Figure. Anteroposterior radiograph of the shoulder; arrow shows area of defect.
A 29-year-old man presents to the office with complaints of right shoulder pain after an injury he sustained during a mixed martial arts competition. During the match, the patient notes that his arm was pinned backward and his right shoulder was anteriorly displaced. At the time of the injury, he was brought to the emergency room where the clinician reduced the anterior shoulder dislocation. The dislocation results in a large deformity to the humeral head that is identified with a white arrow in the Figure.
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The patient has a large Hill-Sachs lesion as a result of his anterior shoulder dislocation. A Hill-Sachs lesion is a compression fracture of the posterior lateral humeral head as it strikes the anterior glenoid during an anterior shoulder dislocation.1 The incidence of a Hill-Sachs lesion after a shoulder dislocation varies widely in the literature ranging from 40% to 90%, and approaches 100% in patients with recurrent anterior shoulder instability.1
Lesions can vary in size with larger lesions being more clinically significant. Lesions involving more than 40% of the humeral surface are almost always associated with recurrent shoulder instability.1 An “engaging” lesion is one that engages the rim of the glenoid when the shoulder is in abduction and external rotation. Symptoms of an engaging lesion include “catching” when the patient abducts and externally rotates the arm such as in a throwing motion.2
Engaging Hill-Sachs lesions have a high rate of instability and surgical failure when treated with a Bankart repair alone. The most common treatment for an engaging Hill-Sachs lesion is an arthroscopic Bankart repair with a remplissage procedure.3 A arthroscopic remplissage procedure involves filling the bony defect with capsule and infraspinatus tissue to prevent engagement of the glenoid.3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
1. Provencher MT, Frank RM, Leclere LE, et al. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg. 2012;20(4):242-452. doi:10.5435/JAAOS-20-04-242
2. Gyftopoulos S, Yemin A, Beltra L, Babb J, Bencardino J. Engaging Hill-Sachs lesions: is there an association between this lesion and findings on MRI? AJR Am J Roentgenol. 2013;201(4):W633-638. doi:10.2214/AJR.12.10206
3. Buza JA, Lyengar JJ, Anakwenze OA, Ahmad CS, Levine W. Arthroscopic Hill-Sachs remplissage: a systematic review. J Bone Joint Surg Am. 2014;96(7):549-555. doi:10.2106/JBJS.L.01760