Examination of the Hip

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

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