Thrissur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
CLINICAL EXAMINATION OF HIP JOINT
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
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/NEO
PLASTIC/DEGENERATIVE/ METABOLIC)
PATIENT’S DEMAND / EXPECTATION
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 Temperature
• Tenderness
• 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 )
24. CORONAL PLANE DEFORMITY
• ABduction / ADduction 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. ABDUCTION 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.
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”
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
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.
38. 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.
39. 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.
44. MOVEMENTS
• FIRST - ACTIVE MOVEMENTS
- Reveals painful movement
- Limits of painless movements
• LATER – PASSIVE MOVEMENTS
45. 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 )
47. 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
48. 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.
49. 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
50. MEASUREMENTS
• Adduction Deformity – further adduct
• Abduction Deformity – further abduct
• Recreate similar deformity in normal side
before measurement
52. 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
57. 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.
64. 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
