A Hill–Sachs lesion, also Hill-Sachs fracture, is a cortical depression in the posterolateral head of the humerus bone. It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly.
It is named after Harold Arthur Hill (1901-1973) and Maurice David Sachs (1909-1987), two prominent radiologists from San Francisco, USA. In 1940, the pair published a report of 119 cases of shoulder dislocations and showed that the defect resulted from direct compression of the humeral head. Before their paper, the fracture was already known to be a sign of shoulder dislocation, but the precise mechanism of the lesion was uncertain.
The lesion is associated exclusively with anterior shoulder dislocations. When it is driven from the glenohumeral cavity, the relatively soft head of the humerus impacts against the anterior edge of the glenoid. The result is a divot or flattening in the posterolateral aspect of the humeral head (typically referred to as a 3 to 6 o'clock lesion for the right humeral head if seen from the bottom). The mechanism which leads to shoulder dislocation is usually traumatic but can vary, especially if there is history of previous dislocations. Sports, falls, seizures, assaults, throwing, reaching, pulling on the arm, or even just turning over in bed can all be causes of anterior dislocations.
Hill–Sachs lesions have been reported in as many as 92% of recurrent anterior dislocations. In all shoulder dislocation patients, the prevalence has been found to be between 35-76%. The presence of a Hill–Sachs lesion is an extremely specific sign of dislocation and can thus be used as an indicator that dislocation has occurred even if the joint has since regained its normal arrangement. The average depth of Hill–Sachs lesion has been reported as 4.1 mm. Large, engaging Hill-Sachs fractures can contribute to shoulder instability and will often cause painful clicking, catching, popping.
The majority of these fractures are found on plain film radiography. Generally, AP radiographs of the shoulder with the arm in internal rotation offer the best yield while axillary views and AP radiographs with external rotation tend to obscure the defect. A special view, the Stryker-Notch view, is often used specifically to look for a Hill–Sachs lesion. The sensitivity and specificity of radiography have been found to be 65% and 67%, respectively. Ultrasonography has also proven itself as a useful method of idenitifying Hill–Sachs lesions with a sensitivity of 96% and specificity of 100%. Finally, MRI has been shown to be 97% sensitive and 91% specific at detecting the fractures. The differential diagnosis of Hill-Sachs lesions includes the naturally occurring bare area of the humerus, which is depicted as a physiological shallow cortical depression located between the articular cartilage and the synovial reflection from the posterior wall of the glenohumeral joint.
Repair of a Hill–Sachs lesions is only indicated when it is associated with significant shoulder instability. The most effective and simplest approach is to prevent the lesion from straddling the anterior glenoid by slightly imbricating the capsule and thus limiting external rotation. The Connolly procedure is an alternative treatment approach and involves transferring the infraspinatus with a portion of the greater tuberosity into the defect. This leaves the lesion extraarticular and again prevents it from coming into contact with the glenoid rim. Finally, some surgeons using humeral osteotomy with subscapularis shortening, hemiarthroplasty, total shoulder arthroplasty, and use of allografts for patients with greater than 40% involvement of the articular surface.
- Hill HA, Sachs MD. The grooved defect of the humeral head: a frequently unrecognized complication of dislocations of the shoulder joint. Radiology 1940; 35:690-700
- Cicak N, Bilic R, Delimar D. Hill-Sachs lesion in recurrent shoulder dislocation: sonographic detection. J Ultrasound Med 1998;17:557-60
- Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013. Free section on Hill-Sachs lesion available at ShoulderUS.com