The HAGL lesion


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  • — Type VII superior labral anteroposterior (SLAP) tear. A, Schematic representation of type VII SLAP lesion shows SLAP tear with extension to middle glenohumeral ligament. Numbers show time zone divisions used to localize labral abnormalities. BT = biceps tendon, G = glenoid, SGHL = superior glenohumeral ligament, MGHL = middle glenohumeral ligament, IGHLC = inferior glenohumeral ligament complex.
  • Oblique coronal fat-suppressed T2-weighted MR image (2,500/60, repetition time msec/echo time msec) of right shoulder in patient with humeral avulsion of the glenohumeral ligament (HAGL) lesion demonstrates J-shaped appearance of inferior glenohumeral ligament (curved arrow) and extravasation of joint fluid (arrowhead) around the humeral detachment and between the medial aspect of the humerus and the tip of the “J.” Note also a humeral head bone bruise from anterior dislocation.
  • The HAGL lesion

    1. 1. The HAGL Lesion 2/10/2012 Blackpool Victoria Hiren M Divecha (ST5)
    2. 2. Overview1. Normal anatomy - stabilisers2. Lesions associated with anterior dislocation3. HAGL Lesion
    3. 3. Glenohumeral Stability• The normal shoulder precisely constrains the humeral head to the center of the glenoid cavity throughout most of the arc of movement• Laxity – Asymptomatic, passive translation of the humeral head on the glenoid (physiological) NOT associated with pain• Instability – Symptomatic pain/apprehension associated with excessive translation of the humeral head during active motion
    4. 4. Normal Anatomy1. Static stabilisers1. Dynamic stabilisers
    5. 5. Static stabilisers• Articular congruence & version• Negative intracapsular pressure• Adhesion-cohesion• Labrum• Capsulo-ligamentous structures: – Coracohumeral ligament – Glenohumeral ligaments
    6. 6. Glenoid Labrum• Fibrocartilaginous ring• Contributes 20% to GH stability• 3 functions: – “chock-block” effect ? – increases surface contact area (deepens by 50%) – attachment site for LHB & GH ligaments
    7. 7. Ligaments• Coracohumeral ligament – O = anterolateral coracoid process – I = greater and lesser tuberosities, blends with capsule in rotator interval – ? Resists inferior translation. Tight in ER• Glenohumeral ligaments• (Coracoacromial ligament)
    8. 8. Modarresi S et al. AJR 2011;197:604-611
    9. 9. SGHL• O = glenoid tubercle• I = upper lesser tuberosity• Limits inferior/ posterior transalation and ER (esp in add)
    10. 10. MGHL• O = superior glenoid and labrum• I = medial lesser tuberosity• Limits ant translation and ER (esp in 45 deg abd)
    11. 11. IGHL• O= ant/post glenoid rim and labrum• I= anatomic neck humerus• Anterior band – Limits ant trans in abd and ER• Posterior band – Limits post trans in flex and IR• Both limit inferior translation at 45° abd
    12. 12. IGHL
    13. 13. Dynamic Stabilisers• Rotator cuff muscles• Deltoid• Long head biceps tendon• Scapulothoracic motion• Co-ordinated contraction• Concavity compression
    14. 14. The humeral head willremained centred onglenoid if:•the glenoid and humeraljoint surfaces arecongruent•the net humeral jointreaction force is withinthe effective glenoid arc
    15. 15. Lesions associated with AnteriorDislocation• Bankart – Capsulo-ligamentous avulsion – +/- bone• Hill-Sachs – Impaction # on posterior humeral head• Humeral Avulsion of Glenohumeral Ligament• ALPSA
    16. 16. Humeral Avulsion Glenohumeral Ligament• IGHL can fail at 3 positions: – Glenoid/ labrum – Mid-substance – Humeral insertion (least common)• Avulsion of IGHL from humeral insertion• <10% of shoulder instability• Can occur with other lesions
    17. 17. Carlson C L Radiology 2004;232:725-726
    18. 18. Clinical• Mechanism – Hyperabduction & ER• Pain, weakness, instability• HIGH suspicion in prior failed stabilisations• ROM, cuff strength• Apprehension-relocation, load-shift tests
    19. 19. Imaging• X-rays – Concentric – Hill-Sachs – Bony Bankart – Bony HAGL• MRI arthrogram – Best modality – Coronal T2 – U-shaped pouch becomes J-shaped
    20. 20. Management• Conservative – Recurrent instability rate unknown – Young, athletic – prefer surgical repair• Surgical repair – Arthroscopic – Open
    21. 21. Outcome• Limited to case series• Most report no recurrent instability after repair – Wolf (1995 Arthroscopy) – 6pts. 40 month – Field (JESS 1997) – 5 pts. 26 month (HAGL + Bankart) – Kon (2005 Arthroscopy) – 3 pts. 16 month
    22. 22. References• George M et al. Humeral avulsion of glenohumeral ligaments. JAAOS 2011; 19:127-33• Melvin JS et al. MRI of HAGL Lesions: Four arthroscopically confirmed cases of false-positive diagnosis. AJR 2008; 191: 730-4•