Hip, Pelvis and Thigh : Anatomy, Evaluation. BONY ANATOMY

  • View
    231

  • Download
    1

Embed Size (px)

Text of Hip, Pelvis and Thigh : Anatomy, Evaluation. BONY ANATOMY

  • Hip, Pelvis and Thigh : Anatomy, Evaluation

  • BONY ANATOMY

  • Hip Capsule LigamentsIliopsoas bursa

  • Hip - AnatomyMultiaxial ball & socket jointAcetabulum 1/2 sphereFemoral head 2/3 sphereStrong ligaments & capsuleMaximally stable

  • ObservationGaitPostureBalanceLimb positionshortened, adducted, medially rotatedabducted, laterally rotatedshortened, laterally rotatedLeg shortening

  • InspectionPelvic unleveling (iliac crest levels)Pelvic rotation (PSIS levels)If asymmetric, measure leg lengths

  • Leg Length MeasurementsEyeball methodMeasurement method

  • Range of MotionFlexion: 110 to 120 degrees

    Extension: 10 to 15 degrees

  • Abduction: 30 to 50 degrees

    Adduction: 30 degrees

  • External rotation: 40 to 60 degreesInternal rotation: 30 to 40 degrees

  • ExaminationStrength testingisometriceccentricknee extensionknee flexion

  • Hip Flexion StrengthIliopsoas, rectus femoris, sartorius, tensor fascia lata, pectineus

  • Hip Extension StrengthHamstrings, gluteus maximus

  • Hip Adduction StrengthAdductor longus, adductor brevis, adductor magnus, gracilis, pectineus, oburator externus

  • Hip Abduction TestingGluteus medius, gluteus minimus, tensor fascia lata

  • Internal Rotation StrengthGluteus medius, gluteus minimus, tensor fascia lata

  • External Rotation StrengthPiriformis, Obturator internus & externus, Superior/inferior Gemelli, Quadratus femoris, Gluteus maximus

  • Special TestsPatricks Test (FAbER)hip joint SI joint

  • Gaenslens SignPain at ipsilateral SIJ is positive test

  • Special Testsmodified Thomas Testhip flexor and quad flexibility

  • Special TestsOber Testiliotibial band flexibility

  • Special TestsPiriformis TestPiriformis flexibility or pain

  • Special TestsPopliteal AngleHamstring flexibilty

  • Special TestsLabral InjuryFAdAxL: flexion, Adduction, Axial Load + some IR/ERpain +/- click

  • Weber-Barstow Maneuver

  • Gross Leg Length DiscrepancyMagee 4thEdition pg. 628

  • Prone Knee Flexion Test for Tibial ShorteningMagee 4thEdition - pg. 630

  • Thomas Test

    3 Muscle Kendall testAs above.but also look at.IP = hip flexor and hip ERRF = hip flexor and knee extensorTFL/ITB = hip flexor and hip abductorMagee - 4th Edition

  • Elys TestProne, passive knee flexion

    Positive for RF tightness if pelvic anterior tilting / hip flexion accompanies knee flexion before end range and if asymmetrical in bilateral comparisonMagee 4th Edition

  • FAIR TestCleland, J. Orthopedic Clinical Examination

    Fishman et. al (2002) Archives of Physical Medicine 10 yr. PiriformisstudySen. .88Spec. .83+LR= 5.2-LR=.14

    (+) = pain atintersection ofsciatic nerveand piriformis

  • Ober TestMagee 4th Edition pg. 633Reese and Bandy (2003) JOSPTOber TestModified Ober Test (4-50 > Ober test)OberICC=.90Modified OberICC=.91

  • Leg Length TestsTrue Leg Length Discrepancy Measure ASIS to medial malleolusPositive = 1-1.5 cmApparent (Functional) Leg LengthUmbilicus to Medial malleolus

  • Trendelenberg TestPt Position = standing on one leg with WB leg being the involved limbPositive = pelvis on opposite side dropsIndications = weak Gluteua medius

  • Kendall TestPt Position = supine with knees bent over the tableEvaluationOne hand under lordotic curve Passively flex hip to chestAllow opposite leg to rest on tablePositive = knee move into extension or leg rises off table

  • Thomas TestPt Position = supine with both leg on tableEvaluationOne hand under lumbar regionPassively flex one leg to chestPositive = straight leg raises off tableIncreased lordotic curve

  • MeasurementsTrue leg lengthMeasure from A.S.I.S to inferior border of medial malleolus

  • MeasurementsTrue ShorteningIn true shortening the affected limb is physically shorter than the other and this may be caused by pathology proximal or distal to the trochanters.True shortening from causes distal to the trochanters most frequently results from previous fractures of the femur or tibia or growth disturbance (e.g. from polio or epiphyseal trauma). Proximal to the trochanters causes include femoral neck fractures, OA and hip dislocation.

  • MeasurementsApparent leg lengthMeasure from tip of xiphoid process to inferior border of medial malleolusApparent ShorteningIn apparent shortening the limb is not altered in length, but appears shortened. This may be as a result of an adduction contracture of the hip joint, which has to be compensated for by tilting of the pelvis, or SIJ pathology causing pelvic rotation.

  • MovementExpected Range of MovementFlexion:0-130 DegreesAbduction:0-45 DegreesAdduction:0-30 DegreesMR:0-45 DegreesLR:0-60 DegreesExtension:0-20 Degrees

  • MovementsThomas test:Place your left hand in hollow of lumbar spineFlex hip and knee of unaffected side Look to see if hip of the affected side lifts from bedFlexion:Flex hip and knee of affected side and note ROM (130)

  • MovementsAbduction:Stabilise pelvis and hold ankle with other handAbduct and note ROM (45)

    Adduction:As above and note ROM (30)

  • MovementsRotation:Flex hip and knee to 90 degrees, externally and internally rotateNote ROM (45)

    Abnormal Movement (telescoping):Alternately push and pull leg along its long axis demonstrates marked instability

  • Trendelenberg TestUsed to assess the ability of the hip abductors to stabilise the pelvis on the femur.A positive test demonstrates that the hip abductors are not functioning. Causes:Disturbance in pivotal mechanism dislocation or subluxation of hip, shortening of femoral neckWeakness of the hip abductors e.g. myopathy, neuropathy

  • Trendelenberg TestThe test is performed with the patients back to the examiner. The model stands on the normal leg and flexes the knee of the other leg to a right angle. The pelvis should remain level or tilt slightly upwards on the unsupported side.The model then stands on the affected leg and flexes the knee of the other leg. If the pelvis tilts downwards on the unsupported side, then this confirms a positive Trendelenberg sign.

  • Trendelenberg Test

    **Ilium - anterior superior iliac spine, anterior inferior iliac spine, Iliac crest, Gluteal Line, Posterior superior iliac spineIschium - Ramus of the ischium, Ischial spine, Ischial tuberosity, body weight rest in the sitting position Pubis - superior and inferior rami, Body of pubis, Pubic crestAll three forms acetabulum articulates with head of femur to form hip joint Three joints SI, Pubic symphysis, Acetabulum

    ***Head of femurLesser trochanterGreater trochanterIntertrochanteric line

    ***Illiofemoral ligament - Y ligament of Bigelow, strongest in body- Extends from the base of the AIIS to the intertrochanteric line- Prevents hyperextension, abduction, lateral rotation Pubicfemoral ligament-Extends from superior pubis ramus to the anterior surface of the intertrochantic fossa, and joins iliofemoral ligament-Reinforces the fibrous capsule inferiorly and anteriorly-Tighten during abduction and extension-Prevents overabduction

    Ischiofemoral ligament-Extends from ischial portion of the acetabulum to the neck of the femur and base of the greater trochanter-Prevents hyperextension of the hip-Fibers relaxed during flexion

    ****Ligamentum Capitis-Also known as the ligament of the head of the femur-attaches to the acetabular notch and extends to the head of the femur-weak, little to strengthen hip-80% of cases, supplies the blood for the femur head

    Acetabular Labrum-Deepen acetabulum and holds femoral head in placeArticular Fibrous Capsule-Extends from acetabular rim to intertrochanteric crest, encloses hip joint and most of femoral neck

    **sacrospinous ligament the ligament that connects the ischial spine to the lateral surface of the sacrum and coccyx together with the sacrotuberous ligament, it converts the greater and lesser sciatic notches into greater and lesser sciatic foramina, main function is to prevent posterior rotation of the ilia with respect to the sacrum. Laxity of this ligament alomg with the sacrotuberous ligament allows for this posterior rotation to occur. Stresses to these ligaments occur most often when leaning forward or getting out of a chair.

    sacrotuberous ligament the ligament that connects the ischial tuberosity to the lateral surface of the sacrum and coccyx together with sacrospinous ligament, it converts the greater and lesser sciatic notches into greater and lesser sciatic foramina, lower border of the ligament was found to be directly continuous with the tendon of origin of the long head of the Biceps femoris in approximately 50% of subjects. Biceps femoris could therefore act to stabilise the sacroiliac joint via the sacrotuberous ligament.************************