Examination of hip joint

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1. EXAMINATION OF HIP JOINT Moderator: Dr.P. Tahbildar HOD. Presenter: Dr.S.H.Ranna, PGT.

2. Few important points before examination proper

3. Professional attitude Polite Gesture Dress Handling Mobile in vibration mode.

4. Traditional steps History of symptoms. General examination Examination of Hip proper. Inspection Palpation Movements Measurements Special tests

5. History proper Pain Swelling Loss of function Loss of weight bearing Limp Limb length discrepancy

6. PAIN Site : Anterior hip pain : arthritis, hip flexor strain, ilio-psoas bursitis, lebral tear. Lateral hip pain : GT bursitis, GM tear, iliotibial band syndrome(athletes),meralgia paresthetica. Posterior hip pain : hip extensor and external rotators pathology, degenerative disc disease, spinal stenosis.

7. Pain cont.. Onset : Gradual : RA,OA, etc Sudden onset : fractures ,muscle tear ,haematoma, Any fall ? Fracture, haematoma, muscle tear Playing sports? Muscle sprain, labral tear, etc Character Sharp: muscle strain/tear, fracture Dull: OA, RA Achy: OA, RA, AVN

8. Contd.. Radiation of pain : knee ,back of thigh, leg Aggravating or relieving factors : OA gets worse as they day goes on and is relieved by rest Muscle tears/sprains may be exacerbated by movement RA is worse after prolonged periods of rest

9. SWELLING Site Onset Duration Association with pain Progression over time

10. LIMP any abnormality of normal rhythmic biphasic walking. Usually noted by kin Onset Duration Association with pain Progression Ambulatory status Stiffness Deformity Limb length disparity Paralytic disability

11. Past history: Trauma Tuberculosis Surgery around hip Skin /hematological disorders Neurological disorders Connective tissue disorder Steroid intake

12. PERSONAL HISTORY Occupation and work tolerance Diet Smoking/alcohol Menopausal history

13. FAMILY HISTORY TB in close relative Dysplasia Metabolic storage disorders Inflammatory arthritis

14. GENERAL EXAMINATION Ht/wt/BMI Fever Vital signs Pallor External iliac/inguinal lymph nodes Stigmata of rheumatoid arthritis/TB Chest expansion

15. Local examination of hip Inspection Palpation Movements Measurements Special tests

16. Inspection Should be done from the front, side and back Gait of the patient. Attitude of the upper and lower limb.

17. Gait : Simplest of all definitions “mode of walking” Normal gait is rhythmical bipedal biphasic walking in which the lumbar spine, hip and legs move in unison.

18. Types of gait : Antalgic gait : In painful hip conditions pt walks with reduced stance phase on the affected side.

19. Waddling gait: Body sways from side to side on a wide base seen in b/l DDH,pregnancy.

20. Circumduction gait In fixed abduction deformity or in hemiparesis the pt moves his limbs while dragging his body along with limb in a semi circle.

21. Gluteus maximus gait- In paralysis of gluteus maximus Pt lurches backward during stance phase.

22. Trendelenberg gait Patient lurches on the affected side and pelvis drops on to sound side.

23. Short limb gait- When the affected limb becomes short Up and down movement of half of the body. Pt lurches on the affected side with a pelvis drop on the same side.

24. Quadriceps gait In quadriceps weakness body collapses-hence the trunk goes for anterior bending to shift the vertical vector anterior to the knee to balance.

25. Toe in and toe out gait: Toe in : Pt walks with both feet turned inwards, seen in femoral antiversion. Toe out : Pt walks with both feet turned outwards- seen in femoral retroversion.

26. Attitude and Diagnosis CDH – Broadening at trochantric level, widening of the perineum, assymetry of gluteal folds Synovitis – mild flexion, abduction, Ext Rotation ,with apparent lengthening True arthritis – Flex Adduc Int Rota(FADIR) with or without true shortening Posterior dislocation – FADIR with apparent and true shortening.

27. Contd … Anterior dislocation – Flex Abd Ext Rota with apparent lengthening # NOF, Troch # - Ext Rota(more in troch #)

28. Inspection (front) Level of shoulder ASIS level Symphysis pubis Iliac fossa Scarpas triangle Groin fold Front of thigh Wasting , swelling , sinuses ,abnormal skin condition, obvious pulsations

29. Inspection (side) Iliac crest /Trochanteric region Lumbar lordosis/Gluteal bulge /supra or infratrochanteric depression & thigh ms mass Level of tip of trochanters.

30. Inspection (back) Scapula, scoliosis Iliac crest / PSIS (dimple of venus),Ischial Tuberosity region Gluteal bulge / fold /back of thigh Popliteal folds, heal Wasting/ swelling /sinus / abnormal pulsation /contracture

31. Inspection (supine) Attitude of lower limb Level of ASIS Limb length discrepancy Scarpas triangle Iliac fossa Ant. Thigh muscle Swelling,scar,skin condition,abn pulsation.

32. Palpation: Marking of bony points. Superficial: Temperature ,Tenderness, area of anesthesia etc. Deep palpation: Tenderness over bony pt( ASIS,PSIS,GT,IT,Pubis,iliac crest)

33. Deep palpation contd … Anterior hip joint(direct) Bitrochanteric compression test. Iliac crest Femoral pulse(vascular sign of Narah ) Iliac fossa Lymb nodes

34. MOVEMENTS: Should be performed in squaring pelvis. Flexion : 0 to 110-130 deg. Extension : o to 20 deg. Abduction: o to 45-55 deg Adduction: 0 to 35-45 deg Internal rotation : 30-40 deg. External rotation: 40-50 deg.

35. Flexion : Other muscle contribution Active SLRT against resistance For ilio-psoas contribution.(sitting)

36. EXTENSION: For gluteus maximus contribution : Hamstring contribution:

37. Abduction and Adduction:

38. External Rotation: In 90 degree flexion In full extension.

39. Internal Rotation: In 90 degree flexion. In full extension

40. THOMAS TEST(IN FFD) Deformity and compensation: Fixed flexion deformity – Lordosis Fixed abd . deformity – lowering of pelvis and scoliosis with convexity towards the affected side Fixed add. deformity – raised pelvis and scoliosis with convexity towards unaffected side Fixed rotational deformity – no compensation

41. CRITICISM OF THOMAS TEST Painful hip Obese or heavily built individuals B/L fixed flexion deformity of the hip In presence of ankylosed knee.

42. KOTHARI”S METHOD: FIXED ADDUCTION FIXED ABDUCTION DEFORMITY DEFORMITY.

43. MEASURMENTS: APPARENT LENGTH MEASURMENTS. TRUE LENGTH MEASURMENTS. SEGMENTAL LENGTH CIRCUMFERRETIAL MEASURMENTS.

44. Apparent measurement Helps in assessing the extent compensation developed for concealing the actual deformity . Prerequisites Lying supine comfortably Lower limbs parallel Measurement taken from central fixed point on the trunk to tip of medial malleolus No squaring of pelvis

45. True length Prerequisites Pt exposed adequately Bony points marked with pencil (metal end of the tape) Squaring of the pelvis

46. Contnd …. Standing position –using wooden blocks Lying down position –ASIS to medial malleolar tip . Limb in identical position

47. Total length (quick assessment ) Allis or Galeazzi sign Hips flexed up to 60 , knees at 90 with feet planted over the bed . Both the knees should be at the same level . Any disparity in level indicates limb length disparity

48. Localization of limb length disparity Segmental measurement Leg length Thigh length Supra trochanteric infra tro - (BRYANT’S TRIANGLE) - chanteric

49. Qualitative assessment of shortening Nelaton’s line – IT to ASIS Schoemaker’s line – Troch tip to ASIS Chiene’s line/test

50. Measurement of muscle bulk Circumferential measurements Any muscle wasting indicates chronic disease. Should be in same position.

51. Tests for stability of hip SLR Test Telescopy Test Trendelenburg’s Test Ortolani’s test Barlow’s Test

52. Telescopy Test Flex the hip to 90 deg • one hand with the thumb on ASIS and the remaining fingers over the soft tissue proximal to femur • other hand at the distal femur • push and pull the femur

53. Trendelenberg Test assess the ability of the hip abductors. A positive test demonstrates that the hip abductors are not functioning. Causes: Power : Weakness of the hip abductors e.g. myopathy , neuropathy Lever : # NOF, Troch # etc Fulcrum : Arthritis,RA,dislocation

54. ORTOLANI TEST First flexion the hips and knees of a supine infant to 90 degrees, then with the examiner's index fingers placing anterior pressure on the greater trochanters gently and smoothly abducting the infant's legs using the examiner's thumbs. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum

55. BARLOW’S MANOUVRE The maneuver is easily performed by adducting the hip while applying light pressure on the knee, directing the force Posteriorly. [ 2] If the hip is dislocatable - that is, if the hip can be popped out of socket with this maneuver - the test is considered positive.

56. Tests for hip pathology PATRIC TESTS Distinguish between SI joint and hip joint pathology. Also known as FABER TEST JANSEN’S TEST FIGURE OF FOUR TEST BUCKET HANDLE TEST

57. Anterior labral tear test TEST FOR starting anterior superior impingement syndrome Anterior labial tear Iliopsoas end tendinitis

58. POSTERIOR LABRAL TEAR TEST Starting end point

59. Craig’s test To measure femoral anteversion Also called Ryder method for measuring femoral anteversion

60. TESTS FOR JOINT CONTRACTURES OBER’S TEST: Test for ileo -tibial tract contracture. In lateral decubitus position knee is flexed to 90 degree hip is abducted to 40 degree and pelvis is stabilised. limb is gently adducted towards the examining table normally the hip adducts and the limb crosses the midline

61. ELY’S TEST for the contracture of the rectus femoris prone position with the knees extended passively flex one knee to be tested normally knee can be flexed fully in contracted rectus full flexion of the knee forces the hip into flexion causing the rise of buttocks

62. PHELP’S TEST: To detect the contracture of gracilis muscle Prone position with the knee extended Passive abduction to the maximum with the extended knee Knees are then flexed to relax gracilis Attempt to further abduct the hip with knee in flexion Further abduction is possible in gracilis contracture

63. PIRIFORMIS TEST(FADIR) Lateral decubitus position • hip is flexed to 45 degree • knee is flexed to 90 degree • one hand stabilises the pelvis • other hand pushes the knee to the floor causing the internal rotation • pain locally-piriformis tendinitis • pain radiates down-piriformis syndrome

64. 0ther examination Other joints Per rectal examination Neurovascular examination

65. Thank you….