Ultrasonography: A Highly Efficient Modality for Diagnosis of Hill-Sachs Lesions

• Zusammenfassung
• Abstract
• Introduction
• Material and Methods
• Results
• Discussion
• References

Zusammenfassung

160 Schultergelenke von 80 konsekutiven Patienten (58 Männer, 22 Frauen) wurden innerhalb von 2 Jahren nach Diagnose einer anterioren Schulterluxation sonographisch untersucht. Eine Hill-Sachs-Läsion fand sich in 73 (91 %) der 80 verletzten Schultergelenke. Die durchschnittliche Tiefe der Läsionen betrug 25,21 mm² (9 bis 110 mm²). Die Sonographie hat sich als effiziente Methode zur Diagnostik von Hill-Sachs-Läsionen erwiesen.

Abstract

Purpose: To assess the usefulness of ultrasound in diagnosing Hill-Sachs lesions. Hill-Sachs lesions are very common findings after anterior gleno-humeral dislocation of the shoulder and especially after recurrent dislocations. The ultrasound examination offers many advantages including low cost, rapidity, repeatability, safety and no radiation exposure. It is an accurate method for diagnosis of Hill-Sachs lesions. We present here our experience with ultrasound usage in the diagnosis of Hill-Sachs lesions. Material and Methods: 160 shoulders of 80 consecutive patients (58 males, 22 females) had ultra-sonograms during two years due to diagnosis of anterior gleno-humeral dislocation of the shoulder. Results: Hill-Sachs lesions were found in 73 (91 %) of the 80 suspicious shoulders that were examined. The average depth of the lesions was 3.08 ± 1.1 mm, range between 2 to 5.2 mm. The average area of the lesions was 25.21 ± 20.66 mm², range between 9 to 110 mm². Conclusions: Sonography is a useful and effective tool in the evaluation and diagnosis of Hill-Sachs lesions.

Introduction

Hill-Sachs lesions are very common findings after anterior gleno-humeral dislocation of the shoulder and especially after recurrent dislocations [[2], [4]]. Although it is not a prognostic factor [[6], [7], [11]], except if the lesion is very big [[1]], it is still important for diagnosis and confirmation of anterior instability. Although in most cases simple radiograms are sufficient to make the diagnosis, there are cases which cannot be diagnosed by X‐ray either because they are to small, or in the acute phase when an optimal X-ray can't be done [[10]]. Others diagnostic modalities, such as CT or MRI, are also very efficient and accurate for detection of Hill-Sachs lesions [[8], [9]]. These modalities have some disadvantages such as high cost, irradiation exposure, claustrophobia, and relative low availability compared to X-ray or ultrasonography.

Ultrasonography is a safe, cheap, available, comfortable and accurate method for diagnosis of Hill-Sachs lesions [[3], [5], [9]]. We present here our experience with ultrasound usage in the diagnosis of Hill-Sachs lesions.

Material and Methods

160 shoulders of 80 consecutive patients (58 males, 22 females) had ultra-sonograms during two years due to diagnosis of anterior gleno-humeral dislocation of the shoulder. The patients mean age was 22.94 ± 4.84 years, range between 14 to 32 years.

The patients' position was sitting, elbow at 90° and the hand in the neutral position. The approach to detect Hill-Sachs lesion is to scan the postero-lateral aspect of the humeral head at the level of the coracoid process in a transverse plane. The correct position of the arm for scanning the circumference of the humeral head is the internal rotation. To demonstrate this lesion the patients arm is rotated internally.

Hill-Sachs deformity was recognized as a defect in the cortical contour of the postero-lateral surface of the humeral head.

The mean examination time was 7.64 ± 1.74 min, ranged between 6 to 13 min.

Real time ultrasound examination was carried out with ATL 5000 and G-50 Siemens machines, using a multiple range 5 - 13 MHz linear transducer.

All examinations were done by the same examiner.

Results

Hill-Sachs lesion was found in 73 (91 %) of the 80 suspicious shoulders that were examined. The average depth of the lesions was 3.08± 1.1 mm, range between 2 to 5.2 mm. The average area of the lesions was 25.21 ± 20.66 mm², range between 9 to 110 mm².

Discussion

Hill-Sachs lesions are very common findings after anterior gleno-humeral dislocation of the shoulder and especially after recurrent dislocations [[2], [4]]. Although it is not a prognostic factor [[6], [7], [11]], except if the lesion is very big [[1]], it is still important for diagnosis and confirmation of anterior instability. The typical patient is a young active adult. Identification of large Hill-Sachs lesions is important because it may indicate a predisposition for recurrent luxation.

Our results, 91 % (71 out of 80 shoulders), are similar to other previous reports, such as 88 % (54 out of 61 shoulders) [[3]] and 94 % (81 out of 86 shoulders) [[5]]. The average lesion size, such as depth of 3.08 ± 1.1 mm, range between 2 to 5.2 mm and area of 25.21 ± 20.66 mm², range between 9 to 110 mm², was close to other reports [[3]].

The impression of the injured humeral head can be seen very clearly in comparison to the smooth normal, contra-lateral humeral head. (Figs. [1] and [2]) The lesion is the result of anterior shoulder dislocation with the humeral head impacting on the antero-inferior aspect of the glenoid. A Hill-Sachs lesion may be detected posteriorly. The humeral head at this level should have a rounded contour. A Hill-Sachs lesion appears as a sudden depression in the bony contour. Although in most cases simple radiograms are sufficient to make the diagnosis, there are cases which cannot be diagnosed either because they are to small, or in the acute phase when an optimal X-ray can't be done [[10]]. The high reflectivity of cortical bone and the tomographic nature of ultrasound imaging make it ideal for evaluation of bony contour.

These post-traumatic defects are often hard to visualize on conventional radiograms.

The large number of special projections advocated for the radiographic visualization of these lesions indicates the difficulty of this problem.

Ultrasound will quickly and clearly demonstrate the contours of the entire circumference of the numeral head.

Ultrasonography proved efficient and accurate in comparison to other diagnostic modalities, such as CT or MRI, for detection of Hill-Sachs lesions [[8], [9]]. These modalities have some disadvantages such as high cost, irradiation exposure, claustrophobia, and relative low availability compared to X-ray or ultrasonography.

Further more, the mean examination time was only 7.64 ± 1.74 min, range between 6 to 13 min, which is usually much shorter than mean CT or MRI examination time.

We found that ultrasonography is a highly efficient modality for diagnosis of Hill-Sachs lesions.

References

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  PubMedSearch in Google Scholar
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A. Blankstein

Department of Orthopedic Surgery and Diagnostic Imaging
The Chaim Sheba Medical Center

Tel Hashomer 52621

Israel

Fax: + 972/3/549-4269

Email: blankali@zahav.net.il

References

• 1 Burkhart S S, De Beer J F. Traumatic glenohumeral bone defects and relationship to failure arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.  Arthroscopy. 2000;  16 677-694
  CrossrefPubMedSearch in Google Scholar
• 2 Calandra J J, Baker C L, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations.  Arthroscopy. 1989;  5 254-257
  PubMedSearch in Google Scholar
• 3 Cicak N, Bilic R, Delimar D. Hill-Sachs lesion in recurrent shoulder dislocation: sonographic detection.  J Ultrasound Med. 1998;  17 557-560
  PubMedSearch in Google Scholar
• 4 Danzig L A, Greenway G, Resnick D. The Hill-Sachs lesion. An experimental study.  Am J Sport Med. 1980;  8 328-332
  PubMedSearch in Google Scholar
• 5 Farin P U, Kaukanen E, Jaroma H, Harju A, Vaatainen U. Hill-Sachs lesion: sonographic detection.  Skeletal Radiol. 1996;  25 559-562
  CrossrefPubMedSearch in Google Scholar
• 6 Hoelen M A, Burgers A M, Rozing P M. Prognosis of primary anterior shoulder dislocation in young adults.  Arch Orthop Trauma Surg. 1990;  110 51-54
  CrossrefPubMedSearch in Google Scholar
• 7 Huttrup S J, Cofield R H, Weaver A L. Anterior shoulder reconstruction: prognostic variables.  J Shoulder Elbow Surg. 2001;  10 508-513
  CrossrefPubMedSearch in Google Scholar
• 8 Kirkley A, Litchfield R, Thain L, Spouge A. Agreement between magnetic resonance imaging and arthroscopic evaluation of the shoulder joint in primary anterior dislocation of the shoulder.  Clin J Sport Med. 2003;  13 148-151
  CrossrefPubMedSearch in Google Scholar
• 9 Pancione L, Gatti G, Mecozzi B. Diagnosis of Hill-Sachs lesion of the shoulder. Comparison between ultrasonography and arthro-CT.  Acta Radiol. 1997;  38 523-526
  PubMedSearch in Google Scholar
• 10 Rozing P M, de Bakker H M, Obermann W R. Radiographic views in recurrent anterior shoulder dislocation. Comparison of six methods for identificatin of typical lesions.  Acta Orthop Scand. 1986;  57 328-330
  PubMedSearch in Google Scholar
• 11 Ungersbock A, Michel M, Hertel R. Factors influencing the results of a modified Bankart procedure.  J Shoulder Elbow Surg. 1995;  4 365-369
  PubMedSearch in Google Scholar

A. Blankstein

Department of Orthopedic Surgery and Diagnostic Imaging
The Chaim Sheba Medical Center

Tel Hashomer 52621

Israel

Fax: + 972/3/549-4269

Email: blankali@zahav.net.il