Examination of hip,final

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

Few important points before
examination proper
Introduce
yourself
consent
exposure
Female
attendant

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

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

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

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.

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

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

SWELLING
Site
Onset
Duration
Association with pain
Progression over time

Swelling around hip
 Gluteal region
1. Cold abscess
2. Femoral head
3. Soft tisue tumour
 Femoral Triangle :
1. Cold abscess
2. Lymph nodes
3. Femoral head
 Tochantric Region
1. Bursitis
2. Malunion
 Medial aspect of thigh
1. Cold abscess
2. Ruptured Iliopsoas tendon

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

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

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

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

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

Local examination of hip
Inspection
Palpation
Movements
Measurements
Special tests

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

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.

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

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

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

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

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.

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.

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

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

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

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

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.

Palpation:
 Marking of bony
points.
Superficial:Temperatu
re ,Tenderness, area of
anesthesia etc.
 Deep palpation:
Tenderness over bony
pt(ASIS,PSIS,GT,IT,Pub
is,iliac crest)
ASIS
PUBIS
GT

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

Trochanteric tenderness
Significance
 Touch – fresh troch#, acute
inflamation
 Deep pressure – healing troch#,
troch bursitis, troch. cyst, #NOF
 Thrust – transmitted tenderness in
#nof, #acetabulum, T.B hip

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.

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

EXTENSION:
 For gluteus maximus
contribution:
 Hamstring
contribution:

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

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

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

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

KOTHARI”S METHOD:
 FIXED ADDUCTION FIXED ABDUCTION
DEFORMITY
DEFORMITY.
above BELOW

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

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

True length
Prerequisites
 Pt exposed adequately
 Bony points marked
with pencil (metal end
of the tape)
 Squaring of the pelvis
 Limb in identical position

Contnd….
• Standing position
–using wooden
blocks
• Lying down
position –ASIS to
medial malleolar
tip .

Total length
(quick assessment )
 Allis or Galeazzi
sign
 Hips flexed up to 600 ,
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

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

Qualitative assessment of
shortening
 Nelaton’s line – IT to
ASIS
 Schoemaker’s line –
Troch tip to ASIS
 Chiene’s line/test
 Morris’s bitrochanteric
test

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

Tests for stability of hip
Telescopy Test
Trendelenburg’s Test
Ortolani’s test
Barlow’s Test

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

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

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

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.

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

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

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

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

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

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

0ther examination
Other joints
Per rectal examination
Neurovascular examination

Examination of hip,final

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Examination of hip,final