clinical examination of the hip

Clinical examination

Ball and socket, Synovial, Multiaxial joint Compensations for hip deficits Referred pain to knee joint Neck shaft angle Femoral anteversion Arterial supply Calcar femorale Capsular reflections Extension-first movement to be lost Joint space- most accomodative in Fl, Abd,ER

Pubic tubercle Femoral head Femoral neck Mid inguinal point Mid point of inguinal ligament Line joining PSIS

Pain – Night cries Limp Trauma Steroid intake Alcohol intake Tuberculosis Bronchial asthma Complaint during childhood

Gait Trendelenberg’s gait-DDH Short limb gait Antalgic gait-OA hip Waddling gait-osteomalacia High stepping gait-foot drop Scissors gait-cerebral diplegia

DDH-wide perinium Synovitis-Flex.,Abd.,ER.,App. lenthening Arthritis-Flex., Add.,IR.,+/- True shortening Posterior dislocation-Flex.,Add.,IR.,True and

App. shortening Anterior dislocation-Flex.,Abd.,ER.,App.

lenthening Fracture trochanter-Marked ER Fracture neck of femur-ER-not so marked-

capsular catch

Skin Exagerrated lumbar lordosis Level of ASIS Wasting Shortening/Lengthening Soft tissue Bony points Swelling

To confirm the findings of inspection Temperature Tenderness-Ant/Post/Lat/Med/Iliac fossa Bony prominences/Greater trochanter Sites to be palpated for psoas abscess

NARATH’S SIGN Femoral arterial pulsations

Positive in Post. dislocation of hip

Excised or dissolved head and neck

Burger’s disease

Lymph nodes-Inguinal and External iliac

Flexion 0-110/130 Psoas major Rectus femoris,Sartorius,Pectinius,TFL,Adductors

Ext 0-20 Gl.max.,Gl.med.,Semitendinosis,Semimembranous,Biceps femoris

Abd. 0-45/55 Gl.Med. Gl.min.,TFL,Gl.max.

Add.

ER

IR

0-35/45

0-40/50

0-30/40

Adductors,Pectinius Grasilis

Obt.ext.,internus,Quad.femoris,Piriformis, Gamelli

Gl.min,TFL

Sartorius,Long head of biceps

Gl.med,semitendinosus,Semimembranous

Flexion

Extension

Rotation

Abduction Adduction

Line joining two ASIS cuts midline at right angle

Fallacies-Not possible in fixed scoliosis due to fixed obliquity of pelvis

Iatrogenic-ASIS removed for bone grafting

Mal or ill development of hemipelvis e.g. residual polio myelitis

Unreduced dislocation of SI joint Malunited or unreduced verticle fracture

of ilium

Position from where limb can’t be brought back to neutral position but further movement in same axis is possible

Causes-Persistent muscular spasm Persistent posture to avoid pain or to

conceal deformity Disparity of limb lengths Destructive changes in joint Fibrotic contractures in periarticular soft

tissues Surgical interventions

To conceal deformity To maintain equilibrium by shifting centre

of gravity To apparently make up the disparity of limb

lengths To stabilise the unstable hip

To assess fixed deformity it is essential to neutralise compensatory mechanisms

Exagerrated lumbar lordosis Thomas test-Hugh Owen Thomas 1876

Critisism-Patient is hurt further in painful hip

Obese or heavily built individuals Bilateral FFDs Ankylosed knee Inappropriate force for flexion Alternative method-Prone position-

Bilat.cases/FFD knee

Fixed abduction-ASIS at lower level

Scoliosis with covexity on affected side

1cm of true shortening-10 degree of fixed abd.

Fixed add.-ASIS at higher level

Scoliosis with convexity to unaffected side

Kothari’s angle

Rotational deformities are usually revealed due to lack of compensation

Shortening compensated by-Pelvic tilt,Ankle equinus,Flexion of opposite hip and knee

Apparent measurement-To assess extent of natural compensation

Pre requisites-Supine with affected limb in line with trunk

Both lower limbs in parallel position Supratsernal notch /Xiphisternum to medial

malleolus

From ASIS to medial malleolus Pre requisites-Square the pelvis Both lower limbs in parallel positions True=App. No compensation True>App. Part of shortening

compensated(Abd. Defo.) True<App. Add. Defo.+ shortening

without compensation

Leg-Central point on medial joint line to tip of med. Malleolus

Thigh-Supratrochanteric- neck and head -Bryant’s triangle

Infratrochanteric-Tip of gr. Tr. to knee joint line

Shortening of base-riding up of tr.,shortening in head neck, dislocation

Reversed Bryant’s triangle-Gross overriding of trochanter

Perpendicular line-Shortening-Post. and central dislocation

Lengthening-FFD hip,Fracture trochanter

Hypotenuse- Central dislocation of hip

Old fracture neck of femur with neck absorption

Absence of head due to disease or surgery

Protrusio acetabuli

Fallacies of Bryant’s triangle-Bilateral affection Excision of ASIS e.g. for bone

graft Limb disarticulated at hip Lines-Nelaton’s line-Supra trochanteric shortening

Schoemaker’s line- DDH, Bilat. Coxa vara Chine’s test-Lines

coverge on that side Morris’s bitroch. Test-Tr.

Ext. rotated or displaced back or vice versa

Bilateral affe.-Seg. Meas. Circum. Meas. At mid

thigh level

Trendelenberg’s sign

Friedrich Trendelenberg’s 1895

Fulcrum-DDH Leverarm- # N/F

Power-Polio myelitis

Fallacies- Intact Quadratus lumborum Incoordination of muscles-Cerebral palsy Affection of SI joint Medial shift of mechanical axis of leg

below hip-bow knee Obese and bulky persons

Dislocatable hip Adduction and

posterior push Relaxed baby

preferably in mother’s lap

Marino Ortolani 1937

Dislocated hip Abduction and

lifting the trochanter

Palpable clunk

To calculate femoral anteversion

Non union fracture neck of femur

Old unreduced posterior dislocation

Paralytic hip

Hip-60 degree Knee-90 degree Foot planted over

bed

Tibial shortening Femoral shortening

IT band contracture Hip abducted knee

flexed 90 Polio myelitis

Meningomyelocele

Flexion Abduction External

rotation Extension

Hart’s sign-Limitation of abduction Klisick’s sign Asymmetrical gluteal folds-Pelvic obliquity -Limb length

discrepancy - Muscular

atrophy Ortolani’s and Barlow’s tests

THANX