Rebecca D.

Richards, MD David
#{149} J. Sartoris, MD Mini
#{149} N. Pathria, MD Donald
#{149} Resnick, MD

Hill-Sachs Lesion and Normal Humeral

Groove: MR Imaging Features Allowing
Their Differentiation’

PURPOSE: To present a method of T HE shoulder is the most mobile In the current investigation, the
differentiating Hill-Sachs lesions joint in the body and, as such, precise location of the Hill-Sachs de-
from the anatomic groove in the pos- suffers from a high degree of inherent fect is described as it appears on
terolateral humeral head with use of instability. It is estimated that almost transaxial MR images of 28 arthro-
magnetic resonance imaging. one-half of all dislocations in the hu- scopically proved lesions. These find-
MATERIALS AND METHODS: A man body occur about the shoulder ings then are compared with the size
(1,2). Of the joints making up the and location of the normal indenta-
3600 reference about the humeral
head was established to define the shoulder, the most frequently affected tion in the posterolateral portion of
locations of Hill-Sachs lesions and is the glenohumeral joint (GHJ). GHJ the humeral head by using both MR
the anatomic groove on transaxial dislocations may be the result of acute images of the shoulder obtained in 21
images. The extension of each find- trauma or repetitive motion; there even asymptomatic persons as well as ra-
ing along the longitudinal humeral is a large number of spontaneous dis- diographic-pathologic correlation in
axis was noted. Eight cadaveric speci- locations (2,3). Approximately 95% of eight cadaveric specimens.
mens were sectioned and similarly GHJ dislocations occur in the anterior
analyzed. direction, secondary to hyperabduc-
MATERIALS AND METHODS
tion, extension, and external rotation.
RESULTS: The
locations of Hill- In cases of anterior dislocation of the Cadavers
Sachs lesions and the anatomic
GHJ, the posterolateral portion of
groove in the circular reference frame Eight fresh cadavenc specimens consist-
the humeral head becomes lodged
were statistically significantly differ- ing of the scapula, proximal humerus, and
against the anterior glenoid rim. This
associated soft tissues were obtained from
ent (P < .001), yet their respective often causes a compression fracture of the anatomy department of our medical
ranges overlapped. Along the longi- this area of the humeral head, corn- school. Although specific information re-
tudinal humeral axis, there was no monly known as a Hill-Sachs lesion garding age and medical history was tim-
overlap between the respective (4). Identification of a Hill-Sachs le- ited, all cadavers were derived from adult
ranges of location (P < .001). sion has remained difficult with use of patients, mostly elderly, and no historical
CONCLUSION: A Hill-Sachs lesion routine radiography and even with data suggesting previous GHJ dislocation
is best differentiated from the ana- more invasive techniques such as were present. Plain radiographs were
taken of each intact frozen specimen. The
tomic groove by means of its more double-contrast computed arthroto-
specimens subsequently were sectioned
cephalic position along the longitudi- mography or arthroscopy (5-8). The
transaxially to a thickness of 3-5 mm. Indi-
nal humeral axis. presence of a Hill-Sachs lesion is be- vidual sections were labeled sequentially,
lieved to have prognostic significance and radiographs of them were obtained.
Index terms: Humerus, 415.42, 415.92 #{149}Shout-
regarding the likelihood of recurrence These radiographs then were analyzed
der, anatomy, 415.92 Shoulder,
#{149} dislocation, and may also be an indicator of prior with regard to the precise size and loca-
415.42 dislocation (9). Accurate diagnosis is tion of the posterotateral humeral groove
thus desirable after an acute disloca- (method described below) and the general
Radiology 1994; 190:665-668
tion to evaluate the need for surgical anatomy of the proximal portion of the
reconstruction or rehabilitative humerus.
therapy.
Recently, several investigators have Patients
found transaxial magnetic resonance
MR images of 28 patients with arthro-
(MR) imaging to be a very accurate
scopicatly proved Hill-Sachs lesions were
means of simultaneously evaluating
obtained for study. These patients have
both bone injury, specifically the Hill- been reported in detail elsewhere (8).
I From the Department of Medicine, Mercy Sachs defect, and soft-tissue damage They consisted of men only, ranging in
Hospital and Medical Center, San Diego, Calif
resulting from shoulder dislocation age from 19 to 44 years, with an average
(R.D.R.); and Osteoradiotogy Division, Veterans
Affairs Medical Center, 3350 La Jolla Village Dr.
(3,5,10). The presence of a normally age of 25 years. MR images of 21 asymp-
San Diego, CA 92161 (D.J.S., M.N.P., DR.). Re- occurring groove in the posterolateral tomatic persons were obtained from re-
ceived June 25, 1993; revision requested July 30; portion of the humeral head as it ap- cruited subjects screened for any history
revision received October 20; accepted October proximates the humeral shaft, how-
26. Supported in part by Veterans Administra-
ever, has been cited as a possible
tion grant FA360. Address reprint requests to
DR. source of false-positive readings in
‘ RSNA, 1994 this type of study (8,10). Abbreviation: GHJ = glenohumerat joint.

665
of shoulder symptoms or injury before
being studied. This population ranged in
age from 28 to 53 years, with an average
age of 38 years. There were 17 men and
four women.
In both populations, transaxial TI-
weighted MR images of the shoulder were
further evaluated in the following fashion:
Initially, a 360#{176}
frame of reference with
regard to the humeral head was estab-
lished. To determine this reference frame,
the length of the articular surface of the
humerat head on each of the transaxial
images was measured, and the image
showing the largest such surface was de-
termined. This section was located ap-
proximately 12-16 mm distal to the most
proximal tip of the humerus. The anterior
and posterior margins of the articular sur-
face in this section then were determined.
The anterior margin of the articular sur-
face was defined as 0#{176}
and the posterior
margin as 180#{176}.
A circle then was com-
pleted, with the midpoint of a line be-
tween the articutar end points used as the with that on the MR images (average
center of the circle. Ninety degrees was midpoint, 183#{176}).
The depth of the
defined at the medial portion of the hu- groove varied from 3 to 6 mm (aver-
merus (within the articular surface) so that
age depth, 4 mm).
degree values would correspond between
the right and left shoulders (Fig 1). This
exact frame of reference then was used to
Patients
analyze each transaxial section through
the humeral head, with the distance from The anatomic groove in the pos-
the midpoint of the circle to the edge of terolateral portion of the humerus
the humerus kept constant at 90#{176}.
In this was visible with MR imaging in each
manner, the Hill-Sachs lesions and the
of the 21 asymptomatic shoulders (Fig
anatomic indentations of the humerus
3) and in 27 of the 28 shoulders with
were defined as occurring at specific de-
gree locations about the humerus. In addi-
Hill-Sachs lesions. The groove was
tion, by using data regarding section located between 140#{176}
and 230#{176}
about
thickness and spacing, the extension dis- the humeral head, with an average
tally along the humerus as well as the midpoint of 183#{176}.
There was no statis-
depths of the Hitl-Sachs lesions and the tically significant difference between
normal groove were noted. the location of the anatomic groove in
Statistical analysis between groups was the right and left shoulders. The aver-
done with the Student t test; significance
age arc of the groove was 53#{176},
and the
was defined as P < .05. Figure 1. Transaxial 1.5-T gradient-echo
average depth was 3 mm. The differ- image (repetition time msec/echo time msec =

ence between the average arc length 300/10) of 28-year-old woman shows circular
RESULTS of the anatomic groove on the radio- frame of reference about the humerat head.
graphs of the cadavers (44#{176})
and on The anterior and posterior end points of the
Cadavers articular surface are defined as 0#{176}
and 180#{176},
the MR images (53#{176})
most likely was
respectively.
The uppermost portion of the hu- related to the different radiologic
meral head approximates a circle. Dis- techniques but also may have been a
tally, the head becomes more irregu- consequence of the much greater av-
lar as the bicipital groove and tubero- erage age of the cadaveric specimens. ible with those reported in reference 8
sities take form. As the humeral head Longitudinally, the groove extended and were statistically significantly dif-
approaches the humeral shaft, a nor- from a minimum of 20 mm distal to ferent from the location of the normal
mal indentation occurs on its postero- the most cephalic portion of the hu- humeral groove (P < .001). There was
lateral side (Fig 2). This indentation meral head, with an average upper no statistically significant difference in
lies underneath the path of the teres margin of 25 mm, to a maximum of the location of the lesions between
minor muscle as it inserts in the lat- 38 mm along the proximal humerus, the right and left sides. The average
eral portion of the humeral head. In at which point the groove flattened to arc from one side of the lesion to the
this series, the indentation was found join the humeral shaft. other was 52#{176}, with a range of 30#{176}-85#{176}.
to lie between 150#{176}and 210#{176}
about the A Hill-Sachs defect clearly was vis- The arc length of the lesion differed
head with use of the circular refer- ible on transaxial MR images in each statistically significantly between
ence frame described above. The av- of the 28 cases of arthroscopically sides, with a mean of 57#{176} in the right
erage arc between
the end points of proved lesions. With use of the crite- shoulders and 47#{176} in the left shoul-
the groove wasstatistically
440 sig- na defined above, all of the lesions ders (P < .05). Depth varied in rela-
nificantly less than that observed on were located within the boundaries tion to overall lesion size, ranging
the MR images (average arc, 53#{176}; of 170#{176}-260#{176}
about the humeral head, from 2 to 6 mm (average depth, 4
P < .001) (Table 1). The average mid- with an average midpoint of 209#{176} mm). Neither depth nor arc length
point of this arc fell at 182#{176}, consistent (Table 2). These findings are compat- differed statistically significantly from

666 Radiology
#{149} March 1994
 significantly different from the loca-
tion of the anatomic groove (P <
.001). In each case, the anatomic
groove was easily differentiated from
the Hill-Sachs lesion (Fig 4). The aver-
age lesion extended 12 mm, with no
statistically significant difference be-
tween the right and left sides.

DISCUSSION
The frequency of a Hill-Sachs lesion
occurring in a primary dislocation of
a. b. the GHJ has been estimated to be from
Figure 2. Radiographs of specimen from 72-year-old man. (a) Section through the midpoint 25% to 100% (11). It is known that any
of the normal humeral head shows no evidence of indentation in the posterolateral area. acute GHJ dislocation is associated
(b ) Section closer to the humeral shaft clearly demonstrates the anatomic posterolateral with an increased risk of future dislo-
groove (arrow).
cation, estimated at 33% in one series
(12). Many investigators have sug-
gested that the presence of a Hill-
Sachs lesion could be an important
prognostic factor in evaluating this
risk (2,4,6,9). The lesion indirectly
could correlate with the risk of recur-
rent dislocation by serving as an mdi-
cator of the extent of damage to the
supporting mechanism of the GHJ. In
addition, the lesion itself could serve
as a lever, facilitating dislocation
when the joint again is placed in an
extended and externally rotated posi-
tion. In either case, accurate diagnosis
of the presence or absence of the le-
sion and associated soft-tissue injury
a. b.
should aid in determination of the
Figure 3. Transaxiat I.5-T gradient-echo images (300/10) of 28-year-old woman. (a) Section 4
therapy and rehabilitation for patients
mm from the top of the humerat head. The normal proximal humerus approximates a circle.
(b) Section 24 mm from the top of the humeral head. The upper extent of the anatomic groove with GHJ dislocation.
(arrow) is seen. In this series, the presence of a Hill-
Sachs lesion easily was diagnosed on
the basis of transaxial MR images. The
lesions were located at the uppermost
portion of the humeral head, invari-
ably visible within the two most
proximal transaxial sections. The de-
fects extended distally to a maximum
of 20 mm. On the basis of the circle
defined above, the lesions were lo-
cated between 170#{176}
and 260#{176}
about
the humeral head.
An anatomic indentation in the
posterolateral portion of the proximal
humerus also was defined. Our analy-
sis of the data on the locations of the
normal groove and the Hill-Sachs de-
fect indicates that they reliably can be
distinguished on the basis of their
a. b.
positions along the longitudinal axis
Figure 4. Transaxial 1.0-T Ti-weighted images (650/25) of 44-year-old man. (a) Section 4 mm
of the humerus. In our series, the nor-
from the top of the humerat head. The Hilt-Sachs lesion is seen as an abnormal indentation
(arrow) of the proximal humerus. (b) Section 30 mm from the top of the humeral head. The
mal groove always began below the
anatomic groove (arrow) is seen approaching the humerat shaft. most distal extent of the Hill-Sachs
lesion (Fig 5). Although it is possible
that more extensive Hill-Sachs defects
might extend inferiorly below the
that of the normal humeral groove. ond section, 4-5 mm distal to the top proximal limit of the anatomic groove,
Twenty-one of the 28 lesions were of the humeral head. The most distal the lesion still would be expected to
visible on the uppermost transaxial extension of any of the Hill-Sachs le- extend superiorly to within the topS
section through the humeral head. sions was 18 mm from the top of the mm of the humeral head. The upper-
The remainder were noted on the sec- humeral head. This was statistically most limit of the anatomic groove was

Volume 190 Number

#{149} 3 Radiology 667
#{149}
found to lie between 20 and 32 mm
distal to the top of the humeral head.
The locations of the two grooves in A
terms of their positions about the
circle defined in this study also dif-
fered statistically significantly (P <
.001). The anatomic indentation oc-
B
curred more posteriorly, and the Hill-
Sachs lesion, more laterally. As these
positions overlapped considerably,
however, this characteristic does not
provide a reliable means of differenti-
ating between the two (Fig 6). The
depth and width of the Hill-Sachs
lesions and the anatomic groove were
not statistically significantly dissimi- Figure 6. Diagram of the ranges of location
lar. In conclusion, then, the positions of the Hill-Sachs lesion (inner arc) and the
of the two findings in the axial plane anatomic groove (outer arc) in the axial plane
(cf Fig 1).
can be useful but are not necessarily
definitive for differentiation. The most Figure 5. Diagram of the ranges of location
accurate means of distinguishing be- of the Hill-Sachs lesion (A) and the anatomic
groove (B) along the long axis of the humerus. 4. Hill HA, Sachs MD. The grooved defect
tween the anatomic groove and the
of the humeral head. Radiology 1940; 35:
pathologic Hill-Sachs lesion relates to 690-700.
their positions along the long axis of 5. Kieft GJ, Btoem JL, Rozing PM, Obermann
the humerus. applicable to the female population. WR. MR imaging of recurrent anterior
We believe that none of these minor dislocation of the shoulder: comparison
Deficiencies in this study include
with CT arthrography. AJR 1988; 150:1083-
the possibility that the cadaveric deficiencies, however, detract from
1087.
specimens had unreported disloca- the importance of the difference in 6. Pring DJ, Constant 0, Bayley JIL, Stoker
tions of the GHJ. This is unlikely, as location of the two grooves along the DJ. Radiology of the humeral head in re-
longitudinal axis of the humerus. #{149} current anterior shoulder dislocations:
they were carefully examined and no
brief report. J Bone Joint Surg [Br] 1989;
abnormalities of the scapula or hu- 71:141-142.
merus were noted. Sources of bias Acknowledgments: The authors acknowledge
7. Resch H, Gelweg G, zur Nedden D, Beck E.
Timothy Workman, MD, Thomas Burkhard,
include evaluation of MR images by MD, and the Department of Radiology of San
Double-contrast computed tomographic
an examiner who was not blinded to examination techniques in habitual and
Diego Naval Hospital for providing the MR im-
recurrent shoulder dislocation. Eur J Radiot
the presence of the Hill-Sachs lesions ages demonstrating arthroscopicatty proved 1988; 8:6-12.
and anatomic groove and the less Hitl-Sachs lesions and Debbie Trudelt for her
8. Workman TL, Burkhard TK, Resnick D, et
help in preparing the cadaveric specimens and
than 100% accuracy of arthroscopy in at. Hill-Sachs lesion: comparison of detec-
illustrations.
diagnosing the lesion, possibly lead- tion with MR imaging, radiography, and
arthroscopy. Radiology 1992; 185:847-852.
ing to false-positive readings. A minor
References 9. Danzig LA, Resnick D, Greenway G.
source of possible error is the fact that 1. Kirtland 5, Resnick D, Sartoris D, et at. Evaluation of unstable shoulders by com-
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1622-1631. of the shoulder. Clin Orthop 1989; 244:48-
normal and Hill-Sachs grooves. Fi- 2. Rockwood CA, Green DP, Bucholz RW. 59.
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was not correlated with the age or sex glenohumeral joint. In: Rockwood CA, Hill-Sachs lesion: an experimental study.
Thomas SC, Matsen FA, eds. Fractures. 3rd Am J Sports Med 1980; 8:328-332.
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merus, or muscle anatomy. As the anterior shoulder dislocation. Am J Sports
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668 Radiology
#{149} March 1994