examination of the hip joint

A thorough examination of the hip joint for medical students and professionals.

1. Examination of the
hip joint
Dr. PALLAV AGRAWAL

2. CLINICAL EXAMINATION OF HIP
USEFUL IN
DDH
NEONATAL SEPTIC
ARTHRITIS
TRANSIENT
SYNOVITIS
PERTHES DISEASE
SCFE
TUBERCULOSIS
OSTEOAARTHROSIS
Avascular Necrosis
TRAUMATIC
CONDITIONS

3. EXAMINATION OF HIP

History of
symptoms
 general
examination
Inspection
Palpation
Looking for Fixed
deformities
Movements
Measurements
Special tests
Tests for instability

4. History
Age & sex
Occupation
Pain
Limp
Amount & nature of violence
Deformity & swelling
locking

5. Past history
ask for previous H/O trauma or
contact with TB
Family history
TB and rheumatism run in families

6. 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

7. Orthopedic Examination
inspection
palpation
range of motion
Special tests

8. 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…

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

10. General  on patient :
Lying uncomfortably in bed
with Rt hip adducted &
internally rotated, and Lt hip
abducted & externally
rotated.

11. General  on patient :
Sitting uncomfortably on a
wheel chair, with both hips
adducted (scissoring) and Lt
hip extended.

12. General  local (hip-thigh-LL):
Position
 Abduction / Adduction
 Flexion / Extension
External / Internal Rotation

13. General  local (hip-thigh-LL):
Lumbar lordosis

14. General  local (hip-thigh-LL):
Major deformity- swelling:
 Lateralized contour.
Asymmetrical skin folds.
 Wide perineum.
 Masses.

15. Wide Perineum Lateralized Contour

16. 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 ! )

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

18. GAIT
Simplest of all definitions “mode of
walking”

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

20. LIMPING
Limping is the most common
abnormality
Can be defined as any abnormality of
normal rhythmic biphasic walking

21. Gait cycle:
Stance phase:
Heel strike.
Mid-stance.
Push off.
Swing phase:

22. Types of gait
Antalgic gait
in painful hip conditions
pt lurches on the same side
Trendelenberg gait
pt lurches to the affected side
seen in hip dislocation, coxa vara
Waddling gait
Body sways from side to side on a wide base
Seen in b/l CDH & b/l coxa vara

23. Cont’d…
Short limb gait-
When the affected limb becomes short
Up and down movement of half of the body\
Circumduction gait-
In fixed abduction deformity
Gluteus maximus gait-
In paralysis of gluteus maximus
Pt lurches backward during stance phase

24. Gait cont’d..
Toe gait
Pt walks with both feet turned inwards- seen
in femoral anteversion

25. 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).

26. Range of motion

27. Must differentiate between true hip joint
motion and pelvic motion.
Must stabilize the pelvis in neutral
position.

28. Movements
During the measurement of movements always
fix the pelvis
Flexion- 0 to 140 degree
Extension- 0 to 15 degree
Abduction- 0 to 40 degree
Adduction- 0 to 30 degree
Internal rotation- 0 to 30 degree
External rotation- 0 to 45 degree
Circumduction-

29. MOVEMENT
Normal flexion
Normal range

30. MOVEMENT
Axis deviation

31. MOVEMENTS
Extension

32. MOVEMENTS
ADDUCTION
Normal range

33. MOVEMENTS
Abduction
In flexion
Normal range

34. MOVEMENTS
Internal rotation
In flexion
Normal range

35. MOVEMENTS
External rotation
In flexion
Normal range

36. MEASUREMENTS
Shortening
Apparent
True

37. 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

38. MEASUREMENTS
True shortening
Square the pelvis
ASIS  MEDIAL JOINT LINE KNEE  MEDIAL MALLEOLUS

39. 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

40. MEASUREMENT- circumferential
Muscle wasting

41. For injuries/pathologies around the
hip
Bryant’s
triangle

42. FIXED DEFORMITIES
Fixed flexion deformity
Concealed during walking by increase in lumbar
lordosis

43. FFD DEMONSTRATION
HUGH OWEN THOMAS’S TEST

44. 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

45. FIXED ABDUCTION &
ADDUCTION DEFORMITY
Pelvic tilt indicated by ASIS at
different level

46. FIXED ABDUCTION &
ADDUCTION DEFORMITY
D
N

47. FIXED ABDUCTION &
ADDUCTION DEFORMITY
N
D

48. FIXED ABDUCTION & ADDUCTION
DEFORMITY-
N
D
Measured by squaring of pelvis

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

50. 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

51. SPECIAL TESTS

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

53. Special Tests - Thomas test
Positive Thomas test in neonates and young children is normal

54. Special Tests - Thomas test
Thomas Test
Precaution  when knee has fixed flexion deformity
Solution  keep knee outside edge of couch

55. Special Tests - Trendelenburgh test

56. 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.

57. 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.

58. Special Tests - Leg length assessment
Galleizzi test
Both heels have to be at the same level

59. Special Tests - Leg length assessment
True Length
ASIS to Medial Malleolus
Apparent Length
Midpoint to Medial Malleolus

60. SPECIAL TESTS
Telescoping test

61. Neonatal Examination for CDH
Feel a clunk
not hear a click !
Special Tests – Ortolani test

62. Special Tests – Barlow test
Neonatal Examination for CDH
Feel a clunk
not hear a click !

63. Special Tests - Ortolani / Barlow

64. Special Tests - Ortolani / Barlow

65. NEUROVASCULAR
ASSESEMENT

66. THANK YOU