When a shoulder is dislocated, the acetabulum may press against the humeral head, creating a Hill-Sachs lesion. This lesion corresponds to a pressure dent on the cartilage or bone of the humerus. Severe Hill-Sachs lesions must be corrected by surgical procedures.
What is a Hill-Sachs lesion?
Hill-Sachs lesion, also known as Hill-Sachs dent, corresponds to a pathologic condition on the head of the humerus. The lesion is usually the symptom of a dislocated shoulder and can affect both the cartilage and the bone at the humeral head. There are two different types of Hill-Sachs lesions.
The ventral form affects the anterior section. The dorsal form is manifested on the posterior section. The type of Hill-Sachs defect is directly related to the direction of shoulder dislocation. The Hill-Sachs lesion corresponds to an impression fracture. Compression fractures are called compression fractures that cause parts of the bone to be displaced or pressed into other parts of the bone.
Accordingly, the Hill-Sachs defect is often noticeable as an indented area on the humerus and is almost never observed independently of findings such as a dislocated shoulder. In most cases, the lesion is preceded by an accidental event.
Causes
The shoulder joint consists of parts of the humerus and shoulder blade. The top of the humerus lies in the socket on the lateral shoulder blade. The socket is referred to as the so-called shoulder socket and is the most important element of the shoulder joint. If the humerus slips out of this shoulder socket, you have a dislocated shoulder. When a dislocated shoulder is found, parts of the humerus may be crushed by the edges of the shoulder socket.
This creates strong pressure on the humeral head, which can manifest as a dent. Thus, the dislocated shoulder is considered to be the cause of the Hill-Sachs lesion. In most cases, the defect only occurs after the shoulder has been dislocated several times. The defect is dorso-lateral to the humeral head in an anterior shoulder dislocation. In a posterior shoulder dislocation, the Hill-Sachs lesion is ventral and is sometimes referred to as an inverse Hill-Sachs lesion. This pathologic phenomenon is often associated with a Bankart lesion that shears off the anterior or posterior acetabular rim.
Symptoms, Ailments & Signs
Since the Hill-Sachs lesion occurs primarily in direct connection with a dislocated shoulder, patients suffer from the typical symptoms of a dislocated shoulder. This includes, above all, restricted or completely abolished mobility in the shoulder joint. In most cases, severe pain is the reason for the restricted mobility.
Those affected hold the affected arm in a slight abduction and move it as little as possible. Most patients complain of spontaneous pain in addition to movement pain. The shoulder contour of those affected appears somewhat angular. In addition, the head of the humerus can be felt within the soft tissues outside the socket. If the dislocated shoulder has damaged vessels, bruising may be evident.
Circulatory disorders are also conceivable in this case. If, on the other hand, nerves have been damaged, there are often sensory disorders in the affected arm in addition to motor deficits. These sensory disturbances can correspond to abnormal sensations or general numbness. The Hill-Sachs lesion itself is usually not visible to the naked eye.
Diagnosis & disease progression
The diagnosis of a Hill-Sach lesion is made along with the diagnosis of shoulder dislocation using x-ray imaging. The doctor collects first indications of the two phenomena during the anamnesis and the physical examination.
If an anterior, inferior and traumatic primary dislocation of the shoulder is suspected, the doctor must also look for a Bankart lesion, even if the x-ray shows no defects. Ideally, he would start his search using an MRI. Alternatively, a diagnostic arthroscopy can take place.
Complications
The Hill-Sachs lesion primarily severely limits the patient’s mobility. In most cases, pain and limitations occur directly on the shoulder, making it difficult for those affected to bend down or lift. The severe pain and restricted mobility of the patient often lead to psychological problems and depression.
Furthermore, irritability can develop in the patient, which can have a negative impact on the social environment. The pain in the shoulder caused by the Hill-Sachs lesion can also occur in the form of pain at rest and can also lead to sleep disturbances at night. The affected region swells a lot and in most cases a bruise forms.
Furthermore, due to pinched nerves or a circulatory disorder, abnormal sensations or paralysis can occur in the shoulder. This feels numb and can often no longer be moved to the usual extent. In most cases, the Hill-Sachs lesion must be treated surgically with no further complications. In some cases, after the treatment, the affected person cannot immediately subject the shoulder to high loads.
When should you go to the doctor?
If you have shoulder problems, you should see a doctor. If the irregularities are not caused by a short-term overload, there is cause for concern. If shoulder discomfort can be traced back to a jerky movement, impact, or accident, it should be evaluated and treated. A doctor is needed in the event of restricted movement, pain or a drop in physical strength.
If the symptoms persist for several days or if they increase in intensity, a doctor should be consulted. It is also unusual for the symptoms to spread or for new symptoms to develop. If blood circulation problems occur or muscle pain occurs, a doctor’s visit is necessary. In the case of a bad posture of the body, one-sided physical strain, headaches or sleep disorders, the symptoms must be clarified by a doctor.
If a dislocated shoulder joint can be felt or recognized by visual inspection, the observations should be discussed with a doctor. Numbness in the shoulder, arm, or fingers, as well as sensory disturbances, should also be evaluated. If the arm can no longer be used as usual or if there is a tingling sensation in the arms or fingers, it is advisable to see a doctor. If there are changes in the complexion and discolouration, a doctor should be consulted.
Treatment & Therapy
The therapy of a Hill-Sach lesion takes place depending on the type of injury in the individual case. If it is the patient’s first shoulder dislocation, the Hill-Sachs defect is usually subtle and does not require further treatment. If a Bakart lesion is present, this defect is corrected with an arthroscopic or open surgical Bankart repair procedure.
On the other hand, if there is a recurrent or habitual shoulder dislocation with increasing instability, other procedures must be used. One such procedure may be Resch’s J-Span plasty. Operations according to Eden-Hybinette or subcapital derotation osteotomies according to Weber are also suitable.
If the Weber’s approach is chosen, the physician shifts the Hill-Sachs lesion out of the area of loading and at the same time tightens the posterior joint capsule with derotation. The tightening prevents a repeated luxation to the front side. A posterior dislocation requires surgery that can eliminate the depressed lesion. A drill hole is made in the posterior region of the humeral head.
The lesion is pushed outwards through this hole and stabilized by autologous cancellous bone. In individual cases, the procedure is carried out in combination with a rear Bankart repair according to Scott and Kretzler. Conversely, if an anterior Hill-Sachs defect is deep and indented, the small humerus tubercle can be displaced into the defect. This procedure corresponds to a Neer operation.
Outlook & Forecast
Many patients have a good prognosis with Hill-Sachs lesions. If the shoulder joint is slightly dislocated for the first time, it can be corrected in just a few simple steps. Afterwards, the patient’s body should be sufficiently rested for some time and heavy loads on the upper body should be avoided. Complete freedom from symptoms is achieved after a few days or weeks. In these cases, long-term consequences are not to be expected.
If the shoulder has already been dislocated repeatedly, the joint has already become loose. Therefore, recovery in these patients is short-lived. The shoulder joint is unstable overall and needs additional strengthening. The treatment is carried out in a surgical procedure and is carried out routinely with few risks. If there are no complications during the procedure, the patient normally experiences an alleviation of his symptoms afterwards. However, full resilience as in a natural joint is not achieved.
Complications during the surgical procedure or further damage to the surrounding areas can lead to permanent disorders and irregularities in movement. Consequential damage is possible, a decrease in physical performance and emotional stress can also develop. The overall prognosis is significantly negatively influenced by this. Nevertheless, the life of the person affected is not endangered by the disease.
Prevention
Hill-Sachs lesions can only be prevented if the patient prevents dislocation of the shoulder. Habitual dislocations due to tissue weaknesses can hardly be prevented. Prevention is also difficult in the context of accidents. However, if the person concerned can relate the repeated dislocations of the shoulder to sports practiced, stopping activity in these sports would, for example, amount to a preventive measure.
Aftercare
The individual follow-up treatment of a Hill-Sachs lesion depends primarily on the respective duration of the impairment, the severity of the paralysis associated with the lesion and the type of previous therapy. In any case, however, extensive and individualized physiotherapy is recommended. The aim of such is always to maintain and regain mobility, coordination and strength.
In addition to conventional physiotherapy with the guidance of a therapist, practicing at home often proves to be extremely useful. If there is time, we recommend short exercise units of 10 to 30 minutes each, spread over the day. Guided mobilization and movement therapy should be started shortly after the operation.
The shorter the time without movement, the easier it is to regain full resilience and mobility. In addition to physiotherapeutic work, closed times must also be observed. Everyday resilience can be expected after four to six weeks. Heavy physical and mechanical stress at work or in your free time should be strictly avoided in the first four weeks.
Elevation of the arm above the head and work done in such a position should be avoided until the injury has fully healed. In addition, attention should be paid regularly to sensory disorders or abnormal sensations in the shoulder and arm in order to prevent possible consequential damage such as circulatory disorders in good time.
You can do that yourself
Hill-Sachs lesions usually require surgical intervention to limit the symptoms and signs of the disease. Opportunities for self-help are therefore hardly available to those affected.
In some cases, however, the disease can be prevented by preventing the affected person from dislocating the shoulder. Attention should be paid to this in particular if these occur as part of a sporting activity. In the case of accidents or other illnesses, the Hill-Sachs lesion cannot be avoided directly. In the event of an accident, immediate medical treatment is advisable. Furthermore, the patient should of course take care of his body and avoid strenuous activities and sports. After the treatment, the movement of the shoulder must be restored. Various therapies are suitable, which can also be carried out at home. Sensitivity disorders or discomfort may be relieved by massageor restricted by heat applications. The circulatory disorders are usually treated as well.
If the person concerned suffers from psychological problems due to the restricted movement, the support of friends or acquaintances is very helpful. Meeting other patients can also have a positive effect on the course of the disease.
