PS SESSION : EXAMINATION OF HIP

This is about PS Session for hip examination for Block 4.4 (Movement)

1. History & Physical
Exam of the Hip
DR UTKARSH SHAHI
ASSISTANT PROFESSOR
DEPARTMENT OF ORTHOPEDICS

2. REVIEW OF HIP ANATOMY
Ball and socket joint of synovial joint.
Connects the pelvic girdle to the lower limb
Made up of femoral head and acetabulum
Designed for stability and wide range of
movement
Covered with a thin layer of hyaline cartilage

3. REVIEW OF HIP ANATOMY
The articular surface of is horse-shoe
shaped and is deficient inferiorly-
acetabular notch
Has a labrum
-It a circular layer of cartilage which
surrounds the outer part of the acetabulum
making the socket deeper and so helping
provide more stability
-Acetabular labraltears are a common injury
from major or repeated minor trauma

4. REVIEW OF HIP ANATOMY
This is a strong ligament which connects
the pelvis to the femur
At the front of the joint
It resembles a Y in shape
Stabilises the hip by limiting
hyperextension

5. REVIEW OF HIP ANATOMY
Pubofemoralligament
The pubofemoralligament attaches the part of the pelvis known as the pubis
(most forward part, either side of the pubic symphysis) to the femur.
Ischiofemoralligament:
This is a ligament which reinforces the posterior aspect of the capsule
attaches the ischium to the two trochanters of the femur.
Transverse acetabular Ligament:
Bridges acetabular notch.
Ligament of head of femur: flat and triangular in shape
Lies within joint, ensheathedby synovium

6. REVIEW OF HIP ANATOMY
Gluteals:
Gluteus Maximus, Gluteus Minimus and Gluteus
Medius
Attach to the Ilium and travel laterally to insert into
the greater trochanter of the femur
Medius and Minimus abduct and medially rotate
the hip joint, as well as stabilising the pelvis
Gluteus maximus extends and laterally rotates the
hip joint

7. REVIEW OF HIP ANATOMY
Quadriceps
The four Quadricepmuscles are Vastus
lateralis, medialis, intermediusand Rectus
femoris
All attach inferiorly to the tibialtuberosity
Rectus femorisoriginates at the Anterior
Inferior Iliac Spine and acts to flex the hip
The 3 other Quad muscles do not cross the
hip joint, and attach around the greater
trochanter and just below it.

8. REVIEW OF HIP ANATOMY
Iliopsoas:
The is the primary hip flexor muscle which
consists of 2 parts
Attaches superiorly to the lower part of the
spine and the inside of the ilium
Cross the hip joint and insert to the lesser
trochanter of the femur

9. REVIEW OF HIP ANATOMY
Hamstrings:
The hamstrings are three muscles which
form the back of the thigh
Attach superiorly to the ischial tuberosity
Cause hip extension

10. REVIEW OF HIP ANATOMY
Flexors:
•Iliopsoas,
•Sartorius
•Tensor fascia lata
•Rectus femoris
•Pectineus
•Adductor longus
•Adductor brevis
•Adductor magnus
•Gracilis
Extensors:
•Hamstrings
•Adductor magnus
•Gluteus maximus
Adductors:
•Adductor longus
•Adductor brevis
•Adductor magnus
•Gracilis
•Pectineus

11. REVIEW OF HIP ANATOMY
Abductors:
•Gluteus medius
•Gluteus minimus
•Tensor fascia lata
External rotators:
•Obturator
externus,
•Obturator
internus
•Piriformis
•Quadratus
femoris
•Gluteus maximus
Internal Rotators:
•Gluteus medius
•Gluteus minimus
•Tensor fascia lata

12. REVIEW OF HIP ANATOMY
Femoral (L2,3,4)
Obturator (L2, 3, 4)
Sciatic (L4,5, S1, 2,)
WHY ARE THESE IMPORTANT???
-Referred pain to the knee can hide
hip pathology and vis versa

13. REVIEW OF HIP ANATOMY

14. HIP CONDITIONS
Injury and mechanical derangement.
Congenital and developmental abnormalities.
Infection and inflammation.
Arthritis and rheumatic disorders.
Metabolic and endocrine disorders.
Tumours and lesions that mimic them.
Neurological disorders and muscle weakness.

15. HISTORY TAKING
PATIENT DETAILS CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS PAST HISTORY
FAMILY HISTORY PERSONAL HISTORY
TREATMENT HISTORY NEGATIVE HISTORY

16. COMPLAINTS
PAIN LIMP
STIFFNESS DEFORMITY
WEAKNESS INSTABILITY
PARASTHESIA LOSS OF FUNCTION
SWELLING

17. PAIN
Site Time and mode of onset
Severity or Intensity Character or Nature
Progression Referred pain
Aggravating factors Relieving factors
Any diurnal variationAny seasonal variation

18. HIP PAIN KEY POINTS
Anterior hip pain
•Arthritis
•Hip flexor strain
•Iliopsoas bursitis
•Labral tear
Lateral hip pain
•Greater trochanteric
bursitis
•Gluteus medius tear
•Iliotibial band syndrome
(athletes)
•Meralgia paresthetica
(an entrapment
syndrome of the lateral
femoral cutaneous
nerve)
Posterior hip pain
•Hip extensor and
external rotator
pathology
•Degenerative disc
disease
•Spinal stenosis

19. REFERRED PAIN
Dermatomes
L2
L3
L4
L5
S1
S2

20. REFERRED PAIN

21. LIMP
Time of Onset
•Congenital
•Developmental
•Acquired
Duration
•Acute
•Chronic
Progression
•Progressive
•Static
•Regressive
Aggravating factors
Associated
symptoms
•Pain
•Disability
•Neurovascular
Associated Illness

22. STIFFNESS
Generalised Localised
Locking Ankylosis

23. DEFORMITY
Site
Associated Symptoms
•Neurological
•Vascular
•Articular
Amount of
disability
Time of Onset
•Congenital
•Developmental
•Acquired
Correctability
•Completely correctable
•Partially correctable
•Incorrectable

24. WEAKNESS
Site
Generalised
Localised
Type
Pure Motor
Sensorimotor
Muscular
Mixed
Duration
Acute
Chronic
Onset
Sudden
Gradual
Progression
Progressive
Static
Regressive

25. INSTABILITY
Time of Onset
•Congenital
•Developmental
•Acquired
Frequency
•Single episode
•Recurrent Aggravating factors
Associated
symptoms
•Pain
•Disability
•Neurovascular
Reducibility
•Reducible
•Irreducible Associated Illness

26. INSTABILITY
History of instability
Anterior or Posterior
Subluxation or dislocation
Aggravating factors
Repetitive movements, sports
Relieving factors/treatments tried
Rest, immobility, medications, other treatments
History of Prior Shoulder Problems or Surgeries

27. PARASTHESIA
Aetiology
Mode of
onset
Duration
Site and
Pattern
Progression
Aggravating
and Relieving
Factors

28. LOSS OF FUNCTION
Mode of onset
•Sudden
•Gradual
Duration
•Congenital
•Chronic
•Acute
Involved region
and function(s)
Progression
Associated
features

29. SWELLING
Site Shape Size
First notice
Associated Symptoms
•Pain
•Pressure
•Neurological
•Vascular
•Articular
Progression
Any other swelling Reducibility
Any discharge
•If present
•Duration
•Regular or intermittent
•Character of discharge

30. DIFFERENTIAL DIAGNOSIS
1._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

31. DIFFERENTIALS IN HIP AND THIGH
Trauma
Hip Dislocation
Femoral Head FX
Femoral Neck FX
Intertrochanteric FX
Sub trochanteric FX
Femoral Shaft FX
Distal Femur FX
Stress Fractures
Femoral Neck Stress FX
Femoral Shaft Stress FX
Tumour
Infections
Sports Conditions
Snapping Hip (Coxa Saltans)
Hip Labral Tear
Femoro-acetabular Impingement
Trochanteric Bursitis
Adductor Strain
Hamstring Injuries
Quadriceps Contusion
Rectus Femoris Strain

32. DIFFERENTIALS IN HIP AND THIGH
Paediatric Conditions
Developmental Dysplasia of
the Hip
Legg-Calve-PerthesDisease
(Coxa plana)
Slipped Capital Femoral
Epiphysis
Developmental Coxa Vara
Sacral Agenesis
Bladder Exostrophy
Avascular Necrosis
Arthritis
Osteoarthritis
Rheumatoid Arthritis
Ankylosing spondylitis
Traumatic arthritis

33. Physical
Examination
General
Examination
Systemic
Examination
Regional
Examination

34. GENERAL EXAMINATION
Vitals
•Pulse
•Blood Pressure
•Respiratory Rate
•Temperature
Consciousness Orientation Comfort level Position of Patient
Height and Weight
General
Appearance
Pallor Icterus Clubbing
Cyanosis Pupillary Reaction Lymphadenopathy Dexterity Anything specific

35. Systemic
Examination
Respiratory
System
Cardiovascular
System
Gastrointestinal
System
Central Nervous
System

36. REGIONAL EXAMINATION
•InspectionLOOK
•PalpationFEEL
•Strength TestingMOVE
•Shortening or Lengthening
•Range of Motion
•Regional measurements
MEASURE
•Depends upon specific region in considerationSPECIAL TESTS

37. EXAMINATION OF THE HIP
Observe the gait and posture.
Observe the patient in standing and lying on couch
Observe the patientfrom front, side and back.
Look for any evidence of shortening.

38. GAIT PATTERN CAUSE
ANTALGIC GAIT Time taken on affected leg is reduced>
Body weight is shifted quickly to normal leg
Hip synovitis
Incomplete fracture
Painfulhip conditions
STIFF HIP GAIT Lifts the pelvis and swing it forward with leg
in one piece
Hipjoint tuberculosis
Rheumatoid Hip
Ankylosing Spondylosis
SHORT LIMB GAIT Becomes apparent only if the affected
limb is shorter than 2 inches.
The body on affected side moves up and
down every time the weight is born on the
affected leg
CongenitalShort Femur
Shortening secondary to
fracture
TRENDELENBURG
GAIT
The body swings to affected side every
time the weight is born on normal side
Dislocated Hip
Congenital Dysplasiaof Hip
Congenital Coxa Vara
GLUTEUS MAXIMUS
LURCH
The body swings backward, every time the
weight is born on affected side
Poliomyelitis

39. INSPECTION: STANDING
Any obvious deformity
Any compensatory mechanism
Gross shortening
Muscle wasting
Any swelling
Any scar
•Active sinus
•Healed sinus
•Scars of old surgery
Trendelenburg’s Test

40. INSPECTION: LYING
Position of anterior superior iliac spine (ASIS)
Lumbar Lordosis
Position of Hip
•FABER (Flexion ABductionExternal Rotation) : Synovitis/Septic Arthritis
•Flexion Adduction Internal Rotation : Posterior Hip Dislocation
Muscle wasting
Any swelling
Any Scar

41. PALPATION
Temperature Tenderness Swelling
Thickening of
Greater Trochanter
Deformity
Position of
ASIS/PSIS

42. Palpation of Hip Joint
1.Greater Trochanter
2.Posterior Superior Iliac Spine
3.Anterior Superior Iliac Spine
4.Lateral Femoral Condyle

43. RANGE OF MOTION (ROM)
Evaluate active ROM
If movement limited by pain, weakness, or tightness, assist
passively
Evaluate bilaterally for comparison

44. RANGE OF MOTION (ROM)

45. 45
RANGE OF MOTION
Movement
Flexion
Extension (behind back)
Abduction
Adduction
External rotation*
Internal rotation*
Normal range
0-125°
0-115°
0-45°
0-45°
0-45°
0-45°

46. OTHER MEASUREMENTS
Shortening/Lengthening
Bryant’s Triangle
Shoemaker’s Line
Nelanton’s Line
Degree of existing deformity
Flexion
Abduction/Adduction
Rotation

47. BRYANT’S TRIANGLE

48. SHOEMAKER’S LINENELANTON’S LINE

49. SPECIAL TESTS
•Allis Test
•Ortolani’s Click Test
Paediatric Hip
•Anvil Test
•Telescoping
Occult Fracture
•Thomas Test
•Ely’s Test
Flexion Deformity
•Trendelenburg’s TestHip Instability
•FABER Test
•Narath Sign
Other Tests

50. ALLIS TEST
Procedure: Infant supine, flex the knees, Feet should approximate
one another on the table.
Positive Test: A difference in the height of the knees is a positive
test.
Short knee on the affected side –posterior displacement of the femoral head
or a short tibia.
Long knee on the affected side –anterior displacement of the femoral head
or increase in tibia length.

51. ALLIS TEST

52. ALLIS TEST

53. ORTALANI’S CLICK TEST
Procedure:
Infant supine.
Grasp both thighs with thumbs on the lesser trochanters.
Flex and abduct the thighs b/l.
Positive Test: Palpable or audible click is a positive sign.
The click signifies displacement of the femoral head in or out
of the acetabular cavity.

54. ORTALANI’S CLICK TEST

55. ANVIL TEST
Procedure:
Patient supine.
Tap the inferior calcaneum with your fist.
Positive Test: Local pain in the hip joint may indicate a femoral
head fracture or joint pathology.
Pain in the thigh or leg secondary to trauma may indicate a femoral, tibial, or
fibula fracture.
Pain local to the calcaneum may indicate a calcaneal fracture.

56. ANVIL TEST

57. THOMAS TEST
Procedure:
Supine patient.
Approximate each knee to the chest one at a time.
Palpate quadriceps on the un-flexed leg.
Positive Test:
No tightness –suspect restriction at the hip joint structure or joint capsule.
If tightness is palpated on the side of the involuntary flexed knee –hip flexure
contraction is suspected.

58. THOMAS TEST

59. ELY’S TEST
Procedure:
Patient prone.
Grasp ankle and passively flex the knee to the buttock.
Positive Test: If the patient has a tight rectus femoris or
hip flexion contracture, the hip on the same side will flex,
raising the buttock off the table.

60. ELY’S TEST

61. PATRICK TEST (FABER)
Procedure:
Patient supine.
Flex leg and place foot flat on table.
Grasp femur and press it into the acetabular cavity.
Cross leg to opposite knee.
Stabilize ASIS opposite and press down on knee of side tested.
Positive Test:
Pain in the hip –inflammatory process in the hip joint
Pain secondary to trauma –may indicate fracture
Pain may indicate avascular necrosis of femoral head

62. PATRICK TEST (FABER)

63. TRENDELENBURG TEST
Procedure:
Patient standing.
Grasp waist.
Thumbs on PSIS b/l.
Instruct patient to flex one leg at a time.
Positive Test:
If the patient cannot stand on one leg because of pain
If the opposite pelvis falls or fails to rise
This tests the integrity of the hip joint opposite the side of hip flexion

64. TRENDELENBURG TEST

65. VASCULAR SIGN OF NARATH
Procedure:
Patient supine.
Palpate femoral artery in femoral triangle.
Positive Test:
If the femoral pulses are not palpable : Hip dislocation
If the femoral pulses are feeble : Fracture neck of femur
Avascular Necrosis of Hip

66. VASCULAR SIGN OF NARATH

67. PROVISIONAL DIAGNOSIS
1._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

68. INVESTIGATIONS
DIAGNOSTIC
IMAGING
LABORATORY
TESTS
OTHER
SPECIALIZED
TESTS

69. DIAGNOSTIC
IMAGING
PLAIN
RADIOGRAPHS
CONTRAST
RADIOGRAPHS
SPECIALIZED
IMAGING
MODALITIES
ULTRASONOGRAPHY

70. LABORATORY
TESTS
HAEMATOLOGY
SEROLOGY
IMMUNOLOGY
ENZYME
ANALYSIS
SYNOVIAL
FLUID ANALYSIS

71. OTHER
SPECIALIZED
TESTS
BONE BIPOSY
BONE MINERAL
DENSITOMETRY
DIAGNOSTIC
ARTHROSCOPY

72. SHENTON’S ARC/LINE

73. DEFINITIVE DIAGNOSIS
1._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

75. THE END
THANK YOU