Raiyyan Tahsan

Raiyyan Tahsan
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TC(1073).(05).Orthopedics Case No 149:- Hill-Sachs Lesion

Hill-Sachs Lesion — বাংলা Clinical Notes + Bangladesh Drug List

Important: Hill-Sachs lesion নিজে “medicine দিয়ে heal” করা যায় না। এটি humeral head-এর bony impaction/compression defect। Medicine মূলত pain, inflammation, muscle spasm, reduction/procedure pain control এবং NSAID-related gastric protection-এর জন্য ব্যবহৃত হয়। Definitive management নির্ভর করে lesion size, glenoid bone loss, on-track/off-track status এবং recurrent instability-এর উপর।

1. Definition / সংজ্ঞা

Hill-Sachs lesion হলো shoulder-এর anterior dislocation হওয়ার সময় humeral head-এর postero-superolateral / posterolateral অংশে anterior glenoid rim-এর সাথে impact হয়ে তৈরি হওয়া depression-type compression fracture বা bony defect। সহজভাবে: shoulder dislocate হলে humeral head socket-এর সামনে থাকা glenoid rim-এ ধাক্কা খেয়ে humeral head-এ “dent” পড়ে—এটাই Hill-Sachs lesion।

2. Etiology / Cause — কারণগুলো

A. Direct mechanism

  • Anterior shoulder dislocation সবচেয়ে common cause।
    Arm সাধারণত abduction + external rotation অবস্থায় থাকে; humeral head anteriorly বের হয়ে গিয়ে glenoid rim-এর সাথে ধাক্কা খায়। এতে humeral head-এর posterolateral অংশে compression defect হয়।

B. Common clinical causes

  • Fall on outstretched hand / হাত পড়ে যাওয়া
  • Contact sports injury — football, rugby, wrestling
  • Overhead sports — cricket throwing, volleyball, badminton, baseball-type throwing
  • Road traffic accident / direct trauma
  • Recurrent anterior shoulder dislocation — বারবার dislocation হলে defect বড় হয় এবং instability বাড়ে।
  • Young male athletes বেশি risk group; first dislocation-এর পর recurrence risk বেশি, বিশেষ করে young male/contact sport group-এ।

C. Important note

  • Posterior shoulder dislocation হলে সাধারণত Reverse Hill-Sachs lesion হয়, যেখানে humeral head-এর anteromedial অংশে defect হয়। এটা classical Hill-Sachs থেকে আলাদা।

3. Pathophysiology — কীভাবে lesion তৈরি হয়

  1. Shoulder anteriorly dislocate করে।
  2. Humeral head glenoid socket-এর সামনে চলে যায়।
  3. Anterior glenoid rim humeral head-এর posterolateral cancellous bone-এ চাপ দেয়।
  4. Compression fracture / depression defect তৈরি হয়।
  5. Lesion বড় বা “off-track/engaging” হলে humeral head আবার glenoid rim-এ আটকে গিয়ে recurrent dislocation হতে পারে। Glenoid track concept অনুযায়ী on-track lesion কম unstable, off-track lesion বেশি unstable।

4. Symptoms / Clinical Features — লক্ষণগুলো

Hill-Sachs lesion সাধারণত shoulder dislocation-এর সাথে থাকে, তাই symptoms অনেক সময় dislocation-এর symptoms-এর মতোই হয়।

Acute stage

  • তীব্র shoulder pain — dislocation moment-এ sudden severe pain
  • Shoulder deformity — shoulder flattened/abnormally prominent দেখাতে পারে
  • Arm move করতে না পারা
  • Swelling ও bruising
  • Muscle spasm
  • Weakness
  • Numbness / tingling — বিশেষ করে axillary nerve involvement হলে deltoid area বা arm-এ altered sensation হতে পারে।

Chronic / recurrent instability stage

  • Shoulder বারবার বের হয়ে যাওয়ার অনুভূতি
  • Apprehension — হাত abducted + externally rotated করলে patient ভয় পায় shoulder বের হয়ে যাবে
  • Clicking / catching sensation
  • Overhead activity বা throwing-এ pain
  • Loss of confidence in shoulder
  • Recurrent subluxation/dislocation

5. Clinical Diagnosis — কীভাবে clinically diagnose করবেন

A. History

  • Recent anterior shoulder dislocation?
  • Previous dislocation কতবার হয়েছে?
  • Mechanism: fall, sports trauma, RTA, seizure?
  • Shoulder নিজে নিজে reduced হয়েছে কি না?
  • Numbness/weakness আছে কি না?
  • Dominant hand involvement?
  • Sports/occupation: overhead worker, athlete?

B. Inspection

  • Loss of normal deltoid contour
  • Anterior fullness
  • Arm held in slight abduction/external rotation
  • Bruising/swelling

C. Neurovascular examination — অবশ্যই করবেন

  • Axillary nerve: lateral deltoid “regimental badge area” sensation, deltoid contraction
  • Radial, median, ulnar nerve function
  • Radial pulse, capillary refill

D. Specific clinical tests

Acute severe pain থাকলে forceful test করা উচিত নয়।

  • Apprehension test: abduction + external rotation করলে dislocation fear/pain
  • Relocation test: posterior pressure দিলে apprehension কমে
  • Surprise/release test: posterior pressure suddenly release করলে apprehension আসে
  • Load-and-shift test: anterior instability assess
  • Sulcus sign: generalized laxity/multidirectional instability
  • Rotator cuff testing: especially age >40 years, because traumatic dislocation-এর সাথে cuff tear থাকতে পারে। BESS/BOA pathway older patients-এ cuff integrity assess করতে early imaging consider করতে বলে।

6. Investigations — specificভাবে কী কী করবেন

1. X-ray shoulder — first-line

Views:

  • AP view
  • Scapular Y view
  • Axillary view — dislocation direction confirm
  • Internal rotation AP / Stryker notch view — Hill-Sachs defect দেখতে helpful

কাজ:

  • Dislocation confirm
  • Fracture exclude
  • Post-reduction X-ray অবশ্যই — reduction successful কি না ও fracture আছে কি না দেখা

2. CT scan / 3D CT — bony defect assessment-এর জন্য best

Indications:

  • Recurrent dislocation
  • Large Hill-Sachs suspected
  • Glenoid bone loss quantification
  • Preoperative planning
  • On-track/off-track calculation

CT দিয়ে humeral head defect ও glenoid bone loss accurately measure করা যায়; recurrent instability management-এ glenoid + humeral bipolar bone loss একসাথে assess করা জরুরি।

3. MRI shoulder / MR arthrogram

Indications:

  • Bankart lesion / labral tear
  • HAGL lesion
  • Rotator cuff tear
  • Cartilage injury
  • Capsuloligamentous injury

MR arthrogram labral injury detect করতে MRI থেকে বেশি sensitive হতে পারে, বিশেষ করে recurrent instability work-up-এ।

4. Ultrasound shoulder

  • Age >40 years বা cuff weakness থাকলে rotator cuff tear screen করতে useful
  • Dynamic, cheap, accessible

5. EMG/NCS

  • Axillary nerve palsy suspected এবং 6 weeks পরও clinical recovery না থাকলে EMG করা যায়; BESS/BOA pathway no recovery হলে nerve injury centre referral suggest করে।

7. Differential Diagnosis

  • Anterior shoulder dislocation without Hill-Sachs
  • Bankart lesion / bony Bankart lesion
  • Rotator cuff tear
  • Greater tuberosity fracture
  • Proximal humerus fracture
  • AC joint injury
  • Labral SLAP tear
  • Posterior dislocation with reverse Hill-Sachs
  • Cervical radiculopathy / brachial plexus injury

8. Complications — বাংলায় ব্যাখ্যা

1. Recurrent shoulder instability

Hill-Sachs defect বড় হলে বা off-track হলে humeral head আবার glenoid rim-এ engage করে shoulder বারবার dislocate করতে পারে।

2. Bankart lesion association

Anterior dislocation-এর সাথে anterior-inferior labrum tear বা Bankart lesion থাকে। Hill-Sachs + Bankart একসাথে থাকলে instability বেশি হয়।

3. Glenoid bone loss

বারবার dislocation হলে socket side অর্থাৎ glenoid-এ bone loss হয়। Glenoid bone loss significant হলে Bankart repair alone fail করতে পারে; তখন Latarjet/bone block procedure দরকার হতে পারে। BESS/BOA guideline 20% glenoid bone loss থাকলে Latarjet consider করতে বলে।

4. Axillary nerve injury

Shoulder dislocation-এর পর deltoid weakness ও lateral shoulder numbness হতে পারে। Deltoid function না ফিরলে EMG এবং specialist referral দরকার।

5. Rotator cuff tear

Age >40 years-এ traumatic shoulder dislocation-এর সাথে rotator cuff tear clinically important হতে পারে; early imaging দরকার হতে পারে।

6. Chronic pain and stiffness

Prolonged immobilization, inadequate rehab, capsular stiffness থেকে painful stiff shoulder/frozen shoulder হতে পারে।

7. Osteoarthritis / dislocation arthropathy

বারবার dislocation ও cartilage damage থাকলে দীর্ঘমেয়াদে shoulder arthritis হতে পারে।

8. Surgical complications

Remplissage করলে external rotation কিছুটা কমতে পারে; Latarjet-এ nonunion, infection, neurovascular injury, recurrence হতে পারে। BESS/BOA reported Latarjet complication rate relatively high, তাই routine primary procedure নয়।

9. Treatment / Management — Guideline-based

A. Acute dislocation stage

  1. Neurovascular exam before reduction
  2. X-ray before reduction — fracture/dislocation confirm
  3. Closed reduction — trained clinician, analgesia/sedation/local anesthesia সহ
  4. Post-reduction X-ray
  5. Sling immobilization — pain control পর্যন্ত short period; prolonged immobilization recurrence কমাতে clearly beneficial নয়। BESS/BOA summary বলছে >1 week immobilization recurrence কমাতে beneficial নয়।
  6. Early supervised physiotherapy

B. Non-operative management — কাদের জন্য

Suitable if:

  • First-time dislocation
  • Small, non-engaging/on-track Hill-Sachs lesion
  • No significant glenoid bone loss
  • Low-demand patient
  • No recurrent instability

Plan:

  • Sling briefly
  • Pain control
  • Physiotherapy: rotator cuff, deltoid, scapular stabilizer strengthening
  • Proprioception training
  • Avoid abduction + external rotation early phase
  • Follow-up for instability

C. Surgical management — কাদের জন্য

1. Arthroscopic Bankart repair

Indication:

  • Bankart lesion with recurrent anterior instability
  • No major bony defect
  • Young athlete/high-demand patient

2. Bankart repair + Remplissage

Indication:

  • Off-track/engaging Hill-Sachs lesion
  • Little or subcritical glenoid bone loss
  • Recurrent instability

Remplissage মানে posterior capsule + infraspinatus tendon দিয়ে Hill-Sachs defect “fill” করা, যাতে defect glenoid rim-এ engage না করে।

3. Latarjet procedure

Indication:

  • Significant glenoid bone loss
  • Failed soft tissue stabilization
  • Recurrent anterior instability with bone loss
  • Some engaging Hill-Sachs/bipolar bone loss cases

BESS/BOA pathway অনুযায়ী recurrent instability with around 20% glenoid bone loss হলে open Latarjet consider করা হয়; engaging Hill-Sachs lesion-এ Latarjet বা remplissage + Bankart acceptable options হলেও high-quality RCT evidence limited।

4. Bone grafting / humeral head reconstruction

Indication:

  • Very large humeral head defect
  • Persistent off-track lesion despite glenoid procedure
  • Complex bipolar bone loss

5. Arthroplasty

Rare; elderly patient with massive humeral head defect, arthritis, irreparable damage.

10. Pharmacological Management — Bangladesh Brand + Dose + Purpose

নিচের dose adult general dose। CKD, liver disease, pregnancy, anticoagulant use, peptic ulcer, asthma, elderly patient, pediatric patient—সব ক্ষেত্রে dose/choice individualize করতে হবে।

1) Generic name: Paracetamol / Acetaminophen

  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative; non-opioid analgesic
  • Purpose / কেন used হয়: Mild–moderate shoulder pain, post-reduction pain, NSAID contraindicated হলে safer first-line analgesic
  • Adult dose: 500 mg–1 g orally every 6–8 hours PRN
  • Max dose: সাধারণত 3 g/day safer; supervised setting-এ 4 g/day পর্যন্ত, liver disease/alcohol use থাকলে কম
  • Duration: 3–5 days PRN
  • Bangladesh available brand examples:
    • Napa 500 mg tablet — Paracetamol
    • Napa Rapid 500 mg tablet — Paracetamol
    • Napa Extend 665 mg ER tablet — Paracetamol
    • Napa One 1000 mg tablet — Paracetamol
    • Ace 500 mg tablet — Paracetamol
      MedEx paracetamol brand list-এ Napa 500 mg, Napa Rapid 500 mg, Napa Extend 665 mg, Napa One 1000 mg উল্লেখ আছে।
  • Side effects: Nausea, rash; overdose হলে severe hepatotoxicity
  • Drug interactions: Warfarin effect chronic high-dose paracetamol-এ বাড়তে পারে; alcohol/isoniazid/enzyme inducer থাকলে liver toxicity risk বাড়ে
  • Avoid/caution: Severe liver disease, chronic alcohol use

2) Generic name: Ibuprofen

  • Therapeutic category: Analgesic, anti-inflammatory, antipyretic
  • Pharmacological class: NSAID; non-selective COX inhibitor; propionic acid derivative
  • Purpose / কেন used হয়: Pain + inflammation কমাতে, soft tissue injury/dislocation-related inflammatory pain
  • Adult dose: 400 mg orally 2–3 times daily after food
  • Duration: 3–5 days; lowest effective dose
  • Bangladesh available brand examples:
    • Flamex 400 mg tablet — Ibuprofen
    • Iburex 200 mg / 400 mg tablet — Ibuprofen
    • Inflam 400 mg tablet — Ibuprofen
      MedEx ibuprofen page mild–moderate pain with inflammation এবং muscular pain indication উল্লেখ করেছে; brand list-এ Flamex 400 mg, Iburex 200/400 mg, Inflam 400 mg আছে।
  • Side effects: Gastritis, dyspepsia, peptic ulcer/bleeding, renal impairment, fluid retention, BP rise, bronchospasm, rash
  • Drug interactions: Warfarin/DOAC/aspirin/clopidogrel/SSRI/steroid → bleeding risk; ACEi/ARB + diuretic → AKI risk; lithium/methotrexate toxicity risk
  • Avoid/caution: PUD/GI bleed, CKD, uncontrolled HTN, heart failure, NSAID-sensitive asthma, late pregnancy

3) Generic name: Naproxen sodium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; non-selective COX inhibitor; propionic acid derivative
  • Purpose / কেন used হয়: Longer-acting NSAID; shoulder injury pain ও inflammation
  • Adult dose: 250–500 mg orally twice daily after food
  • Duration: 3–7 days
  • Bangladesh available brand examples:
    • Naproxen 500 mg tablet — Naproxen sodium
    • Naproxin 250 mg / 500 mg tablet — Naproxen sodium
    • Napryn 250 mg tablet — Naproxen sodium
      MedEx naproxen sodium brand list-এ Naproxen 500 mg, Naproxin 250/500 mg, Napryn 250 mg উল্লেখ আছে।
  • Side effects: GI upset/bleeding, renal impairment, edema, hypertension, dizziness
  • Drug interactions: Anticoagulant/antiplatelet, steroid, SSRI, ACEi/ARB/diuretic, lithium, methotrexate
  • Avoid/caution: PUD, CKD, heart failure, uncontrolled HTN, late pregnancy

4) Generic name: Diclofenac sodium / potassium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative; non-selective COX inhibitor
  • Purpose / কেন used হয়: Acute musculoskeletal pain, sprain, dislocation, soft tissue injury pain
  • Adult dose oral: 50 mg orally 2–3 times daily after food
  • SR dose: 100 mg once daily after food
  • Topical dose: Gel locally 3–4 times daily; systemic risk কম
  • Duration: Oral 3–5 days; topical 1–2 weeks as needed
  • Bangladesh available brand examples:
    • Clofenac 50 mg tablet — Diclofenac sodium
    • G-Diclofenac 50 mg tablet — Diclofenac sodium
    • G-Diclofenac 75 mg/3 ml IM injection — Diclofenac sodium
    • Voltalin SR 100 mg tablet — Diclofenac sodium
    • Voligel 1% gel — Diclofenac sodium
      MedEx Clofenac page-এ surgery/traumatology indications including sprains, dislocations, fractures, soft tissue injuries উল্লেখ আছে; diclofenac brand list-এ tablet/injection/SR forms আছে।
  • Side effects: Gastritis, GI bleed, renal injury, edema, BP rise, hepatotoxicity, cardiovascular thrombotic risk
  • Drug interactions: Anticoagulant/antiplatelet/steroid/SSRI, ACEi/ARB/diuretic, lithium, methotrexate
  • Avoid/caution: Ischemic heart disease, stroke history, uncontrolled HTN, CKD, PUD/GI bleed

5) Generic name: Etoricoxib

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • Purpose / কেন used হয়: Acute pain/inflammation; GI ulcer risk তুলনামূলক কম, তবে CV risk বেশি হতে পারে
  • Adult dose: 60–90 mg once daily after food; severe acute pain-এ 120 mg once daily very short course physician-supervised
  • Duration: 3–5 days; lowest effective dose
  • Bangladesh available brand examples:
    • Etorix 60/90/120 mg tablet — Etoricoxib
    • Etoshine 60/90/120 mg tablet — Etoricoxib
    • Recox 60/90/120 mg tablet — Etoricoxib
    • Ribox 60/90/120 mg tablet — Etoricoxib
    • Riox 60/90/120 mg tablet — Etoricoxib
    • Torcox 90 mg tablet — Etoricoxib
      MedEx etoricoxib brand list-এ Etorix, Etoshine, Recox, Ribox, Riox, Torcox সহ 60/90/120 mg strengths আছে।
  • Side effects: Dyspepsia, edema, hypertension, renal impairment, cardiovascular thrombotic events
  • Drug interactions: Warfarin/anticoagulant, ACEi/ARB/diuretic, lithium, methotrexate
  • Avoid/caution: IHD/stroke/PAD, uncontrolled HTN, severe heart failure, CKD, pregnancy

6) Generic name: Tramadol hydrochloride

  • Therapeutic category: Analgesic
  • Pharmacological class: Centrally acting opioid analgesic; μ-opioid agonist + serotonin/norepinephrine reuptake inhibition
  • Purpose / কেন used হয়: Moderate–severe pain, post-reduction/post-operative pain যখন paracetamol/NSAID insufficient
  • Adult dose: 50 mg orally every 6–8 hours PRN
  • Max dose: 400 mg/day
  • Duration: 1–3 days only; avoid routine long use
  • Bangladesh available brand examples:
    • Trado 50 mg capsule — Tramadol HCl
    • Tramadol 50 mg capsule — Tramadol HCl
    • Tramamax 50 mg tablet — Tramadol HCl
    • Zydol 50 mg capsule — Tramadol HCl
    • Utramal IR 50 mg tablet — Tramadol HCl
    • Winpain 100 mg/2 ml injection — Tramadol HCl
      MedEx tramadol page/table shows Trado 50 mg, Tramadol 50 mg, Tramamax 50 mg, Zydol 50 mg, Utramal IR 50 mg and injection forms।
  • Side effects: Nausea, vomiting, dizziness, sedation, constipation, sweating, respiratory depression, seizure, dependence
  • Drug interactions: Alcohol/benzodiazepine/opioid → respiratory depression; SSRI/SNRI/TCA/MAOI/linezolid → serotonin syndrome; antiepileptic threshold কমায়; CYP2D6/3A4 inhibitors/inducers effect alter করে
  • Avoid/caution: Epilepsy, severe respiratory disease, substance use disorder, severe liver/renal impairment, MAOI use

7) Generic name: Tolperisone hydrochloride

  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: Centrally acting muscle relaxant
  • Purpose / কেন used হয়: Painful muscle spasm থাকলে short course adjunct
  • Adult dose: 50–150 mg orally three times daily after food
  • Duration: 3–5 days; spasm persists করলে reassess
  • Bangladesh available brand examples:
    • Myoson 50 mg / 100 mg tablet — Tolperisone
    • Tolmus 50 mg tablet — Tolperisone
    • Tolcalm 50 mg tablet — Tolperisone
    • Rison 50 mg tablet — Tolperisone
      MedEx tolperisone page adult dose 50–150 mg TID উল্লেখ করেছে; brand list-এ Rison 50 mg, Tolcalm 50 mg, Tolmus 50 mg, Tolpa 50 mg আছে।
  • Side effects: Dizziness, weakness, hypotension, nausea, GI upset, hypersensitivity reaction
  • Drug interactions: Alcohol/CNS depressant-এর সাথে sedation/impairment বাড়তে পারে; other muscle relaxant-এর সাথে additive weakness
  • Avoid/caution: Driving/machinery, hypotension, hypersensitivity

8) Generic name: Esomeprazole

  • Therapeutic category: Anti-ulcerant / gastroprotective
  • Pharmacological class: Proton pump inhibitor, PPI
  • Purpose / কেন used হয়: NSAID দিলে gastritis/ulcer risk কমাতে, especially PUD history, elderly, anticoagulant/steroid user
  • Adult dose: 20 mg once daily before breakfast; high-risk/GERD থাকলে 40 mg once daily
  • Duration: NSAID যতদিন, সাধারণত 5–7 days; high-risk হলে clinician decision
  • Bangladesh available brand examples:
    • Asozit 20/40 mg capsule — Esomeprazole
    • Epa 20 mg tablet/capsule — Esomeprazole
    • Emo-20 20 mg tablet — Esomeprazole
    • REMMO MUPS 20/40 mg tablet — Esomeprazole
    • REMMO IV 40 mg/vial — Esomeprazole
      MedEx esomeprazole brand list-এ 20/40 mg preparations এবং REMMO MUPS/IV forms আছে।
  • Side effects: Headache, nausea, diarrhea/constipation; long-term useে hypomagnesemia, B12 deficiency, fracture/C. difficile risk
  • Drug interactions: Clopidogrel activation কমাতে পারে; warfarin/diazepam level alter করতে পারে; high-dose methotrexate toxicity risk
  • Avoid/caution: Long-term unnecessary use, severe liver disease

9) Generic name: Omeprazole

  • Therapeutic category: Anti-ulcerant / gastroprotective
  • Pharmacological class: Proton pump inhibitor, PPI
  • Purpose / কেন used হয়: NSAID-induced dyspepsia/gastritis prevention or treatment
  • Adult dose: 20 mg once daily 30 min before breakfast
  • Duration: NSAID course duration; usually 5–7 days for short NSAID course
  • Bangladesh available brand examples:
    • Seclo MUPS 20/40 mg tablet — Omeprazole
    • Losectil MUPS 20/40 mg tablet — Omeprazole
    • G-Omeprazole 20 mg capsule / 40 mg IV — Omeprazole
    • O-20 20 mg capsule — Omeprazole
      MedEx omeprazole brand list-এ Seclo MUPS, Losectil MUPS, G-Omeprazole, O-20/O-40 আছে।
  • Side effects: Headache, diarrhea, abdominal discomfort; long-term risks similar to PPI class
  • Drug interactions: Clopidogrel, warfarin, diazepam, phenytoin, high-dose methotrexate
  • Avoid/caution: Unnecessary prolonged use

10) Generic name: Lidocaine hydrochloride injection

  • Therapeutic category: Local anesthetic
  • Pharmacological class: Amide local anesthetic
  • Purpose / কেন used হয়: Emergency shoulder reduction-এর আগে intra-articular anesthesia; procedural pain control
  • Adult dose for shoulder reduction: 1% lidocaine 10–20 ml intra-articular commonly used; max without adrenaline 4.5 mg/kg. Hospital/ED setting only.
  • Duration: Single procedural dose
  • Bangladesh available brand examples:
    • Lidocaine 2% injection — Lidocaine HCl
    • G-Lidocaine 2% injection — Lidocaine HCl
    • Jasocaine 1% / 2% injection — Lidocaine HCl
    • Chemocain 2% injection — Lidocaine HCl
      MedEx lidocaine injection brand list shows Chemocain 2%, G-Lidocaine 2%, Jasocaine 1/2%, and Lidocaine 2% injection।
  • Side effects: Local anesthetic systemic toxicity—perioral numbness, tinnitus, metallic taste, seizure, arrhythmia; allergy rare
  • Drug interactions: Class I antiarrhythmics, beta-blockers/cimetidine may increase lidocaine level
  • Avoid/caution: Cardiac conduction disease, severe liver disease, allergy, exceed max dose

11) Procedural sedation drugs — hospital only

A. Generic name: Midazolam

  • Therapeutic category: Sedative/anxiolytic
  • Pharmacological class: Benzodiazepine
  • Purpose: Shoulder reduction-এর procedural sedation, anxiety control, amnesia
  • Dose: IV titrated 0.02–0.05 mg/kg; continuous monitoring required
  • Bangladesh brand examples: Hypnofast 5 mg/5 ml, Hypnofast 15 mg/3 ml, Midolam 5 mg/ml, Midolam 15 mg/3 ml, Midalam 7.5 mg tablet।
  • Side effects: Respiratory depression, hypotension, paradoxical agitation, sedation
  • Interactions: Opioid/alcohol/CNS depressant → severe respiratory depression; CYP3A4 inhibitors increase level

B. Generic name: Fentanyl citrate

  • Therapeutic category: Opioid analgesic
  • Pharmacological class: Potent μ-opioid receptor agonist
  • Purpose: Severe procedural pain during reduction
  • Dose: IV 0.5–1 mcg/kg titrated; monitoring + resuscitation setup required
  • Bangladesh brand examples: Fentanyl 100 mcg/2 ml injection, Fentyl 100 mcg/2 ml injection; transdermal Durogesic 25/50 mcg/hour is for chronic pain, acute dislocation pain নয়।
  • Side effects: Respiratory depression, bradycardia, hypotension, nausea, chest wall rigidity high dose
  • Interactions: Benzodiazepine/alcohol/CNS depressant, MAOI, serotonergic drugs

11. Bangladesh doctors commonly prescribe — practical list

Hill-Sachs lesion/shoulder dislocation-এর prescription সাধারণত lesion cure করার জন্য নয়, বরং pain + inflammation + spasm control এবং reduction/post-reduction management-এর জন্য।

Common prescription pattern

  1. Paracetamol 500 mg / 1 g
    • Mild–moderate pain control
    • NSAID contraindicated হলে first choice
  2. NSAID: Ibuprofen / Naproxen / Diclofenac / Etoricoxib
    • Pain + inflammatory component কমাতে
    • Short course only; GI/renal/CV risk দেখে choose
  3. PPI: Esomeprazole / Omeprazole
    • NSAID-induced gastritis/ulcer prevention
    • Elderly, PUD history, anticoagulant/steroid user হলে বেশি দরকার
  4. Tramadol 50 mg PRN
    • Severe pain, post-reduction or post-op pain
    • Short course; dependence/sedation/seizure risk
  5. Tolperisone 50 mg
    • Painful muscle spasm থাকলে adjunct
    • Routine সবার জন্য নয়
  6. Lidocaine injection intra-articular
    • ED/procedure setting-এ reduction analgesia
    • Prescription-home use নয়
  7. Midazolam ± Fentanyl
    • Procedural sedation/analgesia for reduction
    • Only monitored hospital setting

12. Prevention — কীভাবে prevent করবেন

A. First dislocation-এর পর

  • Shoulder reduction-এর পর orthopedic follow-up
  • Proper physiotherapy শুরু করা
  • Early phase-এ abduction + external rotation position avoid
  • Pain কমলে supervised ROM
  • Rotator cuff + scapular stabilizer strengthening
  • Proprioception and neuromuscular control exercise

B. Athlete / overhead worker

  • Throwing technique correction
  • Gradual return-to-play
  • Protective bracing in contact sports
  • Return only when:
    • Full pain-free ROM
    • Strength near normal
    • Apprehension negative
    • Functional sport-specific test passed

C. Recurrent dislocation prevention

  • Recurrent instability হলে শুধু painkiller দিয়ে manage না করে CT/MRI-based instability work-up
  • Off-track/engaging lesion থাকলে early surgical opinion
  • Bankart lesion/glenoid bone loss থাকলে appropriate stabilization surgery

D. General prevention

  • Fall prevention in elderly
  • Seizure control
  • Avoid high-risk shoulder positions until rehab complete
  • Muscle strengthening and posture correction

Overview / Summary

Hill-Sachs lesion হলো anterior shoulder dislocation-এর কারণে humeral head-এর posterolateral অংশে compression defect। ছোট on-track lesion conservative physiotherapy + pain control দিয়ে manage হতে পারে। কিন্তু recurrent instability, large/off-track lesion, glenoid bone loss বা engaging defect থাকলে surgical stabilization লাগে—commonly Bankart repair ± remplissage, অথবা significant glenoid bone loss থাকলে Latarjet/bone block procedure। Medicine lesion heal করে না; medicine ব্যবহার হয় pain, inflammation, spasm, procedural analgesia/sedation এবং NSAID gastric protection-এর জন্য।

Actionable Plan / Steps

  1. Acute case: neurovascular exam → X-ray AP/Y/axillary → reduction → post-reduction X-ray.
  2. Pain control: Paracetamol ± short NSAID; high-risk patient হলে PPI add.
  3. Severe pain: short-course tramadol only if needed.
  4. Spasm: tolperisone short course if clinically significant spasm.
  5. Recurrent instability: MRI/MR arthrogram + 3D CT for Bankart, glenoid bone loss, Hill-Sachs size, on-track/off-track.
  6. Small/on-track: rehab-based conservative care.
  7. Off-track/engaging or recurrent: orthopedic shoulder specialist referral for Bankart repair ± remplissage / Latarjet decision.
  8. Prevention: structured physiotherapy, avoid risky positions, return-to-sport criteria follow.

Reference List

Textbooks

  1. Campbell’s Operative Orthopaedics, 14th ed. Shoulder instability and stabilization procedures chapter.
  2. Rockwood and Green’s Fractures in Adults, 9th ed. Glenohumeral dislocation and associated humeral head defects chapter.
  3. DeLee, Drez & Miller’s Orthopaedic Sports Medicine, 5th ed. Traumatic anterior shoulder instability chapter.
  4. Apley & Solomon’s System of Orthopaedics and Trauma, latest ed. Shoulder dislocation and recurrent instability section.
  5. Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 42nd ed. Shoulder joint anatomy and stabilizers.

Guidelines / Pathways

  1. BESS/BOA Patient Care Pathways: Traumatic anterior shoulder instability, Shoulder & Elbow. Pathway highlights: young male recurrence risk, imaging/repair strategy, glenoid bone loss, Hill-Sachs management, remplissage/Latarjet options.

Peer-reviewed journals with DOI

  1. Calvo E, Delgado C. Management of off-track Hill-Sachs lesions in anterior glenohumeral instability. Journal of Experimental Orthopaedics. 2023;10:30. DOI: 10.1186/s40634-023-00588-x.
  2. Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from engaging/non-engaging lesion to on-track/off-track lesion. Arthroscopy. 2014;30(1):90–98. DOI: 10.1016/j.arthro.2013.10.004.
  3. Locher J, Wilken F, Beitzel K, et al. Hill-Sachs off-track lesions as a risk factor for recurrence of instability after arthroscopic Bankart repair. Arthroscopy. 2016;32(10):1993–1999. DOI: 10.1016/j.arthro.2016.03.005.
  4. Calvo C, Calvo J, Rojas D, Valencia M, Calvo E. Clinical relevance of persistent off-track Hill-Sachs lesion after arthroscopic Latarjet procedure. American Journal of Sports Medicine. 2021;49(8):2006–2012. DOI: 10.1177/03635465211019979.
  5. Shaha JS, Cook JB, Rowles D, Bottoni C, Shaha S, Tokish JM. Clinical validation of the glenoid track concept in anterior glenohumeral instability. J Bone Joint Surg Am. 2016;98(22):1918–1923. DOI: 10.2106/JBJS.15.01099.

Md.Rafiqul Islam Lipu,Date:-23-06-2026 Tuesday,Time:-11-46-12 Am

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