HAGL Lesion 718.31

synonyms: humeral avulsion of the glenohumeral ligament

HAGL Lesion ICD-9 

• 718.31 Recurrent shoulder dislocation

HAGL Lesion Etiology / Epidemiology / Natural History

• Forceful abduction may avulse the capsule/glenohumeral ligaments from the humerus ie HAGL lesion.
• Rare cause of recurrent instability.

HAGL Lesion Anatomy

• Thickened edges of the capsule are typically seen in the inferior recess during arthroscopy.

HAGL Lesion Clinical Evaluation

• Apprehension Test: examiner applies anteriorly directed force to the humeral head with the shoulder in abduction and external rotation. Positive result is the patient felling that the shoulder is going to dislocate.
• Relocation Test: posteriorly directed force is applied to the humeral head with patient in abduction and external rotation (Apprhension Test position). Positive result is relief of the feeling of impending dislocation.
• Load and shift:
• Sulcus sign: distraction force is applied to the arm with the patient seated with are at the side. The magnitude of displaced and any apprehension sensations are compared to the contralateral limb. Any abnormalities indicated inferior instability.
• Farber JBJS 2006;88A:
• Evaluate axillary nerve function
• Assessments of generalized ligamentous laxity: ability to touch ipsilateral forearm with the thumb, place palms of hands on floor with knees locked, elbow/knee/MCP hyperextension.

HAGL Lesion Xray / Diagnositc Tests

• Rarely visible with imaging studies.
• A/P and Lateral view in the plane of the scapula, and axillary view. Generally normal.  See Shoulder Xray.
• West Point view: patient prone with arm in 90° abduction and neutral rotation. Xray beam is directed 25° posterior to the horizontal plane and 25° medial to the vertical plane. Useful for evaluating the anterior glenoid rim / bony bankart lesions.
• Hill-Sachs lesion: impression fracture of the posterosuperior aspect of the humeral head, produced by contact with the anteroinferior glenoid when dislocated. Hill-Sachs lesion is demonstrated on plain AP radiograph in internal rotation or Stryker notch view.
• CT scan is best to evaluate bony anatomy and should be considered for the recurrent dislocator suspected of having a large Hill-Sachs or bony Bankart lesion.
• MRI arthrogram (gadolinium): the anterior and posterior labrum are best seen on axial images and appear as dark triangular structures. Bankart lesions appear as a loss of the normal triangular shape or contrast material may extend between the labrum and glenoid( acute injuries.) Chronic injuries may scar down to the glenoid and be difficult to see by MRI.

HAGL Lesion Classification / Treatment

• Open (Arciero RA, Arthroscopy 2005;21:1152) or arthroscopic repair (Kon Y, Arthroscopy 2005;21:632), (Spang JT, Arthroscopy 2005;21:498) indicated.

HAGL Lesion Associated Injuries / Differential Diagnosis

HAGL Lesion Complications

HAGL Lesion Follow-up Care

HAGL Lesion Review References

• Arciero AR, Arthroscopy 2005;21:1152
• Bokor DJ, JBJS 1999;81Br:93
• Wolf EM, Arthroscopy 1995;11:600