PS SESSION : EXAMINATION OF HIP
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This document provides an overview of the anatomy and examination of the hip joint. It begins with a detailed review of hip anatomy including bones, ligaments, muscles and nerves. It then discusses common hip conditions and outlines the components of a history and physical exam for the hip. The physical exam section describes how to inspect, palpate and perform range of motion and special tests on the hip including Bryant's triangle, Shoemaker's line, and tests for instability like FABER. Differential diagnoses for hip and thigh pain are also listed.
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PS SESSION : EXAMINATION OF HIP
- 1. History & Physical Exam of the Hip DR UTKARSH SHAHI ASSISTANT PROFESSOR DEPARTMENT OF ORTHOPEDICS
- 2. REVIEW OF HIP ANATOMY Ball and socket joint of synovial joint. Connects the pelvic girdle to the lower limb Made up of femoral head and acetabulum Designed for stability and wide range of movement Covered with a thin layer of hyaline cartilage
- 3. REVIEW OF HIP ANATOMY The articular surface of is horse-shoe shaped and is deficient inferiorly- acetabular notch Has a labrum - It a circular layer of cartilage which surrounds the outer part of the acetabulum making the socket deeper and so helping provide more stability - Acetabular labral tears are a common injury from major or repeated minor trauma
- 4. REVIEW OF HIP ANATOMY This is a strong ligament which connects the pelvis to the femur At the front of the joint It resembles a Y in shape Stabilises the hip by limiting hyperextension
- 5. REVIEW OF HIP ANATOMY Pubofemoral ligament The pubofemoral ligament attaches the part of the pelvis known as the pubis (most forward part, either side of the pubic symphysis) to the femur. Ischiofemoral ligament: This is a ligament which reinforces the posterior aspect of the capsule attaches the ischium to the two trochanters of the femur. Transverse acetabular Ligament: Bridges acetabular notch. Ligament of head of femur: flat and triangular in shape Lies within joint, ensheathed by synovium
- 6. REVIEW OF HIP ANATOMY Gluteals: Gluteus Maximus, Gluteus Minimus and Gluteus Medius Attach to the Ilium and travel laterally to insert into the greater trochanter of the femur Medius and Minimus abduct and medially rotate the hip joint, as well as stabilising the pelvis Gluteus maximus extends and laterally rotates the hip joint
- 7. REVIEW OF HIP ANATOMY Quadriceps The four Quadricep muscles are Vastus lateralis, medialis, intermedius and Rectus femoris All attach inferiorly to the tibial tuberosity Rectus femoris originates at the Anterior Inferior Iliac Spine and acts to flex the hip The 3 other Quad muscles do not cross the hip joint, and attach around the greater trochanter and just below it.
- 8. REVIEW OF HIP ANATOMY Iliopsoas: The is the primary hip flexor muscle which consists of 2 parts Attaches superiorly to the lower part of the spine and the inside of the ilium Cross the hip joint and insert to the lesser trochanter of the femur
- 9. REVIEW OF HIP ANATOMY Hamstrings: The hamstrings are three muscles which form the back of the thigh Attach superiorly to the ischial tuberosity Cause hip extension
- 10. REVIEW OF HIP ANATOMY Flexors: •Iliopsoas, •Sartorius •Tensor fascia lata •Rectus femoris •Pectineus •Adductor longus •Adductor brevis •Adductor magnus •Gracilis Extensors: •Hamstrings •Adductor magnus •Gluteus maximus Adductors: •Adductor longus •Adductor brevis •Adductor magnus •Gracilis •Pectineus
- 11. REVIEW OF HIP ANATOMY Abductors: •Gluteus medius •Gluteus minimus •Tensor fascia lata External rotators: •Obturator externus, •Obturator internus •Piriformis •Quadratus femoris •Gluteus maximus Internal Rotators: •Gluteus medius •Gluteus minimus •Tensor fascia lata
- 12. REVIEW OF HIP ANATOMY Femoral (L2,3,4) Obturator (L2, 3, 4) Sciatic (L4,5, S1, 2,) WHY ARE THESE IMPORTANT??? - Referred pain to the knee can hide hip pathology and vis versa
- 13. REVIEW OF HIP ANATOMY
- 14. HIP CONDITIONS Injury and mechanical derangement. Congenital and developmental abnormalities. Infection and inflammation. Arthritis and rheumatic disorders. Metabolic and endocrine disorders. Tumours and lesions that mimic them. Neurological disorders and muscle weakness.
- 15. HISTORY TAKING PATIENT DETAILS CHIEF COMPLAINTS HISTORY OF PRESENT ILLNESS PAST HISTORY FAMILY HISTORY PERSONAL HISTORY TREATMENT HISTORY NEGATIVE HISTORY
- 16. COMPLAINTS PAIN LIMP STIFFNESS DEFORMITY WEAKNESS INSTABILITY PARASTHESIA LOSS OF FUNCTION SWELLING
- 17. PAIN Site Time and mode of onset Severity or Intensity Character or Nature Progression Referred pain Aggravating factors Relieving factors Any diurnal variation Any seasonal variation
- 18. HIP PAIN KEY POINTS Anterior hip pain • Arthritis • Hip flexor strain • Iliopsoas bursitis • Labral tear Lateral hip pain • Greater trochanteric bursitis • Gluteus medius tear • Iliotibial band syndrome (athletes) • Meralgia paresthetica (an entrapment syndrome of the lateral femoral cutaneous nerve) Posterior hip pain • Hip extensor and external rotator pathology • Degenerative disc disease • Spinal stenosis
- 19. REFERRED PAIN Dermatomes L2 L3 L4 L5 S1 S2
- 20. REFERRED PAIN
- 21. LIMP Time of Onset •Congenital •Developmental •Acquired Duration •Acute •Chronic Progression •Progressive •Static •Regressive Aggravating factors Associated symptoms •Pain •Disability •Neurovascular Associated Illness
- 23. DEFORMITY Site Associated Symptoms • Neurological • Vascular • Articular Amount of disability Time of Onset • Congenital • Developmental • Acquired Correctability • Completely correctable • Partially correctable • Incorrectable
- 25. INSTABILITY Time of Onset •Congenital •Developmental •Acquired Frequency •Single episode •Recurrent Aggravating factors Associated symptoms •Pain •Disability •Neurovascular Reducibility •Reducible •Irreducible Associated Illness
- 26. INSTABILITY History of instability Anterior or Posterior Subluxation or dislocation Aggravating factors Repetitive movements, sports Relieving factors/treatments tried Rest, immobility, medications, other treatments History of Prior Shoulder Problems or Surgeries
- 27. PARASTHESIA Aetiology Mode of onset Duration Site and Pattern Progression Aggravating and Relieving Factors
- 28. LOSS OF FUNCTION Mode of onset • Sudden • Gradual Duration • Congenital • Chronic • Acute Involved region and function(s) Progression Associated features
- 29. SWELLING Site Shape Size First notice Associated Symptoms •Pain •Pressure •Neurological •Vascular •Articular Progression Any other swelling Reducibility Any discharge •If present •Duration •Regular or intermittent •Character of discharge
- 30. DIFFERENTIAL DIAGNOSIS 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- 31. DIFFERENTIALS IN HIP AND THIGH Trauma Hip Dislocation Femoral Head FX Femoral Neck FX Intertrochanteric FX Sub trochanteric FX Femoral Shaft FX Distal Femur FX Stress Fractures Femoral Neck Stress FX Femoral Shaft Stress FX Tumour Infections Sports Conditions Snapping Hip (Coxa Saltans) Hip Labral Tear Femoro-acetabular Impingement Trochanteric Bursitis Adductor Strain Hamstring Injuries Quadriceps Contusion Rectus Femoris Strain
- 32. DIFFERENTIALS IN HIP AND THIGH Paediatric Conditions Developmental Dysplasia of the Hip Legg-Calve-Perthes Disease (Coxa plana) Slipped Capital Femoral Epiphysis Developmental Coxa Vara Sacral Agenesis Bladder Exostrophy Avascular Necrosis Arthritis Osteoarthritis Rheumatoid Arthritis Ankylosing spondylitis Traumatic arthritis
- 34. GENERAL EXAMINATION Vitals •Pulse •Blood Pressure •Respiratory Rate •Temperature Consciousness Orientation Comfort level Position of Patient Height and Weight General Appearance Pallor Icterus Clubbing Cyanosis Pupillary Reaction Lymphadenopathy Dexterity Anything specific
- 36. REGIONAL EXAMINATION • InspectionLOOK • PalpationFEEL • Strength TestingMOVE • Shortening or Lengthening • Range of Motion • Regional measurements MEASURE • Depends upon specific region in considerationSPECIAL TESTS
- 37. EXAMINATION OF THE HIP Observe the gait and posture. Observe the patient in standing and lying on couch Observe the patient from front, side and back. Look for any evidence of shortening.
- 38. GAIT PATTERN CAUSE ANTALGIC GAIT Time taken on affected leg is reduced > Body weight is shifted quickly to normal leg Hip synovitis Incomplete fracture Painful hip conditions STIFF HIP GAIT Lifts the pelvis and swing it forward with leg in one piece Hip joint tuberculosis Rheumatoid Hip Ankylosing Spondylosis SHORT LIMB GAIT Becomes apparent only if the affected limb is shorter than 2 inches. The body on affected side moves up and down every time the weight is born on the affected leg Congenital Short Femur Shortening secondary to fracture TRENDELENBURG GAIT The body swings to affected side every time the weight is born on normal side Dislocated Hip Congenital Dysplasia of Hip Congenital Coxa Vara GLUTEUS MAXIMUS LURCH The body swings backward, every time the weight is born on affected side Poliomyelitis
- 39. INSPECTION: STANDING Any obvious deformity Any compensatory mechanism Gross shortening Muscle wasting Any swelling Any scar •Active sinus •Healed sinus •Scars of old surgery Trendelenburg’s Test
- 40. INSPECTION: LYING Position of anterior superior iliac spine (ASIS) Lumbar Lordosis Position of Hip •FABER (Flexion ABduction External Rotation) : Synovitis/Septic Arthritis •Flexion Adduction Internal Rotation : Posterior Hip Dislocation Muscle wasting Any swelling Any Scar
- 41. PALPATION Temperature Tenderness Swelling Thickening of Greater Trochanter Deformity Position of ASIS/PSIS
- 42. Palpation of Hip Joint 1. Greater Trochanter 2. Posterior Superior Iliac Spine 3. Anterior Superior Iliac Spine 4. Lateral Femoral Condyle
- 43. RANGE OF MOTION (ROM) Evaluate active ROM If movement limited by pain, weakness, or tightness, assist passively Evaluate bilaterally for comparison
- 44. RANGE OF MOTION (ROM)
- 45. 45 RANGE OF MOTION Movement Flexion Extension (behind back) Abduction Adduction External rotation* Internal rotation* Normal range 0-125° 0-115° 0-45° 0-45° 0-45° 0-45°
- 46. OTHER MEASUREMENTS Shortening/Lengthening Bryant’s Triangle Shoemaker’s Line Nelanton’s Line Degree of existing deformity Flexion Abduction/Adduction Rotation
- 48. SHOEMAKER’S LINE NELANTON’S LINE
- 49. SPECIAL TESTS •Allis Test •Ortolani’s Click Test Paediatric Hip •Anvil Test •Telescoping Occult Fracture •Thomas Test •Ely’s Test Flexion Deformity •Trendelenburg’s TestHip Instability •FABER Test •Narath Sign Other Tests
- 50. ALLIS TEST Procedure: Infant supine, flex the knees, Feet should approximate one another on the table. Positive Test: A difference in the height of the knees is a positive test. Short knee on the affected side – posterior displacement of the femoral head or a short tibia. Long knee on the affected side – anterior displacement of the femoral head or increase in tibia length.
- 51. ALLIS TEST
- 52. ALLIS TEST
- 53. ORTALANI’S CLICK TEST Procedure: Infant supine. Grasp both thighs with thumbs on the lesser trochanters. Flex and abduct the thighs b/l. Positive Test: Palpable or audible click is a positive sign. The click signifies displacement of the femoral head in or out of the acetabular cavity.
- 55. ANVIL TEST Procedure: Patient supine. Tap the inferior calcaneum with your fist. Positive Test: Local pain in the hip joint may indicate a femoral head fracture or joint pathology. Pain in the thigh or leg secondary to trauma may indicate a femoral, tibial, or fibula fracture. Pain local to the calcaneum may indicate a calcaneal fracture.
- 56. ANVIL TEST
- 57. THOMAS TEST Procedure: Supine patient. Approximate each knee to the chest one at a time. Palpate quadriceps on the un-flexed leg. Positive Test: No tightness – suspect restriction at the hip joint structure or joint capsule. If tightness is palpated on the side of the involuntary flexed knee – hip flexure contraction is suspected.
- 58. THOMAS TEST
- 59. ELY’S TEST Procedure: Patient prone. Grasp ankle and passively flex the knee to the buttock. Positive Test: If the patient has a tight rectus femoris or hip flexion contracture, the hip on the same side will flex, raising the buttock off the table.
- 60. ELY’S TEST
- 61. PATRICK TEST (FABER) Procedure: Patient supine. Flex leg and place foot flat on table. Grasp femur and press it into the acetabular cavity. Cross leg to opposite knee. Stabilize ASIS opposite and press down on knee of side tested. Positive Test: Pain in the hip – inflammatory process in the hip joint Pain secondary to trauma – may indicate fracture Pain may indicate avascular necrosis of femoral head
- 63. TRENDELENBURG TEST Procedure: Patient standing. Grasp waist. Thumbs on PSIS b/l. Instruct patient to flex one leg at a time. Positive Test: If the patient cannot stand on one leg because of pain If the opposite pelvis falls or fails to rise This tests the integrity of the hip joint opposite the side of hip flexion
- 65. VASCULAR SIGN OF NARATH Procedure: Patient supine. Palpate femoral artery in femoral triangle. Positive Test: If the femoral pulses are not palpable : Hip dislocation If the femoral pulses are feeble : Fracture neck of femur Avascular Necrosis of Hip
- 66. VASCULAR SIGN OF NARATH
- 67. PROVISIONAL DIAGNOSIS 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- 73. DEFINITIVE DIAGNOSIS 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _