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Hill-Sachs Fracture: Mechanism, Classification, and Treatment of This Shoulder Injury

A Hill-Sachs lesion is a compression fracture of the posterolateral humeral head caused by impaction against the anteroinferior glenoid during anterior shoulder dislocation. Named for radiologists Harold Hill and Maurice Sachs (1940).

Mechanism of Injury

  • Anterior dislocation → humeral head forced anteroinferiorly.
  • Posterolateral humeral head impacts glenoid rim → "dent" (impression fracture).
  • Often associated with Bankart lesion (anteroinferior labral tear).

Classification (Calandra et al.)

GradeDepthArticular Surface InvolvementEngagement Risk
I<25%Subchondral onlyLow
II25–50%Articular cartilage involvedModerate
III>50%Large structural defectHigh (engages in abduction/external rotation)

"On-Track" vs. "Off-Track" (Modern Concept)

  • Glenoid track = 83% of glenoid width.
  • If Hill-Sachs interval (medial margin of lesion to rotator cuff insertion) > glenoid track → Off-track → engages → instability.
  • On-track → does not engage; may be managed non-operatively.

Clinical Presentation

  • Acute: Severe shoulder pain, deformity, inability to move (dislocation).
  • Recurrent: Apprehension, instability, catching, recurrent dislocations.

Imaging

  • AP, axillary, West Point, Stryker notch X-rays.
  • CT with 3D reconstruction (gold standard for size/orientation).
  • MRI/MR arthrogram (labral, capsular, rotator cuff).

Treatment Algorithm

  • Small, on-track (Grade I/II): Non-operative — immobilization, then PT (rotator cuff, scapular stabilizers).
  • Large, off-track / engaging (Grade III): Surgical — remplissage (infraspinatus tenodesis into defect), bone graft (allograft/autograft), partial humeral resurfacing, or arthroplasty (older patients).
  • Concomitant Bankart: Arthroscopic labral repair + Hill-Sachs management.
  • Significant glenoid bone loss (>25%): Latarjet (coracoid transfer) ± Hill-Sachs procedure.

Rehabilitation

Phased: protection → passive/active ROM → strengthening → proprioception → sport-specific. Return to sport 4–6 months post-op.

Accurate characterization (size, engagement, glenoid bone loss) drives management.

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