yogabook / pathologie / hill-sachs-lesion (HSL)

Hill-Sachs-Lesion (HSL) / Hill-Sachs-Delle / humeral head compression fracture / Malgaigne-Furrow

Definition of

Cartilage or bone defect of the humeral head as a result of one or more dislocations of the shoulder joint. Men are affected more frequently than women, with the peak incidence in men between the ages of 20 and 40, although male shoulder joints are no more unstable than female shoulder joints. Risk-taking behavior is discussed as a cause.

The Hill-Sachs lesion is the result of repeated shoulder dislocations. In practice, it almost never occurs independently of dislocations. Depending on the severity, age, activity level and other parameters, it always requires treatment, including surgery if necessary, so that recurrent dislocations do not damage the shoulder joint to the point of osteoarthritis. The lesion occurs approximately inversely to the dislocation:

• dorsolateral in the case of a ventral dislocation, as the humeral head hangs subglenoidally and is displaced ventrally, caudally
• ventral with dislocation to the dorsalolateral (sometimes referred to as inverse HSL)

The defect is caused by pressure of the glenoid rim on the caput humeri in the course of a dislocation of the shoulder joint. It is usually accompanied by a Bankart lesion(shearing of the glenoid rim), which affects only the glenoidlabrum, or also the cartilage or the bone. These must also be examined if the X-ray shows no defects. Impression at the caput humeri, which affects the cartilage or also the bone. This is sometimes referred to as an impression fracture.

The glenoid track concept is used to differentiate between critical and less critical severity. For this purpose, the distance of the medial border of the Hill-Sachs lesion from the infraspinatus attachment tendon is recorded as the Hill-Sachs interval, as well as the depth of the HSL and the extent of bone loss. The articular surface of the humeral head is exrapolated in a spherical shape. The contact zone between the glenoid and the humeral head is referred to as the glenoid track. If the Hill-Sachs interval is greater than the glenoid track, a critical off-track lesion is present; if it is smaller, a less critical on-track lesion is present.

Cause

• Single or recurrent dislocation of the shoulder joint

Predisposing

Diagnosis

• a painful, endorotating subluxation on return of the arm from exorotation and lateral abduction is a red flag and indicates surgery
• X-ray, MRI
• Diagnostic arthroscopy if necessary

Symptoms

• Chronic instability of the shoulder joint with a tendency to dislocation, which, depending on the severity of the HSL, can also be triggered by minor impacts.
• Pain on movement, possibly painful restriction of movement
• If necessary, gentle posture with slight abduction
• possibly spontaneous pain
• Changed shoulder contour if necessary
• possibly hematoma or circulatory disorder due to damage to vessels caused by the dislocation
• possibly sensory disturbances, paresthesia when pressure is exerted on a nerve by the dislocation
• possibly psychological symptoms: irritability, depression
• possibly pain at rest and impairment of night sleep
• The joint may „stick“ during movements with exorotation and lateral abduction(ventral dislocation). An endorotation with transverse adduction can then trigger the dislocation.

Complications

the lesion can favor dislocations. In ventral dislocations, abduction and external rotation can cause the dent to catch on the glenoid rim, while in dorsal dislocations, internal rotation can cause the humeral head to dislocate.

Therapy

• ventral and inferior dislocation must be checked for a Bankart lesion. Bankart repair (refixation of the ventral, caudal labrum plus tightening of the caudal capsule, full fitness for sport only after approx. 8 months) is usually sufficient in the first occurrence. Further options: J-Span plasty according to Resch, surgery according to Eden-Hybinette, subcapital derotation osteotomy according to Weber with displacement of the lesion from the weight-bearing area and tightening of the dorsal capsule. In the case of very deep anterior lesions, the lesser tuberosity may be moved into the area of the lesion. For posterior dislocation: Scott and Kretzler surgery, with Bankart repair if necessary
• Conservative: physiotherapy, massage, strength training
• Transection of the infraspinatus or biceps caput longum and refixation
• Good prognosis for mild initial dislocation
• In chronic cases, the stability and resilience of the shoulder joint is reduced, and post-operative resilience is usually reduced.
• Avoiding risks such as extreme sports that are dangerous to your shoulders
• Promotion of flexibility, coordination and strength, also on the patient’s own initiative, ideally in units of 10 – 30 minutes spread throughout the day. Start early after surgery. The longer the phase without movement, the worse the prognosis. In the first four weeks post-op, avoid heavy shoulder-related physical activity, after which you should be able to cope with everyday activities. Avoid overhead work until healing is complete.