Hill-Sachs lesion

Dr Henry Knipe and A.Prof Frank Gaillard et al.

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.

An "engaging" Hill-Sachs lesion is one that predisposes or causes of symptoms recurrent instability after Bankart lesion repair (see article: On-track and off-track shoulder lesions for further discussion) 10.

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. The concept of engaging

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

Hill-Sachs lesions may be difficult to appreciate on x-rays, frequently requiring CT or MRI for full characterization. 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.

These lesions are best seen following relocation 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, a wedge defect may be evident.

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 edema 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, where 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

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, engaging defects 6,7.

The Connolly procedure is performed by an open posterior approach and involves transferring the infraspinatus with a portion of greater tuberosity into the defect, and rendering the defect extra-articular; although this procedure restores the stability but it reduces the shoulder range of movement 6,7. The arthroscopic approach of the same procedure is known as remplissage (French for fill-in) 6.

It was first described in 1940 by American radiologists Harold Arthur Hill (1901-1973) and Maurice David Sachs (1909–1987) 3,11,12. The "engaging" Hill-Sachs was described by Burkhart and De Beer in 2000 10

On imaging consider:

Fractures
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Article information

rID: 1450
Synonyms or Alternate Spellings:
  • Engaging Hill-Sachs lesion
  • Hill Sach's deformity
  • Hill-Sachs lesions
  • Hill Sachs deformities
  • Hill Sachs lesion
  • Hill Sachs fracture

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Cases and figures

  • Figure 1: illustration
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  • Figure 2: normal shoulder
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  • Case 1
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  • Case 2
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  • Case 3
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  • Case 4: on ultrasound
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  • Case 5: with concurrent Bankart lesion
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  • Case 6
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  •  Case 7
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  • Case 8: on ultrasound
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  • Case 9
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  • Case 10
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  • Case 11
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  • Case 12
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  • Case 13
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  • Case 14
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  • Evident tear of t...
    Case 15: with concurrent bony Bankart lesion
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  • Case 16: annotated x-ray
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  • Case 17: annotated
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  • Case 18: impacted Hill-Sach lesion
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  • Case 19
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