clinical examination of the hip
TRANSCRIPT
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