Examination of the hip joint

Dr. PALLAV AGRAWAL

CLINICAL EXAMINATION OF HIP USEFUL IN

DDH NEONATAL SEPTIC

ARTHRITIS TRANSIENT

SYNOVITIS PERTHES DISEASE

SCFE TUBERCULOSIS OSTEOAARTHROSIS Avascular Necrosis TRAUMATIC

CONDITIONS

EXAMINATION OF HIP

History of symptoms general examination

Inspection

Palpation Looking for Fixed

deformities Movements Measurements Special tests Tests for instability

History

Age & sex Occupation Pain Limp Amount & nature of violence Deformity & swelling locking

Past historyask for previous H/O trauma or

contact with TB

Family historyTB and rheumatism run in families

General examination

In suppurative arthrits of hip , evidence of toxaemia in other parts of body should be noted

In TB – hip look for generalised wasting, cachexia and evening rise of temperature

In rheumatoid arthritis look for rheumatoid stigmata in other parts of body

Look for external iliac & inguinal nodes

Orthopedic Examination

inspection palpation range of motion Special tests

inspection General on patient. General local (hip)

Position. Major deformity, swelling. Extra: cast, splint, traction, dressing …

Anatomic local: Skin: swelling, scars, color, hair, dryness … Subcut.: LN, veins, nerves, tendons … Muscles: bulk, wasting, twitches … Bones: landmarks, swelling, angulation, deformity. Joints: position, swelling, redness…

General on patient : Lying comfortably in bed not in pain. Lying supine, in pain, holding Rt thigh in flexion.

General on patient : Lying uncomfortably in bed

with Rt hip adducted & internally rotated, and Lt hip abducted & externally rotated.

General on patient : Sitting uncomfortably on a

wheel chair, with both hips adducted (scissoring) and Lt hip extended.

General local (hip-thigh-LL): Position

Abduction / Adduction Flexion / Extension External / Internal Rotation

General local (hip-thigh-LL): Lumbar lordosis

General local (hip-thigh-LL): Major deformity- swelling:

Lateralized contour. Asymmetrical skin folds. Wide perineum. Masses.

Wide Perineum Lateralized Contour

Anatomic local: Skin: swelling, scars, color, hair, dryness … Subcut.: LN, veins, nerves, tendons … Muscles: bulk, wasting, twitches … Bones: landmarks, swelling, angulation and deformity. Joints: position, (hip too deep to see swelling).

( Do Not Forget The Posterior Aspect ! )

Important Considerations: Amount of exposure. Duration of exposure. Persons present during exposure. Place of exposure. Attitude and behavior during exposure.

GAIT

Simplest of all definitions “mode of walking”

GAIT

Normal gait is rhythmical bipedal biphasic walking in which the lumbar spine, hip and legs move in unison

LIMPING Limping is the most common

abnormality Can be defined as any abnormality of

normal rhythmic biphasic walking

Gait cycle: Stance phase:

Heel strike. Mid-stance. Push off.

Swing phase:

Types of gait Antalgic gait

in painful hip conditionspt lurches on the same side

Trendelenberg gaitpt lurches to the affected sideseen in hip dislocation, coxa vara

Waddling gaitBody sways from side to side on a wide baseSeen in b/l CDH & b/l coxa vara

Cont’d…

Short limb gait- When the affected limb becomes shortUp and down movement of half of the body\ Circumduction gait-In fixed abduction deformity Gluteus maximus gait-In paralysis of gluteus maximusPt lurches backward during stance phase

Gait cont’d..

Toe gaitPt walks with both feet turned inwards- seen

in femoral anteversion

palpation Temperature: compare distal/proximal, Rt / Lt. Tenderness:

Generalized. Specific.

Anatomic: Skin: dryness, hyper/hypothesia, scars. Subcut.: LN, nerves, vessels, tendons, nodules. Muscle: tone, bulk, twitches, gaps, tenderness. Bone: landmarks (ASIS, Gr Tr. , Isch. Tub.) tenderness, mass, crepitus. Joint: swelling, effusion, crepitation, synovial thickening, joint line tenderness (hip joint too deep to elicit).

Range of motion

Must differentiate between true hip joint motion and pelvic motion.

Must stabilize the pelvis in neutral position.

Movements During the measurement of movements always

fix the pelvisFlexion- 0 to 140 degreeExtension- 0 to 15 degreeAbduction- 0 to 40 degreeAdduction- 0 to 30 degreeInternal rotation- 0 to 30 degreeExternal rotation- 0 to 45 degreeCircumduction-

MOVEMENT

Normal flexionNormal range

MOVEMENT

Axis deviation

MOVEMENTS

Extension

MOVEMENTS

ADDUCTIONNormal range

MOVEMENTS

Abduction

In flexion

Normal range

MOVEMENTS

Internal rotation

In flexion

Normal range

MOVEMENTS

External rotation

In flexion

Normal range

MEASUREMENTS

ShorteningApparentTrue

Apparent measurement

Shows the compensation that the pt has developed to conceal any fixed deformity

Here both limbs should be kept parallel to each other

Measured from xiphisternum or umbilicus to medial malleolus

MEASUREMENTSTrue shortening

Square the pelvis

ASIS MEDIAL JOINT LINE KNEE MEDIAL MALLEOLUS

MEASUREMENTS

Supra trochanteric Coxa Vara Perthes SCFE Malunited basal # NOF Congenital Coxa Vara Arthritis Dislocation

Infra trochanteric Malunion Fracture femur & tibia Growth arrest from

polio Trauma and infective

sequale

True shortening

MEASUREMENT- circumferential

Muscle wasting

For injuries/pathologies around the hip

Bryant’s triangle

FIXED DEFORMITIES Fixed flexion deformity

Concealed during walking by increase in lumbar lordosis

FFD DEMONSTRATION

HUGH OWEN THOMAS’S TEST

Fixed abduction & adduction deformity Fixed abduction is compensated by scoliosis

with convexity towards the affected side & by the pelvis being tilted down causing apparent lengthening of limb

Fixed aadduction is compensated by scoliosis with convexity towards the normal side & by the pelvis being tilted up causing apparent shortening of limb

FIXED ABDUCTION & ADDUCTION DEFORMITY

Pelvic tilt indicated by ASIS at different level

FIXED ABDUCTION & ADDUCTION DEFORMITY

DN

FIXED ABDUCTION & ADDUCTION DEFORMITY

N

D

FIXED ABDUCTION & ADDUCTION DEFORMITY-

N D

Measured by squaring of pelvis

Alternate method for determing Fixed abduction & adduction deformity Kothari’s method

Fixed external & internal rotation deformity Always remains revealed Determined by noting the direction of

anterior surface of patella or the toes when the foot is held at right angle to the leg

SPECIAL TESTS

Special Tests

Thomas test. Trendelenburgh test. Leg length assessment. Instability tests in neonates: (Ortolani / Barlow) Gait – walking. Telescopic Test

Special Tests - Thomas test

Positive Thomas test in neonates and young children is normal

Special Tests - Thomas testThomas Test

Precaution when knee has fixed flexion deformitySolution keep knee outside edge of couch

Special Tests - Trendelenburgh test

Special Tests - Trendelenburgh test

You are testing the hip the patient is standing on !

Normally the pelvis tilts down on the weight-bearing hip.

This is performed by the hip abductors.

Positive Trendelenburgh is when: The pelvis on the non weight-bearing hip tilts down,

and The trunk has to tilt to the weight-bearing side.

Special Tests - Trendelenburgh test Causes of Positive Trendelenburgh:

Weak hip abductors: paralyzed / wasted.

Mechanically inefficient hip abductors: distance between origin & insertion reduced (e.g. coxa vara).

Unstable pivot of motion: hip subluxation / dislocation.

Inhibited hip abductors: painful to move trauma (sprains) / infection / irritation / tumor.

Reduced range of motion: hip incongruent / stiffness / OA.

Special Tests - Leg length assessment

Galleizzi test

Both heels have to be at the same level

Special Tests - Leg length assessment

True LengthASIS to Medial Malleolus

Apparent LengthMidpoint to Medial Malleolus

SPECIAL TESTSTelescoping test

Neonatal Examination for CDH

Feel a clunknot hear a click !

Special Tests – Ortolani test

Special Tests – Barlow test

Neonatal Examination for CDH

Feel a clunknot hear a click !

Special Tests - Ortolani / Barlow

Special Tests - Ortolani / Barlow

NEUROVASCULAR ASSESEMENT

THANK YOU