CLINICAL EXAMINATION OF HIP JOINT

A POWERPOINT PRESENTATION OF CLINICAL EXAMINATION OF HIP JOINT USEFUL FOR ORTHOPAEDIC POSTGRADUATES

1. CLINICAL EXAMINATION OF HIP JOINT DR RITESH JAISWAL M.B.B.S D.Ortho DNB (Ortho) M.N.A.M.S M.Ch (Ortho ) Fellowship in Joint Replacement ( Mumbai ) Fellow AO Trauma ( Switzerland )

2. POINTS TO REMEMBER Always examine the patient from right side. Always examine patient on hard couch. Hip cases require proper exposure ( use T Bandages ). Always respect privacy and feelings of the patient. Demonstrate on the normal side first Female attendent / Nursing staff to accompany female patient.

3. HISTORY CHIEF COMPLAINTS DURATION ONSET PROGRESSION OF THE SYMPTOMS PERTAINING TO VARIOUS AETIOLOGY CONSTITUTIONAL SYMPTOMS COMORBIDITIES HABITS TREATMENT TAKEN OCCUPATION AND RECREATIONAL DEMANDS EFFECT ON DAILY ACTIVITIES (ADL)

4. CHIEF COMPLAINTS PAIN SWELLING LOSS OF FUNCTION LOSS OF WEIGHT BEARING LIMP LIMB LENGTH DISCREPANCY

5. PAIN DURATION ONSET PROGRESSION GRADES OF PAIN SITE AND NATURE CONTINUITY REST PAIN NIGHT PAIN ( NOCTURNAL PAIN) NIGHT CRY

6. SWELLING ,DEFORMITY , STIFFNESS DURATION ONSET PROGRESSION – STATIONARY INCREASING REGRESSING

7. LIMP DURATION ONSET PROGRESSION OF LIMP (GRADES) LIMP WITHOUT AID LIMP WITH AID WHEEL CHAIR BOUND BED RIDDEN

8. PAST HISTORY -TRAUMA -TUBERCULOSIS -SURGERY AROUND HIP -HAEMATOLOGICAL/NEUROLOGICAL/ CONNECTIVE TISSUE/ SKIN DISORDERS -DRUG INTAKE HISTORY

9. PERSONEL HISTORY OCCUPATION & WORK TOLERANCE DIET SMOKING / ALCOHOL FAMILY HISTORY Tuberculosis Dysplasia Metabolic storage disorder Inflammatory Arthritis

10. SUMMARY OF HISTORY ACUTE / CHRONIC PROGRESSIVE / NON PROGRESSIVE /REGRESSIVE MONOARTICULAR / POLYARTICULAR POSSIBLE AETIOLOGY (TRAUMATIC/INFECTIVE/INFLAMMATORY/NEOPLASTIC/DEGENERATIVE/ METABOLIC) PATIENT’S DEMAND / EXPECTATION

11. GENERAL EXAMINATION BUILT WEIGHT PALLOR LYMPH NODES STIGMATA OF RA, TUBERCULOSIS CHEST EXPANSION

12. ORDER OF EXAMINATION ?? Gait Look Feel Deformity Move Measure DNVD / Lymph nodes Squatting and Crossed leg position Opposite Hip/ Ipsilateral Knee /Lumbar spine/SI joint Special Tests ?? Gait

13. HIP EXAMINATION GAIT ?? STANDING POSITION ( Front / Back / Sides ) SITTING POSITION SUPINE POSITION PRONE POSITION G A I T ??

14. INSPECTION (LOOK) Attitude Position of ease Deformity Position from which limb cannot brought back to anatomical position Wasting Soft Tissue Contour Bony Prominences Swellings Limb Length Discrepency Skin over Joint

15. ANTERIOR / FRONT EXAMINATION ASIS level : Higher/Lower/Same Abnormal fullness in scarpa’s triangle Contour and level of Greater Trochanter Contour and bulk of thigh muscles Look abnormal swelling , Scars, Sinuses

16. LATERAL / SIDES EXAMINATION Exaggerated Lumbar Lordosis Level of Trochanter Superior Migration in #NOF, #IT, DDH In Protrusio acetabuli the trochanter will be less prominent . Scars , Sinuses or any abnormal prominences

17. POSTERIOR / BACK EXAMINATION Scoliosis PSIS and Iliac Crest Symmetry of Gluteal folds Wasting of gluteal muscles Scars, Sinuses and abnormal masses

18. PALPATION Local rise of Tem perature Ten derness Feel Scars and Sinuses - Adherence to deeper structures - Adherence to bone Bony Thickening Feel for swelling and Prominences Feel for Abnormal masses

19. PALPATION Anterior Joint Line tenderness ( 2 cm below and lateral to mid-inguinal point ) Confirm level of ASIS Scarpa’s triangle – Fullness, cold abscess Vascular sign of Narath

20. PALPATION Trochanter - Tenderness ( local and thrust ) - Surface ( Smooth or Irregular ) ( Thickened or Broadened ) - Level ( Both superior – Inferior and Anterior – Posterior ) Three digit palpation of Trochanter ( Digital Bryant’s ?? )

21. PALPATION Globular bony mass Posterior joint line tenderness – look for tenderness at OBER’s POINT ( junction of medial 2/3 rd and lateral 1/3 rd of a line joining GT and PSIS )

22. PALPATION Medially ( Commonly missed ) - Tenderness - Contractures Do not forget to palpate Hemi pelvis

23. DEFORMITIES CORONAL PLANE DEFORMITIES AB duction deformity AD duction deformity SAGGITAL PLANE DEFORMITIES Flexion deformity Extension deformity TRANSVERSE PLANE DEFORMITIES Internal Rotation deformity External Rotation deformity

24. CORONAL PLANE DEFORMITY AB duction / AD duction deformity - Kothari’s Method Limbs brought Parallel - Perkin’s Method Limbs not parallel In Perkins Method limbs are taken to be abducted or adducted position depending on deformity so that Pelvis is SQUARED

25. AB DUCTION DEFORMITY Coronal plane deformity ASIS at lower level Apparent lengthening Convexity of lumbar spine on same side Correct the coronal compensatory tilt by squaring the pelvis

26. KOTHARI’s ANGLE Dr Kothari was Registrar in Grants Medical College Mumbai. His Article was published in INDIAN JOURNAL OF SURGERY.

27. AB DUCTION DEFORMITY

28. AD DUCTION DEFORMITY ASIS higher level Apparent shortening Convexity of lumbar spine on opposite side

29. AD DUCTION DEFORMITY

30. SAGGITAL PLANE DEFORMITIES FLEXION DEFORMITY Hugh Owen Thomas ’ well leg flexion test ( If opposite leg is not normal test cannot be done in a usual way ) Flex leg till lumbar lordosis obliterate Check obliteration by passing hand underneath lumbar spine ‘ with palm facing up ’ ‘ Normally there is no lordosis in supine position ”

31. FIXED FLEXION DEFORMITY

32. BILATERAL FLEXION DEFORMITY Flex both legs till lumbar lordosis obliterates. Then extends one hip at a time till pelvis just starts tilting or till lumbar lordosis just begins to reappear In associated flexion deformity at knee joint patient can be shifted at edge of the table either in flexion or extension position. Prone extension test by STAHELI In Bilateral Coronal plane deformity make the pelvis square and then use Perkin’s method

33. BILATERAL FLEXION DEFORMITY

34. STAHELI TEST Prone Position Edge of the table Extend the hip alternately until the pelvis starts to move

35. PELVIC TILT - CAUSES SUPRA PELVIC - Scoliosis PELVIC - Pelvic anomalies INFRA PELVIC - Abduction/ Adduction deformities - LLD

36. BRYANT’s TRIANGLE Mark ASIS Mark GT Drop perpendicular from ASIS to couch Measure distance from GT to perpendicular ?? Should the pelvis be squared before measuring ?? Is it useful in Bilateral hip conditions

37. BRYANT’s TRIANGLE Keep limbs in symmetrical position It is a true measurement of Supratrochanteric shortening. Unreliable in bilateral cases like COXA VARA Miss bilateral symmetrical Supratrochanteric shortening.

38. BILATERAL SUPRATROCHANTERIC SHORTENING Roser Nelaton’s Line – Pt on side , hip flexed to 90 deg ( can be done with any degree of flexion possible in patient ) and adduct to make GT more prominent Mark ASIS Mark most prominent part of ischial tuberosity ( 5cm lateral from midline and 5cm above gluteal fold ) Easily felt with flexed hip Useful in B/L cases like coxa vara Not trustworthy in severe Adduction / Abduction deformity.

39. Roser Nelaton’s Line

40. MOVEMENTS Abduction – 45 – 50 deg Adduction – 25 – 30 deg Internal Rotation – 0 - 35 deg External Rotation – 0 - 45 deg Extension – 0 - 15 deg Flexion – 0 - 120 deg

41. MOVEMENTS FIRST - ACTIVE MOVEMENTS - Reveals painful movement - Limits of painless movements LATER – PASSIVE MOVEMENTS

42. MOVEMENTS ROM associated with pain / spasm or not Terminal restriction because of pain Pain only during particular ROM Exaggerated ROM ( Ex – Extension is more in SCFE ) Exaggerated ROM all ( Ex – DDH, PPRP, Tom smith arthritis )

43. MOVEMENTS Global Restriction Sectoral Sign Axis Deviation (Knee Axilla Sign ) Free ROM

44. AXIS DEVIATION Indicates External Rotation deformity Normally on flexing hip and knee on abdomen, knee bends on same shoulder or can be pushed towards opposite shoulder. But in External rotation deformity it deviates outwards. In Intra articular pathology : - SCFE - Sectoral involvement of Femoral Head in AVN In Extra articular pathology - External rotation contracture - Gluteus Maximus contracture

45. ROTATIONAL MOVEMENTS IN KNEE & HIP FLEXION ( SUPINE ) IN KNEE & HIP EXTENSION ( STRAIGHT LYING ) IN KNEE FLEXION & HIP EXTENSION ( PRONE ) DIFFERENTIAL ROTATION Difference in degree of rotation keeping hip in Extended and Flexed position alternately.

46. MEASUREMENTS APPARENT keep the limbs parallel as possible REAL Square the pelvis Apparent also difficult if limbs are not parallel Measure from GT keeping all the joints symmetrical SEGMENTAL Limb length measurement

47. MEASUREMENTS Adduction Deformity – further adduct Abduction Deformity – further abduct Recreate similar deformity in normal side before measurement

48. SEGMENTAL MEASUREMENTS Supratrochanteric Shortening Bryants triangle Nelatons line Schoemakers line

49. TELESCOPY Patient supine Hip flexed to 45 deg ( Any degree of flexion ) Heel should rest on couch Stabilize pelvis with left hand thumb and Index finger , keeping middle finger on GT Now give pull and push with right hand holding distal end of femur Feel trochanter while checking Need assistance in bulky patient STRAIGHT LEG RAISING - Check instability around hip - Important in case telescopy is doubtful

50. GAIT Lurch – Rotatory movement of trunk Limp – Any abnormality of Gait

51. TRENDELENBURG SIGN Errors Pt cannot stand comfortably approx 30 sec Pt with LLD Pt with FIXED ADDUCTION or ABDUCTION Def. Fixed Pelvic Obliquity ASSISTED TRENDELENBURG SIGN When pt cannot stand independently Pt can stand with both feets on ground and elbows flexed to 90 deg with palm facing down Examiner stands opposite with symmetrical position with palms facing up Pt first stand on normal side On standing on affected side, pateint with positive test will push down the examiners palm on opposite unsupported side.

52. DIAGNOSIS ANATOMICAL Synovitis Arthritis Coxa Vara Unstable Ankylosis PATHOLOGICAL Perthe’s Avascular Necrosis ETIOLOGICAL Post Traumatic Idiopathic

53. WALKING STICK On oppsite hand reduces lurch Opposes body wt by Transfering body wt by stick Reduces turning moment of body wt Reduces antagonistic muscle action from the turning moment

54. THANKS FOR YOUR ATTENTION