examination of the hip
DESCRIPTION
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 … - PowerPoint PPT PresentationTRANSCRIPT
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Examination of the Hip
Prof. Mamoun KremliAlMaarefa College
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Orthopedic ExaminationThe system to use:
LookFeelMoveSpecial tests
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LookGeneral 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…
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LookGeneral on patient :
Lying comfortably in bed not in pain
Lying supine, in pain, holding Rt thigh in flexion
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LookGeneral on patient :
Lying uncomfortably in bed with Rt hip adducted & internally rotated, and Lt hip abducted & externally rotated.
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LookGeneral on patient :
Sitting uncomfortably on a wheel chair, with both hips adducted (scissoring) and Lt hip extended.
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LookGeneral local (hip-
thigh-LL):Position
Abduction / Adduction
Flexion / ExtensionExternal / Internal
Rotation
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LookGeneral local (hip-
thigh-LL):Lumbar lordosis
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LookGeneral local (hip-
thigh-LL):Major deformity-
swelling: Lateralized contourAsymmetrical skin
folds Wide perineum Masses
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LookWide
PerineumLateralized
Contour
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LookGeneral local (hip-
thigh-LL):Extra:
CastSplint
www.oandp.com/
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LookGeneral local (hip-
thigh-LL):Extra:
Skin traction Skeletal traction
www.aidacare.com.au/
www0.sun.ac.za/ortho www.orthopreneurpub.com/
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LookGeneral local (hip-
thigh-LL):Extra:
OrthoticsAFOKAFOHKAFO
Dressings
www.integratif.com.sg/
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LookAnatomic 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) !!!
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LookGeneral 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…
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LookImportant Considerations (more so in hip):
Amount of exposureDuration of exposurePersons present during exposurePlace of exposureAttitude and behavior during exposure
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FeelTenderness:
GeneralizedSpecific
Temperature: compare distal/proximal, Rt / Lt.
Anatomic:Skin: dryness, hyper/hypothesia, scarsSubcut.: LN, nerves, vessels, tendons, nodulesMuscle: tone, bulk, twitches, gaps, tendernessBone: landmarks (ASIS, Gr Tr. , Isch. Tub.) tenderness, mass,
crepitusJoint: swelling, effusion, crepitation, synovial thickening, joint
line tenderness (hip joint too deep to elicit)
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MOVEActive Vs. Passive
Usually passive unless there is a specific reason:Need to assess the painless / painful range of motionNeed to assess muscle power
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MoveMust differentiate between true hip joint motion
and pelvic motion
Must stabilize the pelvis in neutral position
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Move – FlexionInitial (resting) position could only be
determined by a special test: Thomas Test
1. Check for Lumbar lordosis2. Flex other hip fully3. Lumbar lordosis disappears4. Check position of hip5. Flex hip to check range40o FFD
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Move – FlexionInitial (resting) position could only be
determined by a special test: Thomas Test
30o FFD
Range of motion of Rt hip:(Flexion: 300-900 )
• From 30o Fixed Flexion• To 90o Flexion
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Move – Flexion / ExtensionInitial (resting) position could only be
determined by a special test: Thomas Test
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Move – Extension
In Lateral Position:
In Prone Position:
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Move - ExtensionIn presence of fixed flexion deformity:
Extension is already in “minus”
No need to assess !
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Move – Abduction / AdductionMust 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 tableFeeling ASIS to assess pelvic motion
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Move – Abduction / AdductionOn both hips simultaneously
Stabilize pelvis and compare both sides
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Move – Abduction / AdductionOn both hips simultaneously
Stabilize pelvis and compare both sides
The magic lollipop !
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Move – Abduction / AdductionStabilizing the other hip at the edge of couch
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Move – Abduction / AdductionHolding ASIS to assess beginning of pelvic
motion
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Move – internal / external rotation
Must stabilize and prevent pelvic motion
Performing the motion on both hips simultaneously.
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Move – internal / external rotation
1) Patient supine & hip extended
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Move – internal / external rotation
2) Patient supine & hip flexed
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Move – internal / external rotation
3) Patient prone – hip extended
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Special testsThomas test
Trendelenburgh test
Leg length assessment
Instability tests in neonates: (Ortolani / Barlow)
Gait – walking
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Thomas TestPositive Thomas test in neonates and young
children is normal
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Thomas TestPrecaution when knee has fixed flexion deformity
Solution keep knee outside edge of couch
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Trendelenburgh test
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Trendelenburgh test
www.dartmouth.edu
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Trendelenburgh test
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Trendelenburgh test
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Trendelenburgh testYou 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
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Trendelenburgh test Causes of Positive Trendelenburgh:
Weak hip abductors:paralyzed / wasted
Mechanically inefficient hip abductors:distance between origin & insertion reduced(e.g. coxa vara)
Unstable pivot of motion:hip subluxation / dislocation
Inhibited hip abductors: painful to movetrauma (sprains) / infection / irritation / tumor
Reduced range of motion:hip incongruent / stiffness / OA
Almost any disease
In the hip
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Leg length assessmentGalleizzi test
Both heels have to be at the same level
www.aafp.org
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Leg length assessmentTrue Length
ASIS to Medial Malleolus
Apparent Length
Midpoint to Medial Malleolus
Affected by pelvic tilt
Not affected by pelvic tilt
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Leg length assessmentTrue Length
ASIS to Medial Malleolus
Apparent Length
Midpoint to Medial Malleolus
Affected by pelvic tilt
Not affected by pelvic tilt
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Leg length assessmentTrue Length
ASIS to Medial Malleolus
Apparent Length
Midpoint to Medial Malleolus
Affected by pelvic tilt
Not affected by pelvic tilt
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Neonatal Examination for CDHOrtolani Test: (reduces a dislocated hip)
Feel a clunk
Not hear a click !
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Neonatal Examination for CDH Barlow Test: (dislocated a reduced hip)!
Feel a clunk
Not hear a click !
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Ortolani / Barlow
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Ortolani / Barlow
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Special Tests: Gait
Stance phase (60%)
Heel strikeFoot flat - mid-stancePush off
Swing phase (40%)
AccelerationMid-swingDeceleration
The Normal Gait Cycle
http://www.root2being.com/foot-function.html
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Special Tests: GaitGait Explanation
Normal Normal stance and swing phases
Antalgic Painful to weight-bear –short stance phase
Lurch Shortening – painless limping – normal stance period
Circumduction Stiff hip – motion of pelvis compensates
High Step Foot drop – more hip & knee flexion needed to free toes from ground
Tip-toe Heel off the ground
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SummarySystem of clinical examination in orthopedics
Look, Feel, Move, Special testsSub-system helps not to forget a step
Important considerations when exposing hip
In “Move”, must stabilize pelvis
Special tests Thomas, Trendelenburgh, instability, length
Gait