Hill Sachs Lesion: Difference between revisions

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'''Original Editors ''' - [[User:Lien Hennebel|Lien Hennebel]]
'''Original Editors ''' - [[User:Lien Hennebel|Lien Hennebel]]   as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]


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== Description ==


'''**Editing in process - Come back later for updated page***'''
A Hill-Sachs lesion is an osseous defect or "dent" of the postero-supero-lateral humeral head that occurs in association with [[Anterior Shoulder Instability|anterior instability]] or [[Shoulder Dislocation|dislocation of the glenohumeral joint]].<ref name="provencher">Provencher MT, Frank RM, LeClere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. [https://journals.lww.com/jaaos/Abstract/2012/04000/The_Hill_Sachs_Lesion__Diagnosis,_Classification,.11.aspx The Hill-Sachs lesion: diagnosis, classification, and management.] Journal of the American Academy of Orthopaedic Surgeons 2012;20(4):242-52.</ref><ref name=":0">Shoulder Doc. Hill-Sachs Lesion. Available from: https://www.shoulderdoc.co.uk/article/1470 (accessed 24 December 2023).</ref>  It is often associated with a [[Bankart lesion]] of the glenoid.<ref name=":2">Radiopedia [https://radiopaedia.org/articles/hill-sachs-defect?lang=gb Hills Sachs defect] Available from:https://radiopaedia.org/articles/hill-sachs-defect?lang=gb (accessed 24 December 2023)</ref> 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 Labrum|glenoid]] in the dislocated position, causing [[Shoulder Instability|shoulder instability]].<ref name="provencher 2">Provencher MT, Frank RM, Leclere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg. 2012 Apr;20(4):242-52. doi: 10.5435/JAAOS-20-04-242. </ref><ref name="castro">Castro WHM, Jerosch J, Grossman TV. Examination and diagnosis of musculoskeletal disorders. Georg Thieme Verlag: Germany, 2001.</ref><ref name="dodson">Dodson CC, Cordasco FA. [https://www.sciencedirect.com/science/article/pii/S0030589808000461 Anterior glenohumeral joint dislocations.] Orthopedic Clinics of North America 2008;39(4):507-18.</ref>


== Definition/Description  ==
Watch this animated description of Hill-Sachs and [[Bankart lesion|Bankart Lesions]]  that can occur with a shoulder dislocation and contribute to further shoulder instability (2 minutes)
{{#ev:youtube|v=a6BWiufgmsc|300}}<ref> ORTHOfilms. Bankart and Hill-Sachs Lesions. Available from: https://www.youtube.com/watch?v=a6BWiufgmsc [last accessed 10.1.2023]</ref>


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.<ref name="provencher">Provencher MT, Frank RM, LeClere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. [https://journals.lww.com/jaaos/Abstract/2012/04000/The_Hill_Sachs_Lesion__Diagnosis,_Classification,.11.aspx The Hill-Sachs lesion: diagnosis, classification, and management.] Journal of the American Academy of Orthopaedic Surgeons 2012;20(4):242-52.</ref><ref name=":0">Shoulder Doc. Hill-Sachs Lesion. https://www.shoulderdoc.co.uk/article/1470 (accessed 26/08/2018).</ref>  It was first described by two radiologists by the name HA Hill and MD Sachs in 1940.<ref name=":0" /> This lesion is caused by an anterior [http://www.physio-pedia.com/Shoulder_Dislocation 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 [[Shoulder Instability|instability]] at the glenohumeral joint.<ref name="provencher 2">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.</ref><ref name="castro">Castro WHM, Jerosch J, Grossman TV. Examination and diagnosis of musculoskeletal disorders. Georg Thieme Verlag: Germany, 2001.</ref><ref name="dodson">Dodson CC, Cordasco FA. [https://www.sciencedirect.com/science/article/pii/S0030589808000461 Anterior glenohumeral joint dislocations.] Orthopedic Clinics of North America 2008;39(4):507-18.</ref>  
== Epidemiology ==
== Clinically relevant anatomy  ==
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.<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" />
== Etiology ==
* [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 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, et al. [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 2006;76(6):436-8.</ref>


The [[Glenohumeral Joint|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.&nbsp;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.<ref name="dodson" /><ref name="gray 1">Gray’s Anatomy, Anatomy of the human body. 11th edition, 1918.</ref><ref name="bushnell1">Bushnell B, Creighton R, Herring M. T[https://www.sciencedirect.com/science/article/pii/S0749806308005884 he bony apprehension test for instability of the shoulder: a prospective pilot analysis.] Arthroscopy 2008:24(9):974-82.</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 2010;38(10):2071-6.</ref>
== Classification ==
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.<ref name="provencher" /><ref name=":0" /><ref name="calandra" />
*'''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.


This is a brief overview of the relevant anatomy. See the page for the [[Glenohumeral Joint|glenohumeral joint]] for detailed information.
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">Fox JA, Sanchez A, Zajac TJ, Provencher MT. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685959/ Understanding the Hill-Sachs Lesion in Its Role in Patients with Recurrent Anterior Shoulder Instability.] Curr Rev Musculoskelet Med. 2017 Dec;10(4):469-479. doi: 10.1007/s12178-017-9437-0. </ref>
* '''Minor:'''  <20%
* '''Moderate:'''  20%-45%
* '''Severe:'''  >45%


=== Bones ===
The glenoid of the [[scapula]] articulates with the [[Humerus|humeral head]] to form a ball-and-socket joint.<ref name="gray 1" />


=== Labrum ===
Another classification - ON track or OFF track<ref>Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014 Jan 1;30(1):90-8.</ref>
The [[Glenoid Labrum|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 [[Shoulder Dislocation|dislocations]].<ref name="dutton">Dutton, M. Orthopaedic: Examination, evaluation, and intervention (2nd ed.). New York: The McGraw-Hill Companies, 2008.</ref>&nbsp;


=== Ligaments ===
If the Hill-Sachs lesion engages, it is called an “off-track” Hill-Sachs lesion; if it does not engage, it is an “on-track” lesion.
* Glenohumeral ligaments (pars superior, media and inferior):  Assists in strengthening of the capsule<ref name="provencher 2" />
* Coracohumeral ligament: Assists in strengthening of the capsule<ref name="provencher 2" />&nbsp;
* Transversal humeral ligament: Functions with the [[Biceps brachii|Biceps Brachii]] muscle<ref name="gray 1" />


=== Muscles ===
== Clinical Presentation ==
* Abductors:
Shoulder dislocation rarely occur isolated. It causes damage to different tissues surrounding the [[Glenohumeral Joint|glenohumeral joint]], such as ligaments, [[Rotator Cuff|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.<ref name="cluett">Cluett J. Hill-Sachs Injury: Damage to the shoulder joint as result of dislocation. Orthopedics, 2013.</ref><ref name="ahmed">Radiopedia. Hill-Sachs lesion. https://radiopaedia.org/articles/hill-sachs-lesion (accessed 27/08/2018).</ref><ref name="fuller">Wiki Radiography. Hill-Sachs and Bankart lesion. Available from:http://www.wikiradiography.net/page/Hill-Sachs+and+Bankart+Lesions (accessed 25 December 2023).</ref>This is always caused by dislocation, not only subluxation.<ref name="cluett" />
** [[Deltoid]]
** [[Supraspinatus]]
* Adductors:
** Pectoralis major
* Flexors:
** [[Rotator Cuff|Rotator cuff]] (very important for the stability of the articulating humerus):
*** [[Supraspinatus]], [[infraspinatus]], [[Teres Minor|teres minor]], [[subscapularis]]
* Extensors:  
** [[Deltoid]]
** [[Triceps brachii]]
** [[Teres Major|Teres major]]
** [[Latissimus dorsi muscle|Latissimus dorsi]]
* Internal Rotators:  
** [[Teres Major|Teres major]]
** [[Latissimus dorsi muscle|Latissimus dorsi]]
** [[Subscapularis]]
** [[Pectoralis major]]
* External Rotators:  
** [[Teres Minor|Teres minor]]
** [[Infraspinatus]]
<ref name="gray 1" />


=== Bursae ===
According to the page on [[Shoulder Dislocation|shoulder dislocations]], the following indicates an acute anterior glenohumeral dislocation:
There are eight bursae in the shoulder complex as a result of the high amount of muscles surrounding the shoulder.&nbsp;They ensure a smooth contact between the muscle and the underlying structures. The subacromial bursa is the biggest in the body.<ref name="dodson" />
* 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<span style="line-height: 1.5em;"></span>
== Differential diagnosis ==
* [http://www.physio-pedia.com/Bankart_lesion Bankart lesion]: Also as a result of shoulder dislocation, and often goes together<ref name="fuller" /><ref name="ahmed" />
* 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<ref name="ahmed" />


== Epidemiology and Etiology  ==
* Humeral avulsion fractures<ref name="savoie" />
 
* Mid capsular tears<ref name="savoie" />
=== ''Etiology'' ===
* Floating anterior capsule<ref name="savoie" />
* [http://www.physio-pedia.com/Anterior_Shoulder_Instability Anterior shoulder instability] is considered as a risk factor for Hill Sachs lesions. In their study, J.J. Calandra et al. found 47% of the lesions in their patients to be associated with the initial shoulder instability (Level of evidence 2B). They concluded that their research had the same results as the previous studies from Hovelius et al. and Simonet &amp; Cofield et al.<ref name="calandra">Calandra et al. The Incidence of Hill-Sachs Lesions in Initial Anterior Shoulder Dislocations. The Journal of Arthroscopic and Related Surgery 1989; 5(4): 254-257( Level of evidence: 2B)</ref>
* Reverse Hill-Sachs lesion: Lesion on the anterior-superior aspect of the humeral head as the result of a posterior shoulder dislocation<ref name="fuller" /><ref name="savoie" /><ref name="ahmed" />
 
* In 2006 Widjaja et al. (Level of evidence 2B) stated that there is a strong correlation between the [http://www.physio-pedia.com/Bankart_lesion Bankart] and the Hill Sachs lesion. They found that when someone has either of those lesions he is 2.5 times more likely to have the other as well. But the correlation found in this study couldn’t be considered significant due to the small study numbers.<ref name="widjadja">B. Widjadja et al. Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation. ANZ journal of surgery. 2006; 76: 436-438 (Level of evidence: 2B)</ref>Later in 2013, Horst et al. (Level of evidence 2B) did a high-quality MRI study in order to investigate the co-occurrence between Bankart and Hill Sachs lesions. After their study, they stated that when someone has one or the other lesions, he or she is 11 times more likely to have suffered the associated injury.&nbsp;So having a Bankart lesion can be considered a risk factor for developing/having a Hill Sachs lesion.<ref name="horst">K. Horst et al. Assessment of coincidence and defect sizes in Bankart and Hill–Sachs lesions after anterior shoulder dislocation: a radiological study.Britisch journal of radiology. 2014; 87: 20130673 (Level of evidence: 2B)</ref>
 
* There also is a very strong association between a combined engaged Hill-Sachs lesion and anterior glenoid bone loss in case of recurrent instability according to DS. Kim et al.(Level of evidence 3B)<ref name="kim">DS. Kim et al. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. The American journal of sports medicine 2010; 38(10) ; 2071-2076. (Level of evidence: 3B)</ref>
<br>
 
=== ''Epidemiology'' ===
The true incidence of Hill-Sachs lesions is unknown. However, they are associated with approximately 40% to 90% of all [http://www.physio-pedia.com/Anterior_Shoulder_Instability anterior shoulder instability] events. The incidence may be as high as 100% in patients with recurrent anterior instability, stated CDR. Matthew T. Provencher et al. (Level of evidence 2A)<ref name="provencher" /> K. Christos et al. investigated 127 patients with traumatic acute and chronic anterior shoulder instability prospectively. A Hill-Sachs lesion was found in 15 cases in the group with acute dislocations (65.21%) and in 97 cases in the chronic recurrent instability group (93.26%). So after their study, they stated that The incidence of shoulder lesions increases with time because the initial dislocation and secondary lesions are more common in patients with chronic instability. (Level of evidence 2B)<ref name="christos">K. Christos et al. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. The Journal of Arthroscopic and Related Surgery. 2007; 23(9); 985-990 (Level of evidence: 2B)</ref><br><br>
 
== Mechanism of Injury / Pathological Process  ==
 
The glenohumeral joint is the most commonly dislocated joint in the human body and 90% of shoulder dislocations are anterior. The reason for this is that the scapula is oriented about 30 degrees anterior and this to the coronal plane of the body. Because of this, the glenohumeral joint with the humerus is orienting anterior to the glenoid.<ref name="Nepola" /><br>
 
When a trauma takes place, an anterior [[Shoulder Dislocation|shoulder dislocation]] can cause a head impression fracture what we call a Hill Sachs lesion. The posterolateral aspect of the humeral head impacts on the anterior glenoid in the dislocated position, what makes the glenohumeral joint unstable ([[Shoulder Instability|Shoulder_Instability]]). <ref name="Gooding">W.T. Gooding, B., M. Geoghegan, J., A. Manning, P., 'The management of acute traumatic primary anterior shoulder dislocation in young adults', Jornal compilation: British elbow and shoulder society, 2010, p. 141-146 (Level of evidence 1A)</ref><ref name="Cetik">Cetik, O., Uslu, M., K. Ozsar, B., 'The relationship between Hill sachs lesion and recurrent anterior shoulder dislocation', Acta orthopaedica Belgica, VOL. 73 (2007), p. 175-178</ref><ref name="Wilk">E. Wilk, K., C. Macrina, L., M. Reinold, M., 'Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability', North american journal of  sports physical therapy, VOL. 1 (2006), februari, nr. 1, p. 16-31</ref>
 
90% of shoulder dislocations are anterior, so in some cases, there could be a posterior dislocation what can cause a reverse Hill Sachs lesion. This lesion may be present on the anterior aspect of the humeral head. <ref name="Wilk" />
<div><br></div>
== Characteristics/Clinical Presentation  ==
 
=== Classification ===
Several classifications and grading systems have been described for Hill-Sachs lesions, but there still is some controversy among which is most supported. Although the classifications and grading systems can be useful in clinical decision making, especially with larger lesions, they have not yet proved to be helpful in determining successful management strategies.<span style="line-height: 1.5em;">(Level of evidence 2A)</span><ref name="provencher" /><span style="line-height: 1.5em;">&nbsp;</span>
 
One way to grade a Hill-Sachs lesion is how J.J. Calandra et al. did it. They described the lesion arthroscopically in 3 grades (Level of evidence 2B)<ref name="calandra" />:
 
*Grade 1: there is a defect in the articular surface down to, but not including, the subchondral bone.
*Grade 2: the lesion includes the subchondral bone
*Grade 3: the lesion signifies means a large defect in the subchondral bone.
 
<br>
 
[[Image:Physiopedia afb 1.png|left|400x400px|Redrawn with permission from Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16[7]:677-694.]]
 
A, Illustration of an engaging Hill-Sachs lesion (dark gray area). <br>B, With the shoulder in a position of function or in abduction and external rotation, the lesion is oriented parallel with the anterior glenoid and thus engages it.<br>C, Illustration of a nonengaging lesion (dark gray area), which is created in a nonfunctional position. <br>D, When the shoulder is abducted and externally rotated, the lesion is not oriented parallel to the glenoid and thus does not engage.
 
<br>
 
<br>
 
<br>
 
<br>
 
<br>
 
<br>
 
<br>''Redrawn with permission from Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16[7]:677-694.)''
 
depth of the lesion reflects the amount of damage to the opposite side of the joint—the anterior capsule and the labrum. Therefore larger Hill-Sachs lesions are associated with higher risks of recurrent dislocations.-shoulderdoc
 
Shoulder dislocation rarely occur isolated. It causes damage to different tissues surrounding the glenohumeral joint like shoulder ligaments, rotator cuff tendons and the joint capsule. But the bone and cartilage of the humeral head can also be affected. 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 and is called a Hill-Sachs lesion. It can be seen on MRI, CT-scan, but is difficult to see on an x-ray.<ref name="cluett">Cluett J., Hill-Sachs Injury: Damage to the shoulder joint as result of dislocation, Orthopedics, 2013.  (Level of evidence: 5)</ref><ref name="ahmed">Dr. Ahmed Abd Rabou and Dr. Frank Daillard et al. Hill-Sachs lesion, radiopedia.org (Level of evidence: 5)</ref><ref name="fuller">Fuller, M. Hill-Sachs and Bankart lesion, wikiradiography.com. (Level of evidence: 5)</ref>&nbsp;<br>
 
<span>&nbsp;</span>We can order this humeral head compression fractures according to the percentage of humeral head involvement<ref name="cetik">Cetik, O., Uslu, M. &amp; Ozsar, B.(2007).The relationship between Hill sachs lesion and recurrent anterior shoulder dislocation. Acta orthopaedica Belgica, 73: 175-178. (Level of evidence: 2B)</ref><br>• minor defect: less than 20% of the humeral head is involved;<br>• moderate defect: between 20% and 45% of the head is involved;<br>• severe defect: more than 45% of the head is involved.<br>The size of the lesion is in most cases related to the number of times a dislocation took place<ref name="savoie">Savoie F. O’Brien M., Management of Hill-Sachs Lesion, International Conress for Joint Reconstruction, 2014. (Level of evidence: 5)</ref>&nbsp;<br>
 
Figure 1 illustrates how the percentage of the humeral head, which is involved, is calculated. Next to this percentage, a Hill-Sachs lesion is also characterized by its depth ('d' on figure 1) and its size ('s' on figure 1).
 
[[Image:Hill sachs lesion.jpg|center|Figure 1: preoperative double contrast CT arthrography of a 20 year old patient]]
 
<span style="line-height: 1.5em;"></span>
 
<div><span style="line-height: 1.5em;">Figure 1: preoperative double contrast CT arthrography of a 20-year-old patient.<ref name="cetik" /></span></div><div></div><div>When we diagnose a Hill-Sachs defect, we can be sure that there was a complete dislocation of the humeral head out of the socket, and that it was not just a subluxation.<ref name="cluett" />&nbsp;A Hill-Sachs lesion occurs in about 50 percent of the first-time shoulder dislocations. For people with a shoulder dislocations history (= shoulder instability) you can almost always see these humeral head compression fractures.<ref name="fuller" />&nbsp; There is a link between bone loss on either the glenoid side or the humeral side and recurrent shoulder instability during activities.<ref name="savoie" />&nbsp;<br> </div><br>
 
== Differential Diagnosis ==
 
It is important to note that below the level of the coracoid the humeral head normally flattens out posterolaterally (also known as Pseudo-Hill-Sachs lesion), and this should not be misinterpreted as a Hill-Sachs lesion.<ref name="ahmed" /><br>Both a Hill-Sachs lesion (fig 1) as a [http://www.physio-pedia.com/Bankart_lesion Bankart lesion] (fig 2) &nbsp;of the glenoid can be the result of a shoulder dislocation. They often occur together. It is important to inspect the anterior glenoid rim and labrum carefully, to see if there is a potential Bankart Lesion. <ref name="ahmed" /><ref name="fuller" /><br>Fig 1: Hill Sachs lesion Fig 2: Bankart lesion&nbsp;<br>Savoie (2014) describes 3 other injuries that occur commonly with Hill-Sachs lesion:<ref name="savoie" /><br>• Humeral avulsion (HAGL) and mid capsular tears<br>• Floating anterior capsule
 
Anterior glenohumeral ligamentous pathology and glenoid bone loss.<ref name="savoie" />&nbsp;<br>Anterior shoulder dislocation is more common, but sometimes a posterior shoulder dislocation takes place. If that’s the case and there is some damage to the cartilage and bone, we can speak of a Reverse Hill-Sachs lesion. This lesion can be seen on the anterior-superior aspect of the humeral head.<ref name="ahmed" /><ref name="fuller" /><ref name="savoie" />&nbsp;
 
<span>&nbsp;</span>&nbsp;


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


To diagnose pathologies of the humeral head, osseus glenoid and labrum, a number of imaging techniques have been described. <br>In the acute phase, plain radiography can detect bony lesions of the humeral head related to shoulder instability. Radiographic techniques most advantageous for initial evaluation of glenohumeral instability are the Grashey view (anteroposterior view of the shoulder) with internal and external views, the scapular 'Y' view (transcapular view of the shoulder) and the Garth view (x-ray beam caudally from a standard anteroposterior view). When the mobility of the patient allows, axillary, axillary with exaggerated external rotation and West Pont views can be added. In practice, for specific cases (when clinical examination is difficult), sometimes dynamic stress tells more about the instability of the shoulder. The combination of these views is an important first step at effectively evaluating both the glenohumeral relationship as well as osseous pathology on both the humerus and the glenoid.<ref name="provencher 2" /><ref name="omoumi">Omoumi, P. et al. Glenohumeral joint instability. Journal of Magnetic Resonance Imaging. 2010: 33(1): 2-16. (Level of evidence: 1B)</ref>&nbsp;<br>Also, ultrasound can detect and localise a compression fracture in Hill Sachs lesions. The advantage of this method is its cost-effectiveness and its minimal exposure to excessive radiation (see plain radiographs or CT scan). It also provides a comfortable position for the patient.<ref name="omoumi" /><ref name="kodali">Kodali et al. Accuracy of measurement of Hill-Sachs lesions with computed tomography. Journal of shoulder and elbow surgery. 2012: 20 (8): 1328-1334. (Level of evidence: 3)</ref>&nbsp;&nbsp;<br>Firstly, with the arm in a neutral position, the convexity of the humerus in the posterior transversal plane is examined. Special attention should be payed to the layer of cartilage. Secondly, the patient has to flex the arm at a 90-degree angle, to facilitate the examination of the total posterosuperior convexity of the humerus. In Hill Sachs lesions, a triangular depression in the contour of the humerus will be apparent.<ref name="castro" />&nbsp;<br>A study by Pancione et al. (1997) compared the advantages of using ultrasound versus CT scans for the examination of shoulder dislocations. They showed that ultrasounds demonstrated a higher sensitivity (95,6%) and specificity (92,8%) for the detection of Hill Sachs lesions.<ref name="pancione">Pancione, L., Gatti, G. Diagnosis of Hill-Sachs lesion of the shoulder. Comparison between ultrasonography and arthro-CT. 1997: 38 (4): 523-526. (Level of evidence : 3)</ref>&nbsp;Recently, Pavic et al. (2013) found a statistically significant difference between ultrasound and MRI stating that MRI is more accurate than ultrasound. (level of evidence: 3)<ref name="pavic">Pavic et al. Diagnostic value of US, MR and MR arthrography in shoulder instability. Injury-international journal of the care of the injured. 2013: 44: (supplement): 26-32. (Level of evidence: 2A)</ref>&nbsp;<br>MRI is useful to detect a pathology of the soft tissue and to determine the amount of humeral and glenoid bone loss. A double-blind, prospective study by Denti et al.,15 patients underwent MRI with a sensitivity of 60%, specificity of 80% and accuracy of 87´%.<ref name="pancione" />&nbsp;<br>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. Overall, sagittal- and axial-plane measurements are more accurate for evaluation of these defects than the coronal plane.<ref name="kodali" />&nbsp;<br><br>
=== Physical examination ===
 
* [[Apprehension Test|Bony apprehension test]]:<ref name="bushnell1">Bushnell B, Creighton R, Herring M. T[https://www.sciencedirect.com/science/article/pii/S0749806308005884 he bony apprehension test for instability of the shoulder: a prospective pilot analysis.] Arthroscopy 2008:24(9):974-82.</ref>
== Outcome Measures  ==
** Positive test:  Pain/reflex muscle contraction (in case of sublaxation)<ref name="bushnell1" />
 
{{#ev:youtube|xzOlo5c7DpU}}
An outcome measure is a tool the physical therapist can use to follow up the progress of the patient.
* [http://www.physio-pedia.com/Jobes_Relocation_Test Jobe relocation test]:
** Positive test:  Apprehension
** Crepitus and catching may be felt during active and passive abduction and external rotation<ref name="provencher 2" />
** Possible lesion indicated by audible/palpable clunk in active/passive abduction and external rotation or an unstable feeling during mid-range
{{#ev:youtube|watch?v=K0B1lNOVnP4}}
=== Special investigations ===
[[File:Shoulder dislocation, anteroposterior after reduction, with Bankart and Hill-Sachs lesions, with labels.jpeg|thumb|Bankart and Hill-Sachs lesions]]
[[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)
* 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 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
* 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" />
[[CT Scans|CT scan]]:  Reliably assess 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>


*The bony apprehension test <ref name="bushnell2">Bushnell BD et al.; The bony apprehension test for instability of the shoulder: a prospective pilot analysis.; Arthroscopy. 2008; 24(9): 974-82 (level of evidence 2C)</ref><br>
[[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>


== Examination ==
<ref name="fuller" /><ref name="cluett" /><ref name="ahmed" />
 
=== Outcome Measures  ===
A major (passive) test to physically examine a clinically important Hill-Sachs injury is the bony [http://www.physio-pedia.com/Apprehension_Test Apprehension test]. The therapist brings the arm in a 45 degrees abduction and a 45 degrees external rotation. Pressure is applied with the hand on the caput of the humerus to anterior. The test is positive if pain is felt or if the muscle contracts by reflex in the case of a (sub)luxation.<ref name="bushnell1" /> The apprehension test is often combined with [http://www.physio-pedia.com/Jobes_Relocation_Test jobes relocation test].<br>In addition to a positive apprehension test, crepitus (palpable and audible) and catching may be felt during active and passive abduction and external rotation.<ref name="provencher 2" />&nbsp;Also, an audible or palpable clunk in these positions or an unstable feeling during mid-ranges of these motions indicates a possible lesion.<br>


*[https://www.physio-pedia.com/DASH_Outcome_Measure Disabilities of the arm, shoulder and hand (DASH)]
*[[Shoulder Pain and Disability Index (SPADI)]]
*[https://www.physio-pedia.com/Numeric_Pain_Rating_Scale Numeric Pain Rating Scale (NPRS)]
== Medical management  ==
== Medical management  ==
The bony defect usually does not require treatment, though the linked glenohumeral instability and possible anterior labral injuries often need surgical repair.


In the setting of humeral bone loss (Hill-Sachs) injury, treatment can be directed at the restoration of the glenohumeral articular arc with either glenoid-based solutions, 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" /><br>Most of the Hill-Sachs injuries are treated with glenoid-based bone augmentation techniques. Treating the glenoid defects is often the solution to the glenohumeral instability.
# Minimum 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.<ref name="cetik" /><ref name="andrew" />
# Large Defects: Management of the bony defect (as in Hill-Sachs lesion) can be treated with bone grafting or placement of soft tissue within the defect.<ref name=":2" />


Of these techniques, the (open) Latarjet procedure remains the most frequently applied procedure. This procedure includes a variety of methods. The technique whereby the bone from the processus coracoideus is used as an augment to the anteroinferior glenoid bone loss is the most common. By reforming the concavity and width of the glenoid, a Hill-Sachs lesion does not influence the anterior glenoid rim of unstable shoulders. This method is successful in preventing the overtime instability, proving at least two prospective cohort studies by Hovelius et al. (2004) and Schroder et al. (2006) (evidence based level: 1B). However, shoulder arthrosis and loss of function were negative consequences. <ref name="provencher 2" /><ref name="hovellus">Hovellus et. Al. Hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study 1 clinical results. J Shoulder Elbow Surg. 2004:13(5):509-516. (Level of evidence: 1B)</ref><ref name="schroder">Schroder et al. The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy Midshipmen. American Journal Sports Medicine. 2006; 34(5):78-86. (Level of evidence: 1B)</ref>  
=== Surgical management ===
The critical size of the glenoid bone loss has been clarified as 25% of the glenoid width both biomechanically and clinically. This is the determinant factor influencing the choice of the surgical technique: soft tissue procedure or bone block procedure. <ref name=":1">Yamamoto N, Shinagawa K, Hatta T, Itoi E. Peripheral-track and central-track Hill-Sachs lesions: a new concept of assessing an on-track lesion. The American Journal of Sports Medicine. 2020 Jan;48(1):33-8.</ref>


The majority of Hill-Sachs defects can successfully be solved with glenoid-based strategies, however, some of the Hill-Sachs injuries, especially when the glenoid is not touched, require a direct treatment of the injury. Generally taken, the Hill-Sachs deformity can be managed by two techniques: arthrosocopic and open techniques.<ref name="provencher 2" />
'''Arthroscopic technique'''
* '''Arthroscopic techniques:''' include the ‘Remplissage procedure’, a method whereby the defect is filled with soft tissue, usually from the infraspinatus tendon. A second arthroplasty method is the percutaneous humeroplasty, a technique that fills the lesion by using a bone tamp brought into a drilled osseus window 180 degrees from the lesion. The advantage of this procedure is that no rotational osteotomy of the humeral head is needed and the humeral head can be restored without transpositioning the soft tissue. Limitations of this technique are moderate-sized defects and the lack of management of osteochondral defects. Other procedures where arthroscopy intervenes are techniques that use various small bone plugs.<ref name="provencher 2" />&nbsp;
* Remplissage procedure:  Defect is filled with soft tissue, usually from the infraspinatus tendon


* '''Open humeral bony techniques''' include autologous bone plugs, size-matched osteoarticular allografts and rotational humeral osteotomy. The latter, a procedure that includes an osteotomy of the surgical neck and rotates the humeral head for 25 degrees, is not the best chosen method nowadays, given the related risks and the success rates of more recent procedures. The osseus humeral allograft bone plug technique uses a size-matched humeral bone plug of a donor. It is an open procedure because it is performed through a delto-pectoral approach or a deltoid-splitting approach. Advantages of this procedure are its minimal exposure and the fact that the head of the humerus remains in the capsule. A downside of this resurfacing technique is its limitation to small and moderate lesions and the risk of using cadaveric tissue.<ref name="provencher 2" />
* Second arthroplasty method:  Percutaneous humeroplasty
<br>
** Lesion is filled by using a bone tamp brought into a drilled osseous 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
== Physical therapy management    ==
** Limitations: Limited to moderate-sized defects; lack of management of osteochondral defects
* Other procedures:  Techniques that use various small bone plugs
<ref name="provencher 2" />
[[File:Latarjet-Procedure, Bankart repair.jpeg|thumb|Latarjet-Procedure]]
'''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 instability over time
** Negative consequences associated with the Laterjet are shoulder arthrosis and loss of function


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. &amp; Drew, S. Anterior shoulder dislocation, Ann R coll Surg Engl. 2009: 91 (Level of evidence: 2A)</ref>&nbsp;
* 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    ==
'''Aim''': Prevent reoccurrence of dislocations


But most of the time a Hill-Sachs lesion can be neglected, certainly, if there is a minimum of glenoid bone loss and without significant involvement of the humeral head. There is no need for surgical treatment, but important is handling the instability.<ref name="cetik" /> The non-operative rehabilitation of the unstable shoulder consists about seven key factors:<ref name="wilk">Wilk, K., Macrina, L., Reinold, M. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. North american journal of sports physical therapy. 2006; 1 (1): 16-31. (Level of evidence: 1B)</ref>&nbsp;
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 (in this case: traumatic event)
* The onset of pathology
* The degree of instability (in this case: dislocation)
* The degree of instability  
* The frequency of dislocation (in this case acute)
* The frequency of dislocation
* TheDirection of instability (in this case: anterior)
* The direction of instability
* Concomitant pathologies (in this case: Hill Sachs lesion)
* Concomitant pathologies
* Neuromuscular control
* Neuromuscular control
* Activity level
* Activity level
In the non-operative rehabilitation program of the traumatic dislocation of the shoulder, it's important to consider all these seven factors and thus also with the concomitant 'Hill Sachs lesion': [http://www.physio-pedia.com/Rehabilitation_program_of_the_shoulder rehabilitation program of the shoulder].<ref name="wilk" /><br>
[[File:Stiff Brace for after Shoulder Surgery.jpeg|thumb|Stiff sling]]
 
Physiotherapy interventions include:
According to a study from A. L. Chen (Level of evidence 3A), you can treat a Hill Sachs lesion nonoperatively. Therapy aims to prevent reoccurrence of dislocations. So the therapy is based on strengthening the deltoid muscle and the rotator cuff muscles and periscapular muscles.<ref name="andrew">Andrew L. Chen et al. Glenohumeral Bone Loss and Anterior Instability, Bulletin of the NYU hospital for joint diseases, 2006 (Level of evidence 3A)</ref>
* 2-6 weeks of immobilization in a mastersling:
 
** Scapula stabilization exercises
In patients with small defects (< 20% Hill Sachs lesion), nonoperative treatment is recommended. These patients will be immobilized with a sling (2-6 weeks). After this, immobilization, a physical therapist must mobilize the joint. Patients will start with pendulum exercises, followed by passive, active-assisted and active range of motion exercises. Abduction and external rotation is restricted during the initial phase of the rehabilitation, because the ligaments need time to heal, like this we want to prevent other dislocations as well. The patient will do exercises to strengthen the deltoid muscle, the periscapular muscles (pectoralis major) and the rotator cuff muscles. Recent related evidence of A.L Chen et al proofs that the long-term success rate of nonoperative treatment is very high. (Level of evidence 3A)<ref name="andrew" />
** Hand, wrist and elbow exercises
 
** Teach patient on functional adaptions (e.g. personal hygiene, dressing and undressing)
Based on this information the authors will be able to design a treatment program and start physiotherapy.<br><br>
** No driving while still in sling
 
* When use of sling is discontinued (on recommendation of orthopaedic surgeon):
== Key Evidence ==
** Pendulum exercises
 
** Passive, active-assisted and active range of motion exercises (progressions)
CRD Matthew, T. Provencher et al. The Hill-Sachs lesion: Diagnosis, classification and management. Journal of the American Academy of orthopaedic surgeons. 2012; 20:242-252 (Level of evidence 2A)<ref name="provencher" /><br><br>  
** 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>


== Resources    ==
Post-surgical rehabilitation should be guided by the orthopaedic surgeon, and depends on the procedure that was done.
 
- PubMed<br>- Web of Science<br>- Pedro<br>- Google scholar


== Clinical bottom line  ==
== Clinical bottom line  ==


A Hill Sachs lesion is an injury that mostly is secondary to a [http://www.physio-pedia.com/Shoulder_Dislocation 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. <span style="line-height: 1.5em;">(Level of evidence 2A)</span><ref name="provencher" /><span style="line-height: 1.5em;">&nbsp; (Level of evidence 2B)<ref name="calandra" /></span>  
A Hill-Sachs lesion is an injury that occurs secondary to an anterior [http://www.physio-pedia.com/Shoulder_Dislocation 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%.<ref name="provencher" /><span style="line-height: 1.5em;"><ref name="calandra" /></span> A<span style="line-height: 1.5em;">nother pathology secondary to an [http://www.physio-pedia.com/Anterior_Shoulder_Instability anterior shoulder dislocation] is a [http://www.physio-pedia.com/Bankart_lesion Bankart lesion]. This is an injury of the anterior glenoid labrum of the shoulder and often often accompanied by a Hill-Sachs lesion.<ref name="widjadja" /></span>  


<span style="line-height: 1.5em;">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. &nbsp;Level of evidence 2A)<ref name="provencher" /></span>
<span style="line-height: 1.5em;">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.<ref name="provencher" /><ref name="andrew" /></span>  
 
<span style="line-height: 1.5em;">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)<ref name="provencher" />&nbsp;(Level of evidence 3A)<ref name="andrew" /></span>
 
<span style="line-height: 1.5em;">Another pathology secondary to an [http://www.physio-pedia.com/Anterior_Shoulder_Instability anterior shoulder dislocation] is a [http://www.physio-pedia.com/Bankart_lesion 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)<ref name="widjadja" /></span>
 
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)<ref name="arciero">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)</ref>
 
<br>
 
== Recent related research (from pubmed)  ==
 
1. Wolf et al.; Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2- to 10-year follow-up and incidence of recurrence, Journal of Shoulder and Elbow Surgery 2014; 23(6):814-20. (Level of evidence 4)<ref name="wolf">Wolf et al.; Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2- to 10-year follow-up and incidence of recurrence, Journal of Shoulder and Elbow Surgery 2014; 23(6):814-20 (Level of evidence 4)</ref>
 
2. Zhu et al.; Arthroscopic Bankart repair combined with remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesion: a report of 49 cases with a minimum 2-year follow-up.; 2011; 39(8):1640-7. (Level of evidence 4)<ref name="zhu">Zhu et al.; Arthroscopic Bankart repair combined with remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesion: a report of 49 cases with a minimum 2-year follow-up.; 2011; 39(8):1640-7 (Level of evidence 4)</ref>
 
<br>  


== References  ==
== References  ==
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Sites<br>http://www.eorif.com/hill-sachs-lesion<br>http://orthodoc.aaos.org/<br>http://orthopedics.about.com/<br>www.wikiradiography.com<br>


[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Primary Contact]]
[[Category:Primary Contact]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Conditions]]
[[Category:Shoulder - Conditions]]

Latest revision as of 16:37, 25 December 2023

Original Editors - Lien Hennebel as part of the Vrije Universiteit Brussel's Evidence-based Practice project

Top Contributors - Jelle Van Hemelryck, Lien Hennebel, Leana Louw, Pauline Bouten, Simisola Ajeyalemi, Uchechukwu Chukwuemeka, Shreya Pavaskar, Admin, Kim Jackson, Lucinda hampton, Rachael Lowe, Fasuba Ayobami, Wanda van Niekerk, Nupur Smit Shah, 127.0.0.1 and Claire Knott

Description[edit | edit source]

A Hill-Sachs lesion is an osseous defect or "dent" of the postero-supero-lateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint.[1][2] It is often associated with a Bankart lesion of the glenoid.[3] 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 shoulder instability.[4][5][6]

Watch this animated description of Hill-Sachs and Bankart Lesions that can occur with a shoulder dislocation and contribute to further shoulder instability (2 minutes)

[7]

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.[8]
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.[9]

Etiology[edit | edit source]

  • Anterior glenoid bone loss (in cases of recurrent instability)[13]

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][10]

  • 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.[14] The size of the lesion correlates in most cases to the number of previous dislocations.[15]

  • Minor: <20%
  • Moderate: 20%-45%
  • Severe: >45%


Another classification - ON track or OFF track[16]

If the Hill-Sachs lesion engages, it is called an “off-track” Hill-Sachs lesion; if it does not engage, it is an “on-track” lesion.

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][9]This is always caused by dislocation, not only subluxation.[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: Also as a result of shoulder dislocation, and often goes together[9][18]
  • 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[15]
  • Mid capsular tears[15]
  • Floating anterior capsule[15]
  • Reverse Hill-Sachs lesion: Lesion on the anterior-superior aspect of the humeral head as the result of a posterior shoulder dislocation[9][15][18]

Diagnostic Procedures[edit | edit source]

Physical examination[edit | edit source]

  • Jobe relocation test:
    • Positive test: Apprehension
    • Crepitus and catching may be felt during active and passive abduction and external rotation[4]
    • 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]

Bankart and Hill-Sachs lesions

X-ray:[4][20]

  • 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:[20][21]

  • 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[5]

CT scan: Reliably assess the location and depth of the humeral lesion[22]

MRI: Detect pathology of the soft tissue; determine the amount of humeral and glenoid bone loss[22][23]

[9][17][18]

Outcome Measures[edit | edit source]

Medical management[edit | edit source]

The bony defect usually does not require treatment, though the linked glenohumeral instability and possible anterior labral injuries often need surgical repair.

  1. Minimum 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.[14][24]
  2. Large Defects: Management of the bony defect (as in Hill-Sachs lesion) can be treated with bone grafting or placement of soft tissue within the defect.[3]

Surgical management[edit | edit source]

The critical size of the glenoid bone loss has been clarified as 25% of the glenoid width both biomechanically and clinically. This is the determinant factor influencing the choice of the surgical technique: soft tissue procedure or bone block procedure. [25]

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 osseous 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

[4]

Latarjet-Procedure

Open technique

  • Laterjet procedure: Most frequently done[4][26][27]
    • 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[4]

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.[28]

  • The onset of pathology
  • The degree of instability
  • The frequency of dislocation
  • The direction of instability
  • Concomitant pathologies
  • Neuromuscular control
  • Activity level
Stiff sling

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

[24]

Post-surgical rehabilitation should be guided by the orthopaedic surgeon, and depends on the procedure that was done.

Clinical bottom line[edit | edit source]

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%.[1][10] Another pathology secondary to an anterior shoulder dislocation is a Bankart lesion. This is an injury of the anterior glenoid labrum of the shoulder and often often accompanied by a Hill-Sachs lesion.[12]

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.[1][24]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 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. ↑ 2.0 2.1 Shoulder Doc. Hill-Sachs Lesion. Available from: https://www.shoulderdoc.co.uk/article/1470 (accessed 24 December 2023).
  3. ↑ 3.0 3.1 Radiopedia Hills Sachs defect Available from:https://radiopaedia.org/articles/hill-sachs-defect?lang=gb (accessed 24 December 2023)
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Provencher MT, Frank RM, Leclere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg. 2012 Apr;20(4):242-52. doi: 10.5435/JAAOS-20-04-242.
  5. ↑ 5.0 5.1 Castro WHM, Jerosch J, Grossman TV. Examination and diagnosis of musculoskeletal disorders. Georg Thieme Verlag: Germany, 2001.
  6. ↑ Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthopedic Clinics of North America 2008;39(4):507-18.
  7. ↑ ORTHOfilms. Bankart and Hill-Sachs Lesions. Available from: https://www.youtube.com/watch?v=a6BWiufgmsc [last accessed 10.1.2023]
  8. ↑ 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.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Wiki Radiography. Hill-Sachs and Bankart lesion. Available from:http://www.wikiradiography.net/page/Hill-Sachs+and+Bankart+Lesions (accessed 25 December 2023).
  10. ↑ 10.0 10.1 10.2 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.
  11. ↑ Horst K, Von Harten R, Weber C, Andruszkow H, Pfeifer R, Dienstknecht T, et al. 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.
  12. ↑ 12.0 12.1 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.
  13. ↑ 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.
  14. ↑ 14.0 14.1 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.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Fox JA, Sanchez A, Zajac TJ, Provencher MT. Understanding the Hill-Sachs Lesion in Its Role in Patients with Recurrent Anterior Shoulder Instability. Curr Rev Musculoskelet Med. 2017 Dec;10(4):469-479. doi: 10.1007/s12178-017-9437-0.
  16. ↑ Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014 Jan 1;30(1):90-8.
  17. ↑ 17.0 17.1 17.2 Cluett J. Hill-Sachs Injury: Damage to the shoulder joint as result of dislocation. Orthopedics, 2013.
  18. ↑ 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. ↑ 19.0 19.1 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.
  20. ↑ 20.0 20.1 Omoumi P, Teixeira P, Lecouvet F, Chung CB. Glenohumeral joint instability. Journal of Magnetic Resonance Imaging 2011;33(1):2-16.
  21. ↑ 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.
  22. ↑ 22.0 22.1 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.
  23. ↑ Pavic R, Margetic P, Bensic M, Brnadic RL. Diagnostic value of US, MR and MR arthrography in shoulder instability. Injury 2013;44:S26-32.
  24. ↑ 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.
  25. ↑ Yamamoto N, Shinagawa K, Hatta T, Itoi E. Peripheral-track and central-track Hill-Sachs lesions: a new concept of assessing an on-track lesion. The American Journal of Sports Medicine. 2020 Jan;48(1):33-8.
  26. ↑ 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.
  27. ↑ 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.
  28. ↑ 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.


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