Original Editors - Lien Hennebel Show
Top Contributors - Jelle Van Hemelryck, Lien Hennebel, Leana Louw, Pauline Bouten, Simisola Ajeyalemi, Admin, Kim Jackson, Shreya Pavaskar, Rachael Lowe, Fasuba Ayobami, Wanda van Niekerk, Claire Knott and Nupur Smit Shah Definition/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 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 the humerus. It is commonly known that the shoulder joint has a loose capsule, making it the most commonly dislocated joint in the human body, of which 90% of these dislocations are anterior. This is a result of the scapular orientation of about 30° anterior to the frontal plane of the body. The humerus is thus anteriorly orientated to the glenoid in the glenohumeral joint.[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 fibro-cartilaginous structure, surrounds the glenoid to ensure that there is enough contact between the surface of the glenoid and the humeral head. There is a concavity compression mechanism which plays an important role in the stability of the shoulder. The less contact there is, the higher the risk for dislocations.[8] Ligaments[edit | edit source]
Muscles[edit | edit source]
[6] 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] 1. Subacromial-subdeltoid bursa; 2. Subscapular recess; 3. Subcoracoid bursa; 4. Coracoclavicular bursa; 5. Supra-acromial bursa; 6. Medial extension of subacromial-subdeltoid bursa. 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] Etiology[edit | edit source]
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]
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]
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.[18][19][10] This is always caused by dislocation, not only subluxation.[18] According to the page on shoulder dislocations, the following indicates an acute anterior glenohumeral dislocation:
Differential diagnosis[edit | edit source]
Diagnostic Procedures[edit | edit source]Physical examination[edit | edit source]
Special investigations[edit | edit source]
[10][18][19] Outcome Measures[edit | edit source]
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][24] With minimum glenoid bone loss and without significant involvement of the humeral head (<20%), surgical management is not indicated[25]. This instability can be managed conservatively in a master sling for immobilization for 2-6 weeks, before starting with rehabilitation.[16][25] Management of humeral bone loss (as in Hill-Sachs lesion) can be directed at the restoration of the glenohumeral articular arc with either glenoid-based bone augmentation techniques (most commonly used), humeral-based strategies, or a combination. These strategies include open as well as arthroscopic procedures, depending on the extent of the pathology.[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 this, a surgical decision is made.[21] 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. Quantifying bone loss is of utmost importance to decide the best treatment for recurrent anterior glenohumeral instability patients. This is the determinant factor influencing the choice of the surgical technique: soft tissue procedure or bone block procedure. If it is off-track, either Latarjet or remplissage needs to be considered. If it is ontrack, then we need to evaluate whether it is a peripheraltrack lesion or central-track lesion. If a contact athlete has a peripheral-track lesion, we need to consider augmentation such as remplissage or Latarjet.It is generally accepted that anteroinferior glenoid bone loss comprising 25% or more of the inferior glenoid diameter must be addressed by glenoid bone grafting, using either a coracoid graft (Latarjet procedure), iliac graft, or allograft. However, if a noncontact patient has a peripheral-track lesion, we will perform a standard Bankart repair. Patients with a central-track lesion are expected to have satisfactory outcome with a standard Bankart repair regardless of their activity levels[26] Patients with on-track lesions can be divided into 2 subgroups: those with Hill-Sachs occupancy 75% (peripheral track lesion) showed significantly worse WOSI scores without recurrent instability events than those with the Hill-Sacks occupancy of 75% (central-track lesion).[26] Arthroscopic technique[edit | edit source]
[3] It has been clinically mentioned that shoulders with glenoid bone loss .25% confirmed a excessive failure price after arthroscopic stabilization. Open technique[edit | edit source]
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.[29]
Physiotherapy interventions include:
[25] 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 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][12] 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.[14] 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][25] References[edit | edit source]
Which of the following projections can be used to demonstrate the clavicle?Shoulder Girdle/Clavicle. Which of the following projections best demonstrate signs of a Bankart lesion?Terms in this set (42) What projection best demonstrates signs of a Bankart lesion? Grashey Method.
Which of the following projections can be performed using an orthostatic breathing technique?An orthostatic (breathing) technique can be performed for the AP projection of the scapula.
What is the degree of CR angulation for a PA axial projection of the clavicle?T/F: A posteroanterior (PA) axial projection of the clavicle requires a 35-45 degree caudal CR angle. A radiograph of a posterior oblique (grashey method) reveals that the anterior and posterior glenoid rims aren't superimposed.
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