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Hill-Sachs lesion

Hill-Sachs lesions are a posterolateral humeral head compression fracture, typically secondary to recurrent anterior shoulder dislocations, as the humeral head comes to rest against the anteroinferior part of the glenoid. It is often associated with a Bankart lesion of the glenoid.

Pathology

In addition to being acutely painful at the time of dislocation, Hill-Sachs lesions' may promote future dislocation/subluxation due to the lever-like effect of the defect during external rotation 4.

Associations

Bankart lesions are up to 11 times more common in patients with a Hill-Sachs lesion, with increasing incidence with increasing size 8

Radiographic appearance

Hill-Sachs lesions may be difficult to appreciate on x-rays, frequently requiring CT or MRI for full characterisation. When a Hill-Sachs lesion is identified careful assessment of the anterior glenoid rim and labrum should be performed to identify a potential Bankart lesion.

Plain film

Best seen following re-location of the joint, and better appreciated on internal rotation views. It appears as a sclerotic vertical line running from the top of the humeral head towards the shaft. If large then a wedge defect may be evident.

CT and MRI

Both MRI and CT are very sensitive to this lesion, which appears as a region of flattening or a wedge shaped defect (with bone marrow oedema on MRI acutely) seen involving the posterolateral humeral head above the level of the coracoid. This is usually seen in the most superior few slices, were the humeral head should be rounded. It is important to note that below the level of the coracoid the humeral head normally flattens out posterolaterally (sometimes termed pseudo-Hill-Sachs lesion), and this should not be misinterpreted as a Hill-Sachs lesion 2,4

Treatment and prognosis

The bony defect itself does not require treatment, however the associated glenohumeral instability and often co-existent anterior labral injuries often do require surgical repair.

The bony defect can also be treated with bone grafting or placement of soft tissue within the defect but this is generally reserved for large defects 6-7.

The Connolly procedure is performed by an open posterior approach and involves transferring the infraspinatus with a portion of greater the tuberosity into the defect, and rendering the defect extra-articular 6-7.

Alternatively soft tissue transfer can be performed arthroscopically 6.

History and etymology

It was first described in 1940 by H A Hill and M D Sachs 3.

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