A POWERPOINT PRESENTATION OF CLINICAL EXAMINATION OF HIP JOINT USEFUL FOR ORTHOPAEDIC POSTGRADUATES

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

5. PAIN
DURATION
ONSET
PROGRESSION
GRADES OF PAIN
SITE AND NATURE
CONTINUITY
REST PAIN
NIGHT PAIN ( NOCTURNAL PAIN)
NIGHT CRY

6. SWELLING ,DEFORMITY , STIFFNESS
DURATION
ONSET
PROGRESSION –
STATIONARY
INCREASING
REGRESSING

7. LIMP
DURATION
ONSET
PROGRESSION OF LIMP (GRADES)
LIMP WITHOUT AID
LIMP WITH AID
WHEEL CHAIR BOUND
BED RIDDEN

8. PAST HISTORY
-TRAUMA
-TUBERCULOSIS
-SURGERY AROUND HIP
-HAEMATOLOGICAL/NEUROLOGICAL/
CONNECTIVE TISSUE/ SKIN DISORDERS
-DRUG INTAKE HISTORY

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

11. GENERAL EXAMINATION
• BUILT
• WEIGHT
• PALLOR
• LYMPH NODES
• STIGMATA OF RA, TUBERCULOSIS
• CHEST EXPANSION

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 )

22. PALPATION
Medially ( Commonly missed )
- Tenderness
- Contractures
Do not forget to palpate Hemi pelvis

23. DEFORMITIES
CORONAL PLANE DEFORMITIES
ABduction deformity
ADduction deformity
SAGGITAL PLANE DEFORMITIES
Flexion deformity
Extension deformity
TRANSVERSE PLANE DEFORMITIES
Internal Rotation deformity
External Rotation deformity

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.

27. ABDUCTION DEFORMITY

28. ADDUCTION DEFORMITY
• ASIS higher level
• Apparent shortening
• Convexity of lumbar spine on opposite side

29. ADDUCTION DEFORMITY

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”

31. FIXED FLEXION DEFORMITY

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

33. BILATERAL FLEXION DEFORMITY

34. STAHELI TEST
• Prone Position
• Edge of the table
• Extend the hip alternately until the pelvis
starts to move

35. PELVIC TILT - CAUSES
SUPRA PELVIC
- Scoliosis
PELVIC
- Pelvic anomalies
INFRA PELVIC
- Abduction/ Adduction deformities
- LLD

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

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.

40. Roser Nelaton’s Line

43. MOVEMENTS
• Abduction – 45 – 50 deg
• Adduction – 25 – 30 deg
• Internal Rotation – 0 - 35 deg
• External Rotation – 0 - 45 deg
• Extension – 0 - 15 deg
• Flexion – 0 - 120 deg

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 )

46. MOVEMENTS
• Global Restriction
• Sectoral Sign
• Axis Deviation (Knee Axilla Sign )
• Free ROM

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

51. SEGMENTAL MEASUREMENTS
• Supratrochanteric Shortening
- Bryants triangle
- Nelatons line
- Schoemakers line

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

53. GAIT
Lurch – Rotatory movement of trunk
Limp – Any abnormality of Gait

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.

63. DIAGNOSIS
ANATOMICAL
Synovitis
Arthritis
Coxa Vara
Unstable
Ankylosis
PATHOLOGICAL
Perthe’s
Avascular Necrosis
ETIOLOGICAL
Post Traumatic
Idiopathic

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

65. THANKS
FOR YOUR
ATTENTION