The HAGL lesion
•
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The HAGL lesion involves an avulsion of the inferior glenohumeral ligament from its humeral insertion, which is a rare cause of shoulder instability comprising less than 10% of cases. It often occurs with a traumatic mechanism of hyperabduction and external rotation. MRI arthrography is the best imaging modality to diagnose a HAGL lesion. Surgical repair is usually recommended and case series have reported good outcomes with no recurrent instability after repair.
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The HAGL lesion
- 1. The HAGL Lesion 2/10/2012 Blackpool Victoria Hiren M Divecha (ST5)
- 2. Overview 1. Normal anatomy - stabilisers 2. Lesions associated with anterior dislocation 3. HAGL Lesion
- 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. Normal Anatomy 1. Static stabilisers 1. Dynamic stabilisers
- 5. Static stabilisers • Articular congruence & version • Negative intracapsular pressure • Adhesion-cohesion • Labrum • Capsulo-ligamentous structures: – Coracohumeral ligament – Glenohumeral ligaments
- 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. 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)
- 9. Modarresi S et al. AJR 2011;197:604-611
- 10. SGHL • O = glenoid tubercle • I = upper lesser tuberosity • Limits inferior/ posterior transalation and ER (esp in add)
- 11. MGHL • O = superior glenoid and labrum • I = medial lesser tuberosity • Limits ant translation and ER (esp in 45 deg abd)
- 12. 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
- 13. IGHL
- 14. Dynamic Stabilisers • Rotator cuff muscles • Deltoid • Long head biceps tendon • Scapulothoracic motion • Co-ordinated contraction • Concavity compression
- 17. The humeral head will remained centred on glenoid if: •the glenoid and humeral joint surfaces are congruent •the net humeral joint reaction force is within the effective glenoid arc
- 19. Lesions associated with Anterior Dislocation • Bankart – Capsulo-ligamentous avulsion – +/- bone • Hill-Sachs – Impaction # on posterior humeral head • Humeral Avulsion of Glenohumeral Ligament • ALPSA
- 22. 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
- 26. Carlson C L Radiology 2004;232:725-726
- 27. Clinical • Mechanism – Hyperabduction & ER • Pain, weakness, instability • HIGH suspicion in prior failed stabilisations • ROM, cuff strength • Apprehension-relocation, load-shift tests
- 28. Imaging • X-rays – Concentric – Hill-Sachs – Bony Bankart – Bony HAGL • MRI arthrogram – Best modality – Coronal T2 – U-shaped pouch becomes J-shaped
- 29. Management • Conservative – Recurrent instability rate unknown – Young, athletic – prefer surgical repair • Surgical repair – Arthroscopic – Open
- 30. 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
- 31. 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 • www.shoulderdoc.co.uk
Editor's Notes
- — 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.