Hill Sachs Lesion: Difference between revisions
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=== Epidemiology === | === Epidemiology === | ||
The incidence of Hill-Sachs lesions are approximately 40%-90% of all [http://www.physio-pedia.com/Anterior_Shoulder_Instability anterior shoulder instability] cases, and even as high as 100% in patients with recurrent anterior instability.<ref name="provencher" /> A study looking at this found Hill-Sachs lesions in 65% of acute dislocations and 93% in patients with recurrent instability.<ref name="christos">Yiannakopoulos CK, Mataragas E, Antonogiannakis E. [ | The incidence of Hill-Sachs lesions are approximately 40%-90% of all [http://www.physio-pedia.com/Anterior_Shoulder_Instability anterior shoulder instability] cases, and even as high as 100% in patients with recurrent anterior instability.<ref name="provencher" /> A study looking at this found Hill-Sachs lesions in 65% of acute dislocations and 93% in patients with recurrent instability.<ref name="christos">Yiannakopoulos CK, Mataragas E, Antonogiannakis E. [http://www.orthosurgery.gr/dimosieusis/AComparisonoftheSpectrumofIntra-articularLesionsinAcuteandChronicAnteriorShoulderInstability.pdf A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability.] Arthroscopy: The Journal of Arthroscopic & Related Surgery 2007;23(9):985-90.</ref><br> | ||
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.<ref name="fuller" /><ref name="savoie">Savoie F, O’Brien M. Management of Hill-Sachs Lesion, International Congress for Joint Reconstruction, 2014.</ref> <br> | 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.<ref name="fuller" /><ref name="savoie">Savoie F, O’Brien M. Management of Hill-Sachs Lesion, International Congress for Joint Reconstruction, 2014.</ref> <br> | ||
=== Etiology === | === Etiology === | ||
* [http://www.physio-pedia.com/Anterior_Shoulder_Instability Anterior shoulder instability]: | * [http://www.physio-pedia.com/Anterior_Shoulder_Instability Anterior shoulder instability]: | ||
** Approximately 47% of the lesions are associated with the initial shoulder instability according to research studies)<ref name="calandra">Calandra JJ, Baker CL, Uribe J. [https://www.sciencedirect.com/science/article/pii/0749806389901382 The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations.] Arthroscopy: The Journal of Arthroscopic & Related Surgery | ** Approximately 47% of the lesions are associated with the initial shoulder instability according to research studies)<ref name="calandra">Calandra JJ, Baker CL, Uribe J. [https://www.sciencedirect.com/science/article/pii/0749806389901382 The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations.] Arthroscopy: The Journal of Arthroscopic & Related Surgery 1989;5(4):254-7.</ref> | ||
* [http://www.physio-pedia.com/Bankart_lesion Bankart lesion]<ref name="horst">Horst K, Von Harten R, Weber C, Andruszkow H, Pfeifer R, Dienstknecht T, Pape HC. [https://www.birpublications.org/doi/pdfplus/10.1259/bjr.20130673 Assessment of coincidence and defect sizes in Bankart and Hill–Sachs lesions after anterior shoulder dislocation: a radiological study.] The British journal of radiology | * [http://www.physio-pedia.com/Bankart_lesion Bankart lesion]<ref name="horst">Horst K, Von Harten R, Weber C, Andruszkow H, Pfeifer R, Dienstknecht T, Pape HC. [https://www.birpublications.org/doi/pdfplus/10.1259/bjr.20130673 Assessment of coincidence and defect sizes in Bankart and Hill–Sachs lesions after anterior shoulder dislocation: a radiological study.] The British journal of radiology 2014;87(1034):20130673.</ref> | ||
** 2.5 times more likely to for someone with either of those lesions to have the other as well<ref name="widjadja">Widjaja AB, Tran A, Bailey M, Proper S. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1445-2197.2006.03760.x Correlation between Bankart and Hill‐Sachs lesions in anterior shoulder dislocation.] ANZ journal of surgery | ** 2.5 times more likely to for someone with either of those lesions to have the other as well<ref name="widjadja">Widjaja AB, Tran A, Bailey M, Proper S. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1445-2197.2006.03760.x Correlation between Bankart and Hill‐Sachs lesions in anterior shoulder dislocation.] ANZ journal of surgery 2006;76(6):436-8.</ref> | ||
* Anterior glenoid bone loss (in cases of recurrent instability)<ref name="kim">Kim DS, Yoon YS, Yi CH. [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.858.1952&rep=rep1&type=pdf Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder.] The American journal of sports medicine | * Anterior glenoid bone loss (in cases of recurrent instability)<ref name="kim">Kim DS, Yoon YS, Yi CH. [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.858.1952&rep=rep1&type=pdf Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder.] The American journal of sports medicine 2010;38(10):2071-6.</ref> | ||
== Characteristics/Clinical presentation == | == Characteristics/Clinical presentation == | ||
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*'''Grade 3:''' Lesion causes large defect in 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.<ref name="cetik">Cetik O, Uslu M, Ozsar BK. [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.627.9326&rep=rep1&type=pdf The relationship between Hill-Sachs lesion and recurrent anterior shoulder dislocation.] Acta orthopaedica belgica | Further classification can be done by looking at the percentage of the defect of humeral head involvement in the compression fracture.<ref name="cetik">Cetik O, Uslu M, Ozsar BK. [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.627.9326&rep=rep1&type=pdf The relationship between Hill-Sachs lesion and recurrent anterior shoulder dislocation.] Acta orthopaedica belgica 2007;73(2):175-8.</ref> The size of the lesion correlates in most cases to the number of previous dislocations.<ref name="savoie" /> | ||
* '''Minor:''' <20% | * '''Minor:''' <20% | ||
* '''Moderate:''' 20%-45% | * '''Moderate:''' 20%-45% | ||
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{{#ev:youtube|watch?v=5BjDQ-jcBek}} | {{#ev:youtube|watch?v=5BjDQ-jcBek}} | ||
=== Special investigations === | === Special investigations === | ||
* X-ray: <ref name="provencher 2" /><ref name="omoumi">Omoumi P, Teixeira P, Lecouvet F, Chung CB. [https://onlinelibrary.wiley.com/doi/pdf/10.1002/jmri.22343 Glenohumeral joint instability.] Journal of Magnetic Resonance Imaging | * [[X-Rays|X-ray]]: <ref name="provencher 2" /><ref name="omoumi">Omoumi P, Teixeira P, Lecouvet F, Chung CB. [https://onlinelibrary.wiley.com/doi/pdf/10.1002/jmri.22343 Glenohumeral joint instability.] Journal of Magnetic Resonance Imaging 2011;33(1):2-16.</ref> | ||
** 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) | ** 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 | ** 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 | ** Can detect bony lesions related to shoulder instability in the acute phase | ||
** Difficult to see Hill-Sachs lesion | ** Difficult to see Hill-Sachs lesion | ||
* Ultrasound:<ref name="omoumi" /><ref name="kodali">Kodali P, Jones MH, Polster J, Miniaci A, Fening SD. [https://www.sciencedirect.com/science/article/pii/S1058274611000437 Accuracy of measurement of Hill-Sachs lesions with computed tomography.] Journal of shoulder and elbow surgery | * [[Ultrasound Scans|Ultrasound]]:<ref name="omoumi" /><ref name="kodali">Kodali P, Jones MH, Polster J, Miniaci A, Fening SD. [https://www.sciencedirect.com/science/article/pii/S1058274611000437 Accuracy of measurement of Hill-Sachs lesions with computed tomography.] Journal of shoulder and elbow surgery 2011;20(8):1328-34.</ref> | ||
** Detect and localize a compression fracture | ** Detect and localize a compression fracture | ||
** Cost-effective, minimal exposure to excessive radiation, comfortable for patient | ** Cost-effective, minimal exposure to excessive radiation, comfortable for patient | ||
** Hill-Sachs lesions: Apparent triangular depression in the contour of the humerus<ref name="castro" /> | ** Hill-Sachs lesions: Apparent triangular depression in the contour of the humerus<ref name="castro" /> | ||
* CT | * [[CT Scans|CT scan]]: Reliably asses the location and depth of the humeral lesion<ref name="pancione">Pancione L, Gatti G, Mecozzi B. [https://www.tandfonline.com/doi/pdf/10.1080/02841859709174380 Diagnosis of Hill-Sachs lesion of the shoulder: comparison between ultrasonography and arthro-CT.] Acta Radiologica 1997;38(4):523-6.</ref> | ||
* MRI: Detect pathology of the soft tissue; determine the amount of humeral and glenoid bone loss<ref name="pancione" /><ref name="pavic">Pavic R, Margetic P, Bensic M, Brnadic RL. [https://www.sciencedirect.com/science/article/pii/S0020138313701943 Diagnostic value of US, MR and MR arthrography in shoulder instability.] Injury | [[File:Hill sachs lesion.jpg|center|thumb]] | ||
* [[MRI Scans|MRI]]: Detect pathology of the soft tissue; determine the amount of humeral and glenoid bone loss<ref name="pancione" /><ref name="pavic">Pavic R, Margetic P, Bensic M, Brnadic RL. [https://www.sciencedirect.com/science/article/pii/S0020138313701943 Diagnostic value of US, MR and MR arthrography in shoulder instability.] Injury 2013;44:S26-32.</ref> | |||
[[File:Hill sachs MRI.jpg|center|thumb]] | |||
<ref name="fuller" /><ref name="cluett" /><ref name="ahmed" /> | <ref name="fuller" /><ref name="cluett" /><ref name="ahmed" /> | ||
=== Outcome Measures === | === Outcome Measures === | ||
Line 135: | Line 138: | ||
== Medical management == | == Medical management == | ||
Management for 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.<ref name="provencher 2" /> . Treating the glenoid defects is often the solution to the glenohumeral instability. | 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.<ref name="cetik" /><ref name="cutts">Cutts S, Prempeh M, Drew S. [https://publishing.rcseng.ac.uk/doi/pdf/10.1308/003588409X359123 Anterior shoulder dislocation.] The Annals of The Royal College of Surgeons of England 2009;91(1):2-7.</ref> With minimum of glenoid bone loss and without significant involvement of the humeral head (<20%), surgical management is not indicated<ref name="andrew" />. This instability can be managed conservatively in a master sling for immobilization for 2-6 weeks, before starting with rehabilitation (see "Physiotherapy management" later on).<ref name="cetik" /><ref name="andrew" /> | ||
Management for 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.<ref name="provencher 2" /> . Treating the glenoid defects is often the solution to the glenohumeral instability. [[CT Scans|CT scans]] make it possible to reliably asses the location and depth of the humeral lesion. Based on the latter, a surgical decision is made.<ref name="kodali" /> | |||
=== Surgical mangement === | |||
==== Arthroscopic technique ==== | |||
* '''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: Moderate-sized defects and the lack of management of osteochondral defects | |||
* '''Other procedures''': Techniques that use various small bone plugs | |||
<ref name="provencher 2" /> | |||
==== Open technique ==== | |||
* | * '''Laterjet procedure''': Most frequently done<ref name="provencher 2" /><ref name="schroder">Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS. [https://www.researchgate.net/profile/Matthew_Provencher/publication/7371754_The_modified_bristow_procedure_for_anterior_shoulder_instability_26-Year_outcomes_in_Naval_Academy_Midshipmen/links/0912f509b2b2743dea000000.pdf The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen.] The American journal of sports medicine 2006;34(5):778-86.</ref><ref name="hovellus">Hovelius L, Sandström B, Sundgren K, Saebö M. [https://www.sciencedirect.com/science/article/pii/S1058274604000916 One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I—clinical results.] Journal of shoulder and elbow surgery 2004;13(5):509-16.</ref> | ||
** 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 the overtime instability | |||
** 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 | |||
<ref name="provencher 2" /> | |||
== Physiotherapy management == | == Physiotherapy management == | ||
'''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 [http://www.physio-pedia.com/Rehabilitation_program_of_the_shoulder rehabilitation program of the shoulder] after a Hill-Sachs lesion.<ref name="wilk">Wilk KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. North American journal of sports physical therapy 2006;1(1):16.</ref> | |||
* The onset of pathology | |||
* The degree of instability | |||
* The onset of pathology | * The frequency of dislocation | ||
* The degree of instability | * The direction of instability | ||
* The frequency of dislocation | * Concomitant pathologies | ||
* | |||
* Concomitant pathologies | |||
* Neuromuscular control | * Neuromuscular control | ||
* Activity level | * Activity level | ||
Physiotherapy interventions include: | |||
* 2-6 weeks of immobilization in a master sling: | |||
** 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. | |||
<ref name="andrew">Chen AL, Bosco III JA. [http://go.galegroup.com/ps/anonymous?id=GALE%7CA166094301&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=19369719&p=AONE&sw=w Glenohumeral bone loss and anterior instability.] Bulletin of the NYU hospital for joint diseases 2006 Dec 22;64(3-4):130.</ref> | |||
Post-surgical rehabilitation should be guided by the orthopaedic surgeon, and depends on the procedure that was done. | |||
== Resources == | == Resources == |
Revision as of 06:15, 28 August 2018
Original Editors - Lien Hennebel
Top Contributors - Jelle Van Hemelryck, Lien Hennebel, Leana Louw, Pauline Bouten, Simisola Ajeyalemi, Uchechukwu Chukwuemeka, Kim Jackson, Lucinda hampton, Shreya Pavaskar, Admin, Rachael Lowe, Fasuba Ayobami, Wanda van Niekerk, Claire Knott, Nupur Smit Shah and 127.0.0.1
**Editing in process - Come back later for updated page***
Definition/Description[edit | edit source]
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.[1][2] It was first described by two radiologists by the name HA Hill and MD Sachs in 1940.[2] 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.[3][4][5]
Clinically relevant anatomy[edit | edit source]
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 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 degrees anterior to the frontal plane of the body. The humerus is thus anteriorly orientated to the glenoid in the glenohumeral joint.[5][6][7]
This is a brief overview of the relevant anatomy. See the page for the glenohumeral joint for detailed information.
Bones[edit | edit source]
The glenoid of the scapula articulates with the humeral head to form a ball-and-socket joint.[6]
Labrum[edit | edit source]
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 chance for dislocations.[8]
Ligaments[edit | edit source]
- Glenohumeral ligaments (pars superior, media and inferior): Assists in strengthening of the capsule[3]
- Coracohumeral ligament: Assists in strengthening of the capsule[3]
- Transversal humeral ligament: Functions with the Biceps Brachii muscle[6]
Muscles[edit | edit source]
- Abductors:
- Adductors:
- Pectoralis major
- Flexors:
- Rotator cuff (very important for the stability of the articulating humerus):
- Extensors:
- Internal Rotators:
- External Rotators:
Bursae[edit | edit source]
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.[5]
Epidemiology/Etiology[edit | edit source]
Epidemiology[edit | edit source]
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.[1] A study looking at this found Hill-Sachs lesions in 65% of acute dislocations and 93% in patients with recurrent instability.[9]
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.[10][11]
Etiology[edit | edit source]
- Anterior shoulder instability:
- Approximately 47% of the lesions are associated with the initial shoulder instability according to research studies)[12]
- Bankart lesion[13]
- 2.5 times more likely to for someone with either of those lesions to have the other as well[14]
- Anterior glenoid bone loss (in cases of recurrent instability)[15]
Characteristics/Clinical presentation[edit | edit source]
Classification[edit | edit source]
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.[1][2][12]
- 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.[16] The size of the lesion correlates in most cases to the number of previous dislocations.[11]
- Minor: <20%
- Moderate: 20%-45%
- Severe: >45%
Clinical presentation[edit | edit source]
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.[17][18][10] This is always caused by dislocation, not only sublaxation.[17]
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
Differential diagnosis[edit | edit source]
- 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[18]
- Humeral avulsion fractures[11]
- Mid capsular tears[11]
- Floating anterior capsule[11]
- Reverse Hill-Sachs lesion:
Diagnostic Procedures[edit | edit source]
Physical examination[edit | edit source]
- Bony apprehension test:[7]
- Positive test: Pain/reflex muscle contraction (in case of sublaxation)[7]
- Jobe relocation test:
- Positive test: Apprehension
- Crepitus and catching may be felt during active and passive abduction and external rotation[3]
- Possible lesion indicated by audible/palpable clunk in active/passive abduction and external rotation or an unstable feeling during mid-range
Special investigations[edit | edit source]
- X-ray: [3][19]
- 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
- Ultrasound:[19][20]
- 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[4]
- CT scan: Reliably asses the location and depth of the humeral lesion[21]
- MRI: Detect pathology of the soft tissue; determine the amount of humeral and glenoid bone loss[21][22]
Outcome Measures[edit | edit source]
- Disabilities of the arm, shoulder and hand (DASH)
- Shoulder Pain and Disability Index (SPADI)
- Numeric Pain Rating Scale (NPRS)
Medical management[edit | edit source]
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.[16][23] With minimum of glenoid bone loss and without significant involvement of the humeral head (<20%), surgical management is not indicated[24]. This instability can be managed conservatively in a master sling for immobilization for 2-6 weeks, before starting with rehabilitation (see "Physiotherapy management" later on).[16][24]
Management for 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.[3] . 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 latter, a surgical decision is made.[20]
Surgical mangement[edit | edit source]
Arthroscopic technique[edit | edit source]
- 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: Moderate-sized defects and the lack of management of osteochondral defects
- Other procedures: Techniques that use various small bone plugs
Open technique[edit | edit source]
- Laterjet procedure: Most frequently done[3][25][26]
- 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 the overtime instability
- 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
Physiotherapy management[edit | edit source]
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.[27]
- 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 master sling:
- 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.
Resources[edit | edit source]
Clinical bottom line[edit | edit source]
A Hill Sachs lesion is an injury that mostly is secondary to a shoulder dislocation. The humeral head ‘collides’ with the anterior part of the cavitas glenoidale, this often causes a lesion, bone loss, defect and deformity of the humeral head. There are different grades (3) in the severity of the lesion, these grades are described in the definition. The incidence of Hill Sachs lesion in patients with anterior shoulder instability approaches 100%. A Hill Sachs lesion is a deformity or a type of fracture that change the shape of the humeral head. This may cause a change in the range of motion. Other symptoms are instability feeling, pain. (Level of evidence 2A)[1] (Level of evidence 2B)[12]
The most common dislocation in the glenohumeral joint is an anterior dislocation. Secondary to this injury there may occur a Hill Sachs lesion. When the patient got a fracture in the humeral head caused by a posterior dislocation, then it is called a reverse Hill Sachs lesion. Level of evidence 2A)[1]
Conservative treatment is only recommended in cases of small bony defects (Less than 20% Hill sachs lesion), in other cases (larger and more significant lesions), surgical treatment is needed. Elderly people or people with high medical risk may be best treated nonsurgically. The conservative treatment should be based on strengthening the deltoid, the rotator cuff muscles and scapular stabilizers.(Level of evidence 2A)[1] (Level of evidence 3A)[24]
Another pathology secondary to an anterior shoulder dislocation is a bankart lesion. This is not located at the humeral head like a Hill Sachs lesion, but this is an injury of the anterior glenoid labrum of the shoulder. When people got a Hill Sachs lesion, it is often accompanied by a Bankart lesion. (Level of evidence 2B)[14]
A study by Arciero et al. proves that combined humeral and glenoid bone defects have a negative effect on the glenohumeral stability. (Level of evidence 5)[28]
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Provencher MT, Frank RM, LeClere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. The Hill-Sachs lesion: diagnosis, classification, and management. Journal of the American Academy of Orthopaedic Surgeons 2012;20(4):242-52.
- ↑ 2.0 2.1 2.2 Shoulder Doc. Hill-Sachs Lesion. https://www.shoulderdoc.co.uk/article/1470 (accessed 26/08/2018).
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Provencher M, Rose M, Peace W. Hill-Sachs Injuries of the Shoulder: When are these important and how should I manage them? In: Abrams JS editor. Management of the unstable shoulder: arthroscopic and open repair. Slack Incorporated, 2011.p.235-252.
- ↑ 4.0 4.1 Castro WHM, Jerosch J, Grossman TV. Examination and diagnosis of musculoskeletal disorders. Georg Thieme Verlag: Germany, 2001.
- ↑ 5.0 5.1 5.2 Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthopedic Clinics of North America 2008;39(4):507-18.
- ↑ 6.0 6.1 6.2 6.3 Gray’s Anatomy, Anatomy of the human body. 11th edition, 1918.
- ↑ 7.0 7.1 7.2 Bushnell B, Creighton R, Herring M. The bony apprehension test for instability of the shoulder: a prospective pilot analysis. Arthroscopy 2008:24(9):974-82.
- ↑ Dutton, M. Orthopaedic: Examination, evaluation, and intervention (2nd ed.). New York: The McGraw-Hill Companies, 2008.
- ↑ Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2007;23(9):985-90.
- ↑ 10.0 10.1 10.2 10.3 10.4 Wiki Radiography. Hill-Sachs and Bankart lesion, http://www.wikiradiography.net/page/Hill-Sachs+and+Bankart+Lesions (accessed 27/08/2018).
- ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Savoie F, O’Brien M. Management of Hill-Sachs Lesion, International Congress for Joint Reconstruction, 2014.
- ↑ 12.0 12.1 12.2 Calandra JJ, Baker CL, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthroscopy: The Journal of Arthroscopic & Related Surgery 1989;5(4):254-7.
- ↑ Horst K, Von Harten R, Weber C, Andruszkow H, Pfeifer R, Dienstknecht T, Pape HC. Assessment of coincidence and defect sizes in Bankart and Hill–Sachs lesions after anterior shoulder dislocation: a radiological study. The British journal of radiology 2014;87(1034):20130673.
- ↑ 14.0 14.1 Widjaja AB, Tran A, Bailey M, Proper S. Correlation between Bankart and Hill‐Sachs lesions in anterior shoulder dislocation. ANZ journal of surgery 2006;76(6):436-8.
- ↑ Kim DS, Yoon YS, Yi CH. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. The American journal of sports medicine 2010;38(10):2071-6.
- ↑ 16.0 16.1 16.2 Cetik O, Uslu M, Ozsar BK. The relationship between Hill-Sachs lesion and recurrent anterior shoulder dislocation. Acta orthopaedica belgica 2007;73(2):175-8.
- ↑ 17.0 17.1 17.2 Cluett J. Hill-Sachs Injury: Damage to the shoulder joint as result of dislocation. Orthopedics, 2013.
- ↑ 18.0 18.1 18.2 18.3 18.4 Radiopedia. Hill-Sachs lesion. https://radiopaedia.org/articles/hill-sachs-lesion (accessed 27/08/2018).
- ↑ 19.0 19.1 Omoumi P, Teixeira P, Lecouvet F, Chung CB. Glenohumeral joint instability. Journal of Magnetic Resonance Imaging 2011;33(1):2-16.
- ↑ 20.0 20.1 Kodali P, Jones MH, Polster J, Miniaci A, Fening SD. Accuracy of measurement of Hill-Sachs lesions with computed tomography. Journal of shoulder and elbow surgery 2011;20(8):1328-34.
- ↑ 21.0 21.1 Pancione L, Gatti G, Mecozzi B. Diagnosis of Hill-Sachs lesion of the shoulder: comparison between ultrasonography and arthro-CT. Acta Radiologica 1997;38(4):523-6.
- ↑ Pavic R, Margetic P, Bensic M, Brnadic RL. Diagnostic value of US, MR and MR arthrography in shoulder instability. Injury 2013;44:S26-32.
- ↑ Cutts S, Prempeh M, Drew S. Anterior shoulder dislocation. The Annals of The Royal College of Surgeons of England 2009;91(1):2-7.
- ↑ 24.0 24.1 24.2 24.3 Chen AL, Bosco III JA. Glenohumeral bone loss and anterior instability. Bulletin of the NYU hospital for joint diseases 2006 Dec 22;64(3-4):130.
- ↑ Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS. The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. The American journal of sports medicine 2006;34(5):778-86.
- ↑ Hovelius L, Sandström B, Sundgren K, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I—clinical results. Journal of shoulder and elbow surgery 2004;13(5):509-16.
- ↑ Wilk KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. North American journal of sports physical therapy 2006;1(1):16.
- ↑ Arciero RA et al., The Effect of a Combined Glenoid and Hill-Sachs Defect on Glenohumeral Stability: A Biomechanical Cadaveric Study Using 3-Dimensional Modeling of 142 Patients. The American journal of sports medicine, July 2014. (Level of evidence 5)
Sites
http://www.eorif.com/hill-sachs-lesion
http://orthodoc.aaos.org/
http://orthopedics.about.com/
www.wikiradiography.com