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Examination of the Hip

Examination of the Hip. Prof. Mamoun Kremli AlMaarefa College. Orthopedic Examination. The system to use: Look Feel Move Special tests. Look. General  on patient. General  local (hip, thigh, leg): Position. Major deformity, swelling. Extra: cast, splint, traction, dressing …

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Examination of the Hip

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  1. Examination of the Hip Prof. Mamoun Kremli AlMaarefa College

  2. Orthopedic Examination • The system to use: • Look • Feel • Move • Special tests

  3. Look • General  on patient. • General  local (hip, thigh, leg): • 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…

  4. Look • General  on patient : • Lying comfortably in bed not in pain • Lying supine, in pain, holding Rt thigh in flexion

  5. Look • General  on patient : • Lying uncomfortably in bed with Rt hip adducted & internally rotated, and Lt hip abducted & externally rotated.

  6. Look • General  on patient : • Sitting uncomfortably on a wheel chair, with both hips adducted (scissoring) and Lt hip extended.

  7. Look • General  local (hip-thigh-LL): • Position • Abduction / Adduction • Flexion / Extension • External / Internal Rotation

  8. Look • General  local (hip-thigh-LL): • Lumbar lordosis

  9. Look • General  local (hip-thigh-LL): • Major deformity- swelling: • Lateralized contour • Asymmetrical skin folds • Wide perineum • Masses

  10. Look Wide Perineum Lateralized Contour

  11. Look • General  local (hip-thigh-LL): • Extra: • Cast • Splint www.oandp.com/

  12. Look • General  local (hip-thigh-LL): • Extra: • Skin traction • Skeletal traction www.aidacare.com.au/ www.orthopreneurpub.com/ www0.sun.ac.za/ortho

  13. Look • General  local (hip-thigh-LL): • Extra: • Orthotics • AFO • KAFO • HKAFO • Dressings www.integratif.com.sg/

  14. Look • 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 orget the posterior aspect) !!! • (All patients have a posterior aspect) !!!

  15. Look • General  on patient. • General  local (hip, thigh, leg): • 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…

  16. Look • Important Considerations (more so in hip): • Amount of exposure • Duration of exposure • Persons present during exposure • Place of exposure • Attitude and behavior during exposure

  17. Feel • Tenderness: • Generalized • Specific • Temperature: compare distal/proximal, Rt / Lt. • 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)

  18. MOVE • Active Vs. Passive • Usually passive unless there is a specific reason: • Need to assess the painless / painful range of motion • Need to assess muscle power

  19. Move • Must differentiate between true hip joint motion and pelvic motion • Must stabilize the pelvis in neutral position lordosis

  20. Move – Flexion • Initial (resting) position could only be determined by a special test: Thomas Test Check for Lumbar lordosis Flex other hip fully Lumbar lordosis disappears Check position of hip Flex hip to check range 40o FFD

  21. Move – Flexion • Initial (resting) position could only be determined by a special test: Thomas Test • Range of motion of Rt hip: • (Flexion: 300-900 ) • From 30oFixed Flexion • To 90oFlexion 30o FFD

  22. Move – Flexion / Extension • Initial (resting) position could only be determined by a special test: Thomas Test

  23. Move – Extension • In Lateral Position: • In Prone Position:

  24. Move - Extension • In presence of fixed flexion deformity: • Extension is already in “minus” • No need to assess !

  25. Move – Abduction / Adduction • Must stabilize and prevent pelvic motion • Performing the motion on both hips simultaneously. • Anchoring the knee of the other side over the edge of the examination table • Feeling ASIS to assess pelvic motion

  26. Move – Abduction / Adduction • On both hips simultaneously • Stabilize pelvis and compare both sides

  27. Move – Abduction / Adduction • On both hips simultaneously • Stabilize pelvis and compare both sides The magic lollipop !

  28. Move – Abduction / Adduction • Stabilizing the other hip at the edge of couch

  29. Move – Abduction / Adduction • Holding ASIS to assess beginning of pelvic motion

  30. Move – internal / external rotation • Must stabilize and prevent pelvic motion • Performing the motion on both hips simultaneously.

  31. Move – internal / external rotation 1) Patient supine & hip extended

  32. Move – internal / external rotation 2) Patient supine & hip flexed

  33. Move – internal / external rotation 3) Patient prone – hip extended ```` ``````

  34. Special tests • Thomas test • Trendelenburgh test • Leg length assessment • Instability tests in neonates: (Ortolani / Barlow) • Gait – walking

  35. Thomas Test • Positive Thomas test in neonates and young children is normal

  36. Thomas Test • Precaution  when knee has fixed flexion deformity • Solution  keep knee outside edge of couch

  37. Trendelenburgh test

  38. Trendelenburgh test www.dartmouth.edu

  39. Trendelenburgh test

  40. Trendelenburgh test

  41. 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, & • the trunk has to tilt to the weight-bearing side

  42. Trendelenburgh test • Causes of Positive Trendelenburgh: • Weak hip abductors: • paralyzed / wasted • Mechanically inefficient hip abductors: • distance between origin & insertion reduced (e.g. coxavara) • 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 Almost any disease In the hip

  43. Leg length assessment Galleizzi test www.aafp.org Both heels have to be at the same level

  44. Leg length assessment Apparent Length Midpoint to Medial Malleolus True Length ASIS to Medial Malleolus Affected by pelvic tilt Not affected by pelvic tilt

  45. Leg length assessment Apparent Length Midpoint to Medial Malleolus True Length ASIS to Medial Malleolus Affected by pelvic tilt Not affected by pelvic tilt

  46. Leg length assessment Apparent Length Midpoint to Medial Malleolus True Length ASIS to Medial Malleolus Affected by pelvic tilt Not affected by pelvic tilt

  47. Neonatal Examination for CDH • Ortolani Test: (reduces a dislocated hip) Feel a clunk Not hear a click !

  48. Neonatal Examination for CDH • Barlow Test: (dislocated a reduced hip)! Feel a clunk Not hear a click !

  49. Ortolani / Barlow

  50. Ortolani / Barlow

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