Summary Humeral Avulsion of the Glenohumeral Ligament (HAGL) is an injury to the inferior glenohumeral ligament causing instability and/or pain and a missed cause of recurrent shoulder instability. Diagnosis requires suspicions of injury and can be noted as an inferior pouch irregularity on MRI. Non-operative first-line treatment for acute presentation includes sling immobilization and physical therapy while operative treatment is recommended for recurrent instability. Epidemiology Incidence 1.6% of patients with shoulder pain Demographics male > female (94% male) average age 25-30 Anatomic location anterior band most common (93%) medial (glenoid) versus lateral (humerus) failure IGHL at labral complex - 40% intrasubstance tear - 35 % humeral insertion - 25% Risk factors 10% of recurrent anterior shoulder dislocators have HAGL 27% of shoulder instability patients without bankart have HAGL 18% of failed anterior stabilization have HAGL Etiology Pathophysiology mechanism of injury hyperabduction and external rotation is the main mechanism login to view 1 more bullet Associated conditions orthopedic conditions labral tears - 25% rotator Cuff tears - 23% Hill-Sachs Deformity - 17% bony Bankart Anatomy Static stabilizers glenohumeral ligaments glenoid labrum attachment of glenohumeral ligaments deepens glenoid cavity articular congruity and version negative intraarticular pressure Dynamic stabilizers rotator cuff muscles the primary biomechanical role of the rotator cuff is stabilizing the glenohumeral joint by compressing the humeral head against the glenoid rotator interval biceps long head periscapular muscles deltoid Capsuloligamentous Complex coracohumeral Ligament superior glenohumeral ligament (SGHL) middle glenohumeral ligament (MGHL) inferior glenohumeral ligament (IGHL) hammock-like Structure login to view 3 more bullets 2 types of Insertion on Humerus login to view 2 more bullets Blood Supply anastamosis of branches of humeral sided and scapular sided vessels lateral: Anterior humeral circumflex artery, Posterior humeral circumflex artery medial: Suprascapular artery, Circumflex scapular arteries watershed area anterolaterally: near humeral insertion anterior capsule 3 cm medial to intertubercular groove Nervous system axillary nerve close to HAGL lesion at 6'oclock position (2-7mm, overestimated on MRI by 2mm) Biomechanics most taught between 45 - 90 degrees abduction anterior band of IGHL - anterior and inferior restraint taught at 90 degrees abduction and external rotation posterior band of IGHL- posterior and inferior restraint taught at 90 degrees abduction and internal rotation Classification West Point Classification - by Bui-Mansfield West Point Classification Based on 3 Factors: Anterior or Posterior Involvement Presence or Absence of Bony Avulsion Presence of Associated Labral Pathology (Floating) Anterior 93% Anterior HAGL 55% Anterior Bony HAGL 17% Floating AIGHL 21% Posterior 6% Posterior HAGL 2% Posterior Bony HAGL 0% Floating PIGHL 4% Presentation History position of arm at injury direction of instability recurrent instability failed surgery to correct instability Symptoms severe persistent pain after instability event recurrent instability Physical exam provocative tests apprehension and relocation tests load and shift posterior stress and posterior jerk tests sulcus sign in neutral and external rotation Neurovascular check axillary nerve function Imaging Radiographs recommended views true AP radiographs in neutral and internal rotation scapular Y axillary lateral findings glenoid rim fractures, hypoplasia, fractures of humeral head optional views Garth View login to view 2 more bullets arthrogram login to view 2 more bullets CT indications lower utility than MRI consider combination with arthrogram for contraindication to MRI views best seen on sagittal findings Oberlander described bony HAGL lesion posterior to MGHL MRI indications gold standard for diagnosis of HAGL recurrent instability or persistent pain after instability event login to view 1 more bullet views coronal oblique T2 weighted fat suppressed MRI sagittal oblique T2 weighted fat suppressed MRI findings: J Sign login to view 5 more bullets Differential Anterior Bankart Tear/ Anterior Inferior Labrum tear Posterior Bankart/ Posterior Inferior Labrum tear Treatment Nonoperative sling immobilization and physical therapy indications login to view 1 more bullet outcomes login to view 1 more bullet Operative open HAGL repair indications login to view 5 more bullets techniques login to view 6 more bullets prognosis login to view 2 more bullets arthroscopic HAGL repair indications login to view 1 more bullet techniques login to view 9 more bullets prognosis login to view 1 more bullet Techniques Sling immobilization and physical therapy Technique 4 week sling immobilization shoulder strengthening following sling immobilization period Open Anterior Repair advantages visualization of neurovascular structures less technically difficult approach deltopectoral approach 3 subscapularis approaches login to view 8 more bullets technique bone preparation login to view 1 more bullet instrumentation login to view 2 more bullets complications specific to this treatment login to view 2 more bullets rehabilitation anterior HAGL Protocol login to view 8 more bullets Open Posterior Repair approach Judet approach login to view 2 more bullets technique bone work login to view 1 more bullet instrumentation login to view 1 more bullet rehabilitation posterior HAGL Protocol login to view 5 more bullets complications Axillary nerve entrapment login to view 1 more bullet Anterior Arthroscopic Repair approach 3 portal approach login to view 3 more bullets accessory Portals login to view 8 more bullets technique bone work login to view 2 more bullets soft tissue login to view 2 more bullets instrumentation login to view 2 more bullets complications axillary nerve damage arthrofibrosis Posterior Arthroscopic Repair approach may Switch viewing portal from posterior to anterior using 30 degree scope accessory inferior-lateral posterior portal technique bone work login to view 1 more bullet instrumentation login to view 2 more bullets soft tissue login to view 4 more bullets Complications Arthrofibrosis with Loss of External Rotation Treatment Physical Therapy for external rotation stretching Axillary Nerve Injury Axillary nerve is 10 mm inferior to the glenoid and 2.5 mm inferior to capsule Chondrolysis risk factors reported with thermal capsulorrhaphy overtightening anterior may be associated with accelerated posterior wear Pulmonary Embolism Incidence 0.6% with shoulder arthroscopy Recurrence of instability Very Rare Per systematic review: 0/25 operative, 9/10 nonoperative Odds ratio 0.05 recurrence with operative vs nonoperative treatment (p=.006) Prognosis Good with adequate recognition and treatment