discontinued (on recommendation of orthopaedic surgeon):
- Pendulum exercises
- Passive, active-assisted and active range of motion exercises (progressions)
- Abduction and external rotation is restricted during the initial phase of the rehabilitation
- Ligaments healing needs to take place to prevent dislocation
- Strengthening of the deltoid, rotator cuff and periscapular (e.g. pectoralis major) muscles
Post-surgical rehabilitation should be guided by the orthopaedic surgeon, and depends on the procedure that was done.
- Update on Hill-Sachs lesion
- Non-operative management of anterior shoulder dislocation
- Treatment options for Hill-Sachs lesion (Othopaedics Today, Hawaii 2018)
A Hill-Sachs lesion is an injury that occurs secondary to an anterior shoulder dislocation. The humeral head ‘collides’ with the anterior part of the glenoid, causing a lesion, bone loss, defect and deformity of the humeral head. This may cause a change loss of range of motion, feelings of instability and pain. A grading system is used based on the amount of bone loss or severity of the humeral head deformity. The incidence of Hill-Sachs lesion in patients with anterior shoulder instability can be as high as 100%. Another pathology secondary to an anterior shoulder dislocation is a Bnkart lesion. This is an injury of the anterior glenoid labrum of the shoulder and often often accompanied by a Hill-Sachs lesion.
Conservative treatment is only recommended in cases of small bony defects (<20% Hill-Sachs lesion), in other cases (larger and more significant lesions), surgical treatment is needed. The conservative treatment should be based on strengthening the deltoid, the rotator cuff muscles and scapular stabilizers.
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