Clinical Hip Examination

7/26/2019 Clinical Hip Examination

1/90

CLINICAL EXAMINATIONOF THE HIP

MAJ VIVEK MATHEW

PHILIP

RESIDENT

ORTHOPAEDICS

AFMC


2/90

CLINICAL EXAMINATIONOF THE HIPAnatomy

History

ClinicalExamination


3/90

ANATOMY.

Ball and socket type of synovialjoint.

Connects the pelvic girdle tothe lower limb

Made p of femoral head andacetablm

!esigned for stability and widerange of movement

Covered with a thin layer ofhyaline cartilage


4/90

Anatomy

"he articlar srface ofis horse#shoe shaped andis de$cient inferiorly#acetablar notch

Has a labrm#is a circlar layer ofcartilage whichsrronds the oter part

of the acetablmmaking the socket

deeper and so helpingprovide more stability

Capsule


5/90

Ilio!mo"alLi#am!nt

"his is a strong ligamentwhich connects thepelvis to the femr

at the front of the joint

%t resembles a & inshape

'tabilises the hip bylimitinghyperextension


6/90

I$%&io!mo"al li#am!nt'"his is a ligament which reinforces the posterioraspect of the capsleattaches the ischim to the two trochanters of

the femr.


7/90

P()o!mo"al li#am!nt"he pbofemoral ligament attaches the pbis tothe femr


8/90

T"an$*!"$! a%!ta)(la" Li#am!nt'Bridges acetablar notch.

Li#am!nt o &!a+ o !m("' (at andtrianglar in shape)ies within joint* ensheathed by synovim


9/90


10/90

M($%l!$

,l(t!al$'

,l(t!($ Ma-im($ ,l(t!($Minim($ an+ ,l(t!($M!+i($

Attach to the %lim and travel

laterally to insert into thegreater trochanter of the

femr

Medis and Minims abdct

and medially rotate the hip

joint* as well as stabilising thepelvis

+ltes maxims extends and

laterally rotates the hip joint


11/90

Mo"! M($%l!$

/(a+"i%!0$

"he for ,adricep msclesare -asts lateralis* medialis*intermedis and ectsfemoris

All attach inferiorly to thetibial tberosity

ects femoris originates atthe Anterior %nferior %liac

'pine and acts to (ex the hip

"he / other ,ad mscles donot cross the hip joint* andattach arond the greatertrochanter and jst below it.


12/90

'

Ilio0$oa$'

"he is the primary hip (exormscle which consists of 0parts

Attaches speriorly to thelower part of the spine andthe inside of the ilim

Cross the hip joint and insertto the lesser trochanter ofthe femr


13/90

M($%l!$'

Ham$t"in#$'

"he hamstrings are threemscles which form the backof the thigh

Attach speriorly to theischial tberosity

Case hip extension


14/90

F(n%tional ,"o(0 o M($%l!$ A%tin#on t&! Hi0

Fl!-o"$' %liopsoas* sartoris* tensor fascia lata* rects femors*

E-t!n$o"$'

# hamstrings* addctor magns* gltes maxims

A++(%to"$'

# addctor longs* brevis* and magns* gracilis* pectinesA)+(%to"$'

# gltes medis* minims* tensor fascia lata

# gamelli* obtrators* piriformis in sitting

E-t!"nal "otato"$'

# obtrator externs* interns* piriformis* 1adratsfemoris* gltes maxims

Int!"nal Rotato"$'

# gltes medis* minims* tensor fascia lata.


15/90

N!"*!$

F!mo"al 1L2345

O)t("ato" 1L2 3 45

S%iati% 1L46 S7

25


16/90

8loo+ S(00ly


17/90

EXAMINATION OF HIP

Hi$to"y

,!n!"al!-amination

,ait

In$0!%tion

Pal0ation

Mo*!m!nt$

M!a$("!m!nt$

S0!%ial t!$t$


18/90

Clini%al !at("!$ o Hi0Pat&olo#y'

2ain.

'welling.

)oss offnction.

)imp.

)eg lengthdiscrepancy.


19/90

2A%3

Most important reported symptom.SiteAnterior hip pain 4 arthritis* hip (exor strain* iliopsoas

brsitis* labral tear

)ateral hip pain 4 greater trochanteric brsitis* gltesmedis tear* iliotibial band syndrome 5athletes6* meralgiaparesthetica 5an entrapment syndrome of the lateral femoralctaneos nerve syndrome6

2osterior hip pain !!x4 hip extensor and external rotator

pathology* degenerative disc disease* spinal stenosis

E7EE! 2A%34 toknee. hip pathology can be referred to theknee


20/90

"he 2ain Contines...

Onset4 8hen did it start9 Hors* days* weeks* yearsCharacter

'harp4 mscle strain:tear* fractre

!ll4 ;A* AAchy4 ;A* A* A-3

Radiation

'ciatica can rn from the hip* down the backof the thigh* into the footadiates to the groin can imply inginal

hernia* groin strain* etc.


21/90

Pain'

8hat were they doing when the pain cameon9!id they fall9fractres* mscle tears* haematomas* etc

2laying sports9Mscle sprain* labral tear* etc

2rolonged exercise9;A

+radal vs sdden9A*;A vs. trama


22/90

Pain'!o they have any aggravating or relieving

factors9;A gets worse as they day goes on and is

relieved by rest

Mscle tears:sprains may be exacerbated bymovement

A is worse after prolonged periods of rest

%f analgesia works* $nd ot what they take andhow oftenclty walking p:down stairs9

Are they still able to do their favoritehobbies9

Has their partner noticed their pain limiting

them9

Are they taking reglar analgesia9


24/90

'8E))%3+

'ite

;nset

!ration

Association with pain

2rogression over time


25/90

)%M2

?sally noted by kin

;nset

!ration

Association with

pain

2rogression

Amblatory stats


26/90

2A'" H%'";&"rama

"berclosis

'rgery arond hip

'kin :hematological

disorders

3erological disorders

Connective tissedisorders

'teroid intake

Any othersigni$cant

medical :srgicalillness


27/90

2E';3A) H%'";&

;ccpation and work tolerance

!iet

'moking:alcohol

'exal history

Menopasal history


28/90

7AM%)& H%'";&

"B in close relative

!ysplasia

Metabolic storage disorders

%n(ammatory arthritis


29/90

,ENERALEXAMINATION

Ht:wt:BM%

7ever

-ital signs

2allor

Externaliliac:inginal lymph

nodes

'tigmata ofrhematoid

arthritis:"B

Chest expansion


30/90

);CA) E@AM%3A"%;3

In$0!%tion

Pal0ation

Mo*!m!nt$

M!a$("!m!nt$

S0!%ial t!$t$


31/90

+A%"Sim0l!$t o all

+!9nition$ :mo+! o;al


32/90

"&2E' ;7 +A%"

Antalgic gait

in painfl hipconditionspt walks withredced

stance phaseon thea=ected side


33/90

Waddling gait

Body sways

from side toside on a widebase seen in b:l!!H*pregnancy

T d l b it


34/90

Trendelenberg gait

In +o()l! $tan%!o"%!$ +i$t"i)(t!+!>(ally o*!" t;o &i0$

In $in#l! $tan%! o"%!$

in%"!a$!$ ? ol+

Pati!nt l("%&!$ on t&!a@!%t!+ $ia+! an+0!l*i$ +"o0$ on to$o(n+ $i+!


35/90

Trendelenburg gait


36/90

Contd

Short limb gait-8hen the a=ected

limb becomes short

?p and downmovement of halfof the body

2t lrches on the

a=ected side witha pelvis drop onthe same side


37/90

Circumduction gait- %n $xed abdction

deformity or inhemiparesis the pt

moves his limbswhile dragging hisbody along withlimb in a semi

circle


38/90

Gluteus maximusgait-

%n paralysis ofgltes maxims

2t lrchesbackward dringstance phase


39/90

,adriceps gait

%n 1adricepsweakness bodycollapses#hencethe trnk goesfor anteriorbending to shiftthe vertical

vector anterior tothe knee tobalance


40/90

"oe ingait

2t walks with bothfeet

trned inwards#

seen in femoralanteversion


41/90

"oe otgait

2t walks with bothfeet

trned otwards#

seen in femoralretroversion


42/90

A""%"?!E ;7 "HE )%MBStanding : position of the head

level of scaplae and nipples

crvatre of the spine

attitde of hip* knee ankle

position of the A'%'#s1are or obli1e

,


43/90

A""%"?!E ;7 "HE )%MB

Supine: 2ositionof the pper limbs

lower limbs

parallel:rotated

2atella facingp:in:ot

exaggerated lmbarlordosis


44/90

%3'2EC"%;3 7;M BACD

'coliosis

+lteal msclewasting

2'%'

Back of iliac crest

'cars and sinses


45/90

);;D 7; )%MB )E3+"H!E'CE2A3C&


46/90

2A)2A"%;3

Conrms the ndingso! inspection"

)ocal temperatre

%ncreased in acte arthritis

oint tendernessAnteriorl##0cms below and

lateral to mid# inginalpoint

$osteriorl## jnction of

medial 0:/rdand lateralF:/rdof a line joining+" 2'%'


47/90

"enderness

A'%'

+"

2'%'

pbicsymphysis

'% joint ischial

tberosity


48/90

2A)2A"%;35Contd6

7emoral arteryplsation atmidinginal pont

2alpation of +"4smooth:irreglar

proximal migration

!igital Bryants "est

4spratrochanteric

shortening


49/90

MEA'?EME3" ;7!E7;M%"&

7ixed 7lexion !eformity

unilateral #Thomas Test

"he examiner blocks thepelvis by bringing the

contralateral sond hip intomaximal (exion. "hiseliminates lmbar lordosisthat can be sed tocompensate for the hip(exion contractre of the

a=ected hip. "he leg to beexamined is then broght intomaximal extension with thehip in netral addction androtation.


50/90

Pati!nt in 0"on!0o$ition ;it& lo;!"lim)$ &an#i#n# o(t"om t&! !+#! o

t&! ta)l!2atient shold be

able to kep boththighs extended

Measre the anglebetween thigh andbed for =d

BILATERAL FFD


51/90

7ixed Abdction!eformity

%t is compensatedby scoliosis with

convexity towardsthe a=ected side by the pelvis beingtilted down casing

apparentlengthening of limb


52/90

7ixed addctiondeformity

%t is compensatedby scoliosis with

convexity towardsthe normal side by the pelvis beingtilted p casing

apparentshortening of limb


53/90

7ixed external internal rotationdeformity

Always remains revealed

!etermined by noting the direction ofanterior srface of patella or the toes whenthe foot is held at right angle to the leg


54/90

Mo*!m!nt$

Fl!-ion 1736+!#64sitting

7or ilio psoascontribtion4

7lex knee and move it

towards the chestwithot moving theopposite leg whenpatient sits with the legshanging on the edge of

the examination coch

Active ')" againstresistance5spine6


55/90

Mo*!m!nt$

E-t!n$ion 1 to 2+!#5

7or gltes maximscontribtion4

Hamstring contribtion


56/90

Mo*!m!nt$

Abdction 5 G to I deg6

Addction5G to I deg6


57/90

Mo*!m!nt$

External rotation

JG deg (exion5I deg6

fll extension5Ideg6


58/90

Mo*!m!nt$

Int!"nal "otation

Int!"nal "otation in B+!# !-ion146 +!#5

Int!"nal Rotation in (ll

!-t!n$ion146 +!#6

LIM8 LEN,TH


59/90

LIM8 LEN,THMEASREMENTS


60/90

MEASREMENT M($%l!)(l


61/90

LIM8 LEN,TH'APPARENTK fnctional length

K patient in straight line andlimbs parellel* defromities notcorrected

K from the $xed midpoint to themedial malleols

shows the compensation thatthe pt has developed toconceal any $xed deformity

here both limbs shold bekept parallel to each other

measred from xiphisternmor mbilics to medialmall!ol($


62/90

TRE LEN,TH

anatomical length

patient in straighat line and

deformities corrected and thelimbs are kept in identical position

measured from the ASIS to

medial malleolus


63/90

8LOCK METHOD


64/90

MEA'?EME3"'

%f "re 'hortening L Apparent 'hortening43o compensation

"re 'hortening apparent shortening4 only

part of the deformity is compensated bytilting the pelvis5$xed abdction deformity6

"re 'horteningNapparent 'hortening4$xedaddction deformity with no compensation

Every FG degree of deformity 4 GF cm

APPARENT SHORTENIN,


65/90

APPARENT SHORTENIN, LEN,THENIN,

ADDUCTION :APPARENT SHORTENING

ABDUCTION :APPARENT LENGTHENING

'E+ME3" ;7 "?E


66/90

'E+ME3" ;7 "?E'H;"E3%3+

SE,MENTALSHORTENIN,'SPRATROCHANTERIC


67/90

SHORTENIN,'SPRATROCHANTERIC

B&A3"' "%3+)E 3E)A";3' )%3E


68/90

MEA'?EME3"'

Chienes lines"he lines joining the

two A'%' and thetwo +"s are parallel

to each other

!istrbed inspratrochantericshortening

'hoemakers lines


69/90

MEA'?EME3"'

Morris Bistrochanteric "est4 it meases the distance between the +"

and pbic symphysis on both sides

edced in hip dislocations


70/90

S(0"a t"o%&ant!"i% Co-a Va"a

P!"t&!$ SCFE

Mal(nit!+ )a$al GNOF

Con#!nital Co-aVa"a

A"t&"iti$

Di$lo%ation

In"a t"o%&ant!"i%Mal(nion

F"a%t("! !m(" ti)ia

,"o;t& a""!$t "om0olio

T"a(ma an+in!%ti*! $!>(al!

True shortening

TELESCOP&


71/90

TELESCOP&

Fl!- t&! &i0 to B+!#Kon! &an+ ;it& t&!t&(m) on a$i$ an+t&! "!mainin#9n#!"$ o*!" t&!$ot ti$$(!0"o-imal to !m("Kot&!" &an+ at t&!

+i$tal !m("K0($& an+ 0(ll t&!!m("

VASCLAR SI,N OF


72/90

VASCLAR SI,N OFNARATH

TRENDELEN8R,


73/90

TRENDELEN8R,TEST


74/90

"his test examine the strength of the abdctor mechanism of thehip.

%ulcrum4 head of femr

&oad arm4weight of the body

$o'er arm4 abdctors

&e(er4 neck and trochanters of the femr

3ormally* in a one legged stance* the pelvis is raised p on thenspported side. %f the weight bearing hip is nstable* the pelvis

drops on the nspported side* to avoid falling the patient has tothrow his or her body towards the loaded side.

K%n the classic test* the examiner stands behind the patient. %f thepatient stands on a healthy hip the glteal fold on this side drops.

K%f the patient stands on a diseased leg the glteal fold on theopposite side drops 5the sond side sags6.

F.. 8eakness of the hip abdctors e.g. poliomyelitis

0.. 'hortening of femoral neck e.g. coxa vara.

/. !islocation or sblxation of the hip


75/90

"E'"' 7; !!H

8ARLOWS MANOVRE "hemanever is

easily performed byaddctingthe hip whileapplying light pressre

on the knee* directingthe force posteriorly.O0P%f the hip isdislocatable # that is* ifthe hip can be popped

ot of socket with thismanever # the test isconsidered positive

ORTOLANI TEST

%t is performed by an examiner$rst (exingthe hips and kneesof a spine infant to JGdegrees* then with theexaminerQs index $ngersplacing anteriorpressre on the

greater trochanters* gently andsmoothly abdctingthe infantQslegs sing the examinerQsthmbs.

A positive sign is a distinctiveQclnkQ which can be heard and

felt as the femoral headrelocates anteriorlyinto theacetablm4O0P

hip
http://en.wikipedia.org/wiki/Adductionhttp://en.wikipedia.org/wiki/Barlow_maneuverhttp://en.wikipedia.org/wiki/Anatomical_terms_of_motionhttp://en.wikipedia.org/wiki/Anteriorhttp://en.wikipedia.org/wiki/Greater_trochanterhttp://en.wikipedia.org/wiki/Anatomical_terms_of_motionhttp://en.wikipedia.org/wiki/Femur_headhttp://en.wikipedia.org/wiki/Anteriorhttp://en.wikipedia.org/wiki/Acetabulumhttp://en.wikipedia.org/wiki/Ortolani_testhttp://en.wikipedia.org/wiki/Ortolani_testhttp://en.wikipedia.org/wiki/Acetabulumhttp://en.wikipedia.org/wiki/Anteriorhttp://en.wikipedia.org/wiki/Femur_headhttp://en.wikipedia.org/wiki/Anatomical_terms_of_motionhttp://en.wikipedia.org/wiki/Greater_trochanterhttp://en.wikipedia.org/wiki/Anteriorhttp://en.wikipedia.org/wiki/Anatomical_terms_of_motionhttp://en.wikipedia.org/wiki/Barlow_maneuverhttp://en.wikipedia.org/wiki/Adduction


76/90

CONTRACTRES


77/90

CONTRACTRES

7)E@%;34"H;MA' "E'"

TESTS FOR JOINT


78/90

TESTS FOR JOINTCONTRACTRES

O8ERS TEST' T!$t o" il!oti)ial

t"a%t %ont"a%t("!.

In lat!"al +!%()it($0o$ition


79/90

TESTS FOR JOINTCONTRACTRESELYS TEST o" t&! %ont"a%t("! o

t&! "!%t($ !mo"i$

0"on! 0o$ition ;it& t&!


80/90

2HE)2' "E'"4

To +!t!%t t&! %ont"a%t("!o #"a%ili$ m($%l!

P"on! 0o$ition ;it& t&!


81/90

TEST FOR FEMORALANTEVERSION'CRAI,S TEST

F.2ositioned prone0.Dnee (exed JG deg

/.;ne hand over

trochanter

.;ther hand is rotatingthe leg till thetrocanter felt

prominent

I.Angle sbtended

between the imaginaryvertical to the longaxis of the leg

PIRIFORMIS TEST1FADIR5


82/90

Lat!"al +!%()it($ 0o$itionK&i0 i$ !-!+ to 46 +!#"!!

K


83/90

PATRICKS TEST1FA8ER5

T!n+ to $t"!$$t&! i0$ilat!"al $i

oint

K0ain i$ 0o$t!"io"

in $i a"t&"iti$K0ain i$ ant!"io"

in &i0 a"t&"iti$


84/90

PELVIC STRESS TESTS

)A"EA) 2E)-%CC;M2E''%;3

"E'"

A3"E%; 2E)-%CC;M2E''%;3

"E'"


85/90

PELVIC STRESS TESTS

2?B%C '&M2H&'%''"E'' "E'"

'"%3CH7%E)! "E'"


86/90

IMPIN,EMENT TEST

7)E@%;3

A!!?C"%;3

%3"E3A);"A"%;3


87/90

FLCRM TEST

%t tests for thestress fractres ofthe shaft of femr


88/90

NOT TO FOR,ET

K;"HE );8E )%MB ;%3"'

K'2%3E

K2E EC"A) E@AM%3A"%;3


89/90

"HA3D &;?


90/90

Documents

Clinical Hip Examination