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A Case of Shoulder Instability
17 year old football player with prior shoulder dislocation landed on his shoulder and felt immediate pain.
A Case of Shoulder Instability
Author: Mark Hopkins, MD
Peer-reviewer: Will Denq, MD
Editor: H. Megan French, MD, FACEP
17 year old football player with prior shoulder dislocation landed on his shoulder and felt immediate pain.
Image 1. Courtesy of Richard Hopkins, MD
What additional lesion can also be seen in these injuries?
A Hill-Sachs lesion (see Image 2). Hill-Sachs lesions are compression fractures caused by the soft postero-lateral humeral head forcefully striking the bony anterior glenoid rim as the head tries to reenter the socket immediately following dislocation (see Image 3). These lesions have been reported in up to 90% of first-time dislocations, and can be seen on MRI in nearly all patients with recurrent instability [5].
- Pearl: If either a Bankart or Hill-Sachs deformity is seen, the patient is 11 times more likely to have suffered the associated injury as well, so be on the lookout (see Image 4). Co-occurrence was even more likely when large Hill–Sachs lesions were present [4].
- Pearl: Also watch for rotator cuff tears. Their incidence has been reported in 35% of patients over 40 years of age and greater than 80% of those over 60 [6].
Image 2. Case (and arrows) courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 58016
Image 3: Posterior view of Hill-Sachs Lesion in action. Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 65796
Why is this important in the ED?
Bankart and Hill-Sachs lesions allude to potential glenohumeral instability. Keep this in mind even with patients who present without dislocation. Recurrent dislocations or feelings of instability with daily activity merit sports medicine or orthopedic follow-up.
Image 4: Bony Bankart with concurrent Hill-Sachs Lesion. Case courtesy of Dr. Maulik S Patel, Radiopaedia.org, rID: 10089
References
[1] Zacchilli M.A., and Owens B.D.: Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010; 92: pp. 542-549
[2] Carrazzone, Oreste Lemos et al. "PREVALENCE OF LESIONS ASSOCIATED WITH TRAUMATIC RECURRENT SHOULDER DISLOCATION." Revista brasileira de ortopedia vol. 46,3 281-7. 8 Dec. 2015, doi:10.1016/S2255-4971(15)30196-8
[3] Sugaya H., Moriishi J., Dohi M., Kon Y., and Tsuchiya A.: Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am. 2003; 85: pp. 878-884
[4] Horst, K et al. "Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study." The British journal of radiology vol. 87,1034 (2014): 20130673. doi:10.1259/bjr.20130673
[5] Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997; 25(3):306-11.
[6] A. Rumian, D. Coffey, S. Fogerty, R. Hackney. "Acute first-time shoulder dislocation." Orthop Trauma, 25 (2011), pp. 363-368
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