HIP EXAMINATION Clinical pediatric (1).pptx

Clinical examination of hip

1. Clinical examination of pediatric Hip Prof. B. Pasupathy

2. Children present differently Pain refusal to bear weight Decreased ROM Altered gait painful / painless limp Thorough history, Physical examination and understanding of paediatric skeletal problem will help in proper diagnosis & management

3. Art of Examining the Pediatric Patient Comfortable atmosphere Conversation with parents then child casual touch like handshake Observation -> examination Examination of normal limb / Examination by parents Avoid any provoking activities

4. Anatomy of Acetabulum CUP like structure Interposed between ilium above and ischium below and pubis anteriorly Outer 2/3 - Acetabular cartilage and inner 1/3 rd-Triradiate Fibrocartilaginous labrum forms at margin of acetabular cartilage Joint capsule inserts just above the labrum

5. Factors determines the Acetabular growth Presence of a spherical femoral head inside the Cup Interstitial growth within the acetabular &Tri radiate cartilage Appositional growth under the periosteum of pelvic bones Development of three secondary ossification center near puberty

6. Growth of Proximal femur Cartilaginous at birth Femoral head ossification : 4 to 7 months Growth areas : Growth plate of femoral head Growth plate of the greater trochanter Femoral neck isthmus Contributes 30% of the femoral growth

7. History Taking Unilateral / Bilateral Pathology Congenital Developmental Post Traumatic Inflammatory Infection Miscellaneous

8. Complaints Pain Limp Deformity Stiffness Shortening

9. Referred pain Localisation of pain Aggravation/Relief Associated factors Pain – Where it is coming from?

10. Limp Painful/painless Progressive / static Any treatment / alteration of activities Current level of function

11. Deformity Duration Progressive/static Painful/painless ROM

12. Shortening Gross shortening/less shortening Stable walking / unstable walking Explained by walking style / pain on the back Difficulty in Daily activities Stiffness

13. Past history antenatal / natal / postnatal Neonatal illness Milestone development Any other siblings / family history of congenital illness Trauma history ( sports activities ) Vaccination history Socioeconomical and nutritional status

14. General Examination Vital parameters Anthropometry Genetic predisposing factors excessive stiffness joint laxity Increased or decreased muscle tone

15. Functional Biomechanics Gait Squatting Single leg hopping Lunging Zig zag running Sit ups Lumbar spine SI Joint Knee and abdomen

16. Screening Examination Height Weight Head Circumference Spine Torticolis Foot Deformity

17. Gait

18. Determinants of Gait Pelvic rotation Pelvic tilt Knee flexion after initial contact in stance phase Foot and ankle motion Knee motion Lateral displacement of pelvis

19. Focused Examination In Toeing Flat foot Leg length discrepancy Spinal deformity

20. Tibial torsion:

21. Metatarsus adductus :

22. Gower’s sign

23. Observation Standing Pelvis heights Degree of lumbar lordosis Lower limb alignment Sitting/Supine Lower limb lengths & Alignment

24. Limb Length Discrepancy Asymmetric thigh/gluteal folds

25. Fixed Deformities Flexion – Thomas test

26. Range of Movements Active ROM Flexion – 120 – 135 degree Extension – 30 degree Abduction – 45 – 50 degree Adduction – 20 – 30 degree Passive ROM Rotation measured with Hip & Knee flexed to 90 degree IR + ER = 90 IR is greater with Femoral Anteversion & ER is greater with Femoral retroversion Anteversion decrease with age (30 – 15) degree

27. The Galeazzi sign.

28. Special tests Nelaton’s line Bryant’s triangle Schoemaker’s line Chiene’s line Morris bitrochanteric distance Trendelenburg test Telescopy test

29. Positive telescopy test observed in: Nonunion femoral neck fracture or intertrochanteric fracture
Chronic posterior dislocation of the hip Developmental dysplasia of the hip

30. Anterior impingement test : FADDIR (flexion, adduction, internal rotation) test
Method and interpretation: With the patient supine, the index hip is flexed to 90°, adducted, and internally rotated. Pain in the anterior part of the hip/groin indicates anterior impingement Tests for Hip Impingement

31. Anterolateral impingement test FABER (Flexion, abduction, external rotation) test Method and interpretation: With patient supine, the index hip is flexed, abducted, and externally rotated (figure-of-four position). Then, a downward force is applied to the medial aspect of the knee, forcing the hip into further abduction and extension, This may produce pain over the hip joint.

32. Posterior impingement test: HABER (Hyperextension, abduction, external rotation) test Method and interpretation: The patient lies supine and the index hip is flexed to 90°. Now gradually abduct, externally rotate, and extend the hip by letting the lower limb hang from the edge of the couch and applying a downward force at the knee. Any pain in the posterior part of the hip during this maneuver indicates posterior impingement.

33. Common Pediatric Hip Disorders

34. Congenital : Developmental dysplasia of the hip (DDH), congenital coxa vara • Developmental : Slipped capital femoral epiphysis (SCFE) • Idiopathic : Avascular necrosis (AVN) of the head of the femur, Perthes ’ disease • Traumatic : Non-union neck femur • Infective : Tom Smith arthritis, tubercular arthritis • Others : Femoroacetabular impingement (FAI)

35. Relevance of age and gender in the diagnosis of hip conditions. Age • 0–5 years: Developmental dysplasia of the hip (DDH), septic arthritis, Tom Smith arthritis • 5–10 years: TB hip, Perthes ’ disease • 10–15 years: Slipped capital femoral epiphysis (SCFE), infections, Perthes ’ disease.

36. Developmental Dysplasia of the Hip (DDH) – Predisposition

37. Developmental Dysplasia of Hip Etiology Ligamentous laxity (often inherited) Breech position (especially footling) Postnatal positioning (hips swaddled in extension) Primary acetabular dysplasia (unlikely)

38. NEONATE Dislocatable Reducible Klisic sign WALKING CHILD Remains dislocated Klisic sign Decreased abduction Galeazzi sign Limp Short leg Increased lordosis (bilateral) INFANT Dislocatable (occasionally) Reducible (occasionally) Klisic sign Decreased abduction Galeazzi sign

39. L imited abduction

40. The Galeazzi sign.

41. Limb Length Discrepancy Asymmetric thigh/gluteal folds

42. Klisic sign

43. E xcessive lordosis Trendelenburg sign and gait

44. DDH – Clinical Features Painless limp Restricted abduction ↑ Internal & External rotation Supratrochanteric shortening Positive Tests: Trendelenburg, Telescopy , Narath’s sign Barlow’s & Ortolani’s (± age dependent)

45. DDH – Diagnosis X-ray: Dislocated/ subluxated femoral head, dysplastic acetabulum out of the inferomedial quadrant formed by Perkin and Hilgrenreiner line

46. DDH – Treatment Options Pavlik harness bracing (infants) Hip spica Closed/Open reduction Varus derotation osteotomy Pelvic osteotomy

47. Developmental Coxa Vara – Presentation & Pathology Presentation: Painless limp after walking age Abnormal proximal femoral physis Triangular metaphyseal fragment (inferomedial neck)

48. Coxa Vara – Clinical Features Restricted abduction, ↑ Adduction External > Internal rotation Supratrochanteric shortening Positive: Trendelenburg Negative: Telescopy , Narath’s sign

49. Coxa Vara – Diagnosis X-ray: Neck Shaft angle <120°, Increased Hilgenreiner epiphyseal (HE) angle (normal <25°) Triangular metaphyseal fragment in infero­medial femoral neck [Fairbank`s triangle]

50. Clinical Evaluation & Idiopathic Hip Disorders Perthes Disease, SCFE, AVN

51. Legg- Calvé -Perthes Disease FACTORS THAT MAY BE ETIOLOGIC Susceptibility in a child Trauma Hyperactivity Socioeconomic deprivation Passive smoking Coagulopathy Type II collagenopathy FACTORS UNLIKELY TO BE ETIOLOGIC Hereditary factors Endocrinopathy Urban environment Synovitis

52. Perthes ’ Disease – Clinical Signs Clinical: • Restricted abduction, internal rotation (all ROM in late cases) • Narath’s sign: Negative • Supratrochanteric shortening (later stage) • Axis deviation in late cases • Trendelenburg: Positive • Telescopic sign: Negative

53. L imited abduction Combined Antalgic gait + Trendelenburg test

54. Perthes’ Disease – Diagnosis & Treatment Diagnosis: X-ray Treatment Options: • Age and stage-based • Conservative • Varus derotation or pelvic osteotomy (containment surgery)

55. Slipped Capital Femoral Epiphysis (SCFE) Affects: Obese adolescents; may have endocrine disorders Presents with: • Painful limp • Hip/knee pain • Often bilateral involvement

56. SCFE – Clinical Signs Clinical: • Adduction & external rotation deformity • Flexion, abduction, internal rotation restricted • Axis deviation present • Supratrochanteric shortening in later stage • Trendelenburg: Positive • Telescopic sign: Negative • Narath’s sign: Negative

57. Drehmann sign and axis deviation

58. SCFE – Diagnosis & Treatment Diagnosis: • X-ray • Hormonal workup (rule out hypogonadism) Treatment: • Observation • In situ pinning • Proximal femoral osteotomy

59. Avascular Necrosis (AVN) of the Hip – Overview Affects: Young adults Risk Factors: • Trauma (fracture/dislocation) • Steroids, Alcohol, Gout • Sickle Cell, Caisson’s, Goucher’s disease

60. AVN – Clinical Features Clinical: • Tender joint line • Painful, limited ROM (especially abduction & internal rotation) • Axis deviation • Sectoral sign: Positive • Narath’s : Negative • Telescopy : Negative • Slight limb shortening

61. AVN – Diagnosis & Treatment Diagnosis: • X-ray • MRI: Diagnostic Treatment: • Core decompression ± fibula graft • Total Hip Replacement (THR)

62. Femoroacetabular Impingement (FAI) – Overview Affects: Young men and women Presents with: • Hip pain during walking, sitting, sports • 'C-sign' pain indicator

63. FAI – Pathology & Clinical Features Types: • Pincer – Excess acetabular coverage → Labrum/cartilage damage • Cam – Excess bone at head-neck junction → Labrum/cartilage damage • Combined lesions (Pincer + Cam) Clinical Features: • Painful, limited internal rotation • Positive impingement tests

64. FAI – Diagnosis & Treatment Diagnosis: X-ray, MRI Treatment: • Conservative: Analgesics, physiotherapy, modify activity • Surgical: Cam debridement, labral repair, chondroplasty

65. Thank you