Hill Sachs Lesion

A Hill Sachs Lesion or Hill Sachs Fracture is a dent or a compression injury to the posterolateral part of the humeral head created by the glenoid rim during dislocation. It occurs when the humeral bone pops out of the socket, its relatively soft head impacts against the anterior edge of the glenoid.

Shoulder can dislocate forward, backward or downward. A Hill-Sachs injury occurs only when there is a forward dislocation of the shoulder.

Hill Sachs Lesion is named after two American radiologists Harold Hill and Maurice Sachs – who in 1940, popularized the injury, provided radiographic evidence and determined a link between the lesion and recurrent instability.

Symptoms

Symptoms of a Hill sachs dislocation include:
Severe pain
Difficulty moving the joint
Visible deformation of the shoulder sometimes with a bulge in the front of the joint
Swelling or inflammation
Nausea and Weakness

Causes

The Hill Sachs lesion is typically caused by a shoulder dislocation.
Sudden falls
Sports injuries
Trauma like car accidents

Diagnosis

Your shoulder specialist will diagnose a Hill-Sachs Lesion using one or more of the following methods:

Physical examination
X-rays
Ultrasound
MRI

Treatment

The bony defect itself does not require treatment, but the associated injuries and continuous symptoms and instability requires treatment. Shoulder dislocations don’t occur isolated, it causes damage to other tissues surrounding the glenohumeral joint like the ligaments, tendons and the joint capsule.
Treatment depends on the extent of injury, the size of the lesion, its placement etc. Small injuries, where less than 20% of humeral head is involved, can be left alone with some physiotherapy.
Larger lesions which involves 20-40% of the humeral head and is contributing to instability require arthroscopic surgery. Such lesions generally damage other tissues like labrum, rotator cuff, anterior capsule etc. Surgery is very successful in preventing repeat dislocations and restoring motion.
The biggest concern post a Hill Sachs injury is the redislocation rate. More redislocations occur in teenagers than in older people as teenagers have higher percentage of loose tissue.
Treatment options include:
Capsular Shift- is done to tighten up the soft tissues
Remplissage – is primarily a tissue filling process

Disimpaction – this is a relatively new procedure which is still being explored

Shoulder Replacement or Shoulder Resurfacing – some cases of Hill sachs lesion can only be treated with a Shoulder Replacement or Shoulder Resurfacing

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Q&As on Hill Sachs Lesion

How does a Hill Sachs lesion occur?

A Hill Sachs lesion, also called a Hill Sachs impaction fracture, occurs when the back of the head of the humerus (the bone in the upper arm) is injured. This injury happens when the head of the humerus pops out of the glenoid cavity (socket) of the shoulder joint. It scraps against the edge of the socket when it pops out.
So, there is an injury to both the backside of the head of the humerus and the edge of the glenoid socket.
Hill Sachs lesion occurs when the shoulder joint gets dislocated. Shoulder joint dislocation can be downward, forward, or backward. Hill Sachs lesion only happens in a forward dislocation of the shoulder, which is the most common shoulder dislocation.
Shoulder dislocations happen due to specific and frequent, repetitive actions of the shoulder joints like throwing or lifting heavy weights above the shoulder.
Trauma like road traffic accidents, falls, etc., also cause shoulder dislocations.

What are the symptoms of the Hill Sachs lesion?

A shoulder dislocation is an emergency and requires urgent care. Mostly, more than one part of the affected shoulder may be injured in a shoulder dislocation.
Severe pain localized to the shoulder is the most common symptom of a Hill Sachs impaction fracture.
There is difficulty in shoulder movements, weakness, and some swelling and bruising of the shoulder.
There is visible deformation in the shape of the shoulder with a bulge in the front of the joint. There may be muscle spasms of the shoulder muscles.

How is a Hill Sachs fracture treated?

Treatment for a Hill Sachs fracture depends on the size of the lesion, its placement, arm mobility, and the extent of the involvement of the glenoid cavity bone.
In cases of small lesions with less than 20% involvement of the head of the humerus, only physical therapy and rest are advised by the doctor.

In medium-sized lesions, where the involvement of the head of the humerus is 20% to 40%, the doctor first assesses the stability of the affected shoulder.
If the shoulder is unstable in such lesions, surgery is advised. Various surgical options are available, like bone augmentation, disimpaction surgery, or Remplissage.
In cases where there is a large lesion, affecting more than 40% of the head of the humerus, resurfacing is advised. This involves a metal implant or a complete replacement of the humeral head. It is not advised in younger individuals.

Who is at risk of having a Hill Sachs lesion?

Everyone is at risk of having an injury that leads to a Hill Sachs lesion. Most people who play sports like baseball, cricket, basketball, golf, lacrosse, swimming, weight lifting, etc. are at a greater risk of having a Hill Sachs lesion
People who have had previous shoulder dislocations with Hill Sachs are at a higher risk of having it again. It has a high chance of recurrence.

How common is Hill Sachs lesion?

In individuals with an anterior or forward shoulder dislocation, a Hill Sachs lesion is reported in 40% to 90% of the patients. It may be as high as 100% in recurrent forward shoulder dislocation cases.

Dislocation of the shoulder joint is the most common joint dislocation amongst the major joints of the body.