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EXAMINATION OF HIP JOINT

NAME ; identity

AGE ;

SEX; male (ctev), female (CDH)

OCCUPATION;

SOCIO ECONOMIC STATUS ;–TB hip is common in low SES

CHIEF COMPLAINTS :

1) PAIN

2) DEFORMITY AND LURCH

3) INABILITY TO WALK

4) LIMB LENGTH DESCREPANCY

AND LURCH 3) INABILITY TO WALK 4) LIMB LENGTH DESCREPANCY HISTORY OF PRESENTING ILLNESS: ‐ (it

HISTORY OF PRESENTING ILLNESS: (it includes 2 sub headings, ADL, & NEGATIVE HISTORY)

PLEASE ELOBORATE ON chief complaints

PAIN; (remember SOCRATES –SITE ,ONSET, CHARECTER, RADIATION , ASSOCIATION,TIMING ,EXCERBATING AND RELEVING FACTORS ,SEVERITY)

DEFORMITY SITE, ONSET, DURATION, PROGESSIVE OR NON PROGRESSIVE, ANY CORRECTION ATTEMPTED/associated symptoms.

ACTIVITIES OF DAILY LIVING (ADL) :is he able to sit cross legged, squatting possible or not, able to use a bicycle to work,

NEGATIVE HISTORY :This is very important, here you almost come to a diagnosis by ruling out things that has caused his problems, pls rule outNeglected TRAUMA(non unions, #NOF, #TROCH, Pain in multiple joints(Rheumatoid), Constitutional symptoms loss of weight , appetite, evening rise in temperature(tuberculosis), Fever(septic), long consumption of drugs eg steroids, alcohol ,(AVN hip) anti epilepsy drugs(osteoporosis) , obesity and endocrine disorders in children( SCFE),Painful crisis in hip (sickle cell anemia) bleeding PR ( ulcerative colitis), back pain and stiff neck(Ankylosing spondylitis)

PAST HISTORY: Any previous accidents, or operations on hip (non unions of neck and trochanter, Septic arthritis hip), Old history of tuberculosis, rheumatoid, bleeding diasthesis, DM, HTN,

PERSONEL HISTORY:Smoking, Alcohol, diet,

FAMILY HISTORY: TB, RHEUMATIOD, CDH, ANKYSPONYLITIS,DWARFISM,ANGULAR DEFORMITIES

Smoking, Alcohol, diet, FAMILY HISTORY: ‐ TB, RHEUMATIOD, CDH, ANKY ‐ SPONYLITIS,DWARFISM,ANGULAR DEFORMITIES

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Page 2 OBSTRETIC HISTORY: ‐ FTND – breech (CDH) , HOSP OR HOME DELIVERY(Septic arthritis sequel),

OBSTRETIC HISTORY: FTND breech (CDH) , HOSP OR HOME DELIVERY(Septic arthritis sequel), BCIAB,

IMMUNISATION HISTORY: ‐‐ Complete or Incomplete,

GENERAL PHYSICAL EXAMINATION :

PICKLE(++++++),

SYSTEMS SCREENING ; HMF,CNS, CVS,RS,PA,SPINE(Scoliosis, tuft of hair, spina bifida,neurocutaneous markers ,coast of maine,)(kindly do a PR examination in hip caseprotrusio acetabuli )

LOCAL EXAMINATION :Standing position or Supine position

GAIT:

Bi pedal, (yes or no )

Aided or unaided,(uses a crutch , walker or not )

stable or unstable, ( lurching towards right or left side)

co ordinated ,(is he able to walk in a single line )

Antalgic(painful) or painless

ATTITUDE ; (Defn; its position of ease) The Patient in supine position,

Look for exaggerated lumbar lordosis(look for concealed FFD), then ASIS(Same or different level) (to find ADD and ABD deformities), comment on position of the limb starting from HIP,KNEE,ANKLE,FOOT(is it in flexion or extension, comment whether the limb is in external or internal rotation)

(egin a trochanteric fractureThe patient in supine position ,no exaggerated lumbar lordosis,ASIS at same level ,the limb is in external rotation with the hip in 30deg flexion , knee in 15 deg flexion, ankle in 5 deg plantar flexion and the outer border of foot touching the bed ‐‐ is the attitude in supine positon)

INSPECTION ;should be done 1. ANTERIORLY, 2. LATERAL SIDE,3. POSTERIOR SIDE, 4. MEDIAL SIDE,

1. ANTERIORLY

ASIS Comment on the Level,

Comment on Any fullness in the scarpa s triangle (bound medially by adductor longus, laterally by Sartorius, base by inguinal ligament), any scars, discharging sinuses,

Then look for wasting of quadriceps muscle (it’s a tell tale sign of any pathology in hip or knee vastus medialis is first muscle in quadriceps to get wasted) (thigh folds symmetry in children only asymmetry seen in CDH)

LEVEL OF PATELLA ; is it at Same level as the opposite side, facing of patella towards the roof normal, facing the angle of the roof, or the wall on that side,

side, facing of patella ‐ towards the roof normal, facing the angle of the roof, or
side, facing of patella ‐ towards the roof normal, facing the angle of the roof, or

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Comment on fullness in suprapatellar fossa, parapatellar and infrapatellar fossae

Then any wasting in calf ,

Limb length discrepancy: apparent shortening or lengthening,

discrepancy: ‐ apparent shortening or lengthening, 2.&3. FROM THE SIDE: ‐ Exaggerated Lumbar

2.&3. FROM THE SIDE: Exaggerated Lumbar lordosis ,Prominence of trochanter lost(protrusion) or present, supra trochanteric fossa , scars , sinuses,

4 .FROM THE BACK:Look for gluteal folds, scoliosis, (symmetry in children) and wasting(gluteal ) in adults .

PALPATION ;

Superficial palpationlocal raise in temperature(septic hip) and increased superficial tenderness(seen in cellulitis)

Deep palpation – Tenderness in scarpa triangle , Antr hip joint line , over the trochanter, posterior hip joint line ( obers point).

Bony palpation; look for level of trochanter ( Digital Bryands triangle ), tenderness over trochanter, irregularity, thickening, broadening (all these is seen in malunited trochanteric #,fibrous dysplasia),

Look for(globular mass) head of femur posterior and its movement with femur(in CDH)

LOOK for Vascular sign of Narath( pulse felt –Negative, if not felt positive)

Look for inguinal Lymph Nodes both Vertical and horizontal group,

MOVEMENTS :Use goniometer (practice using it )

ASSES THE ROM

ACTIVE PASSIVE
ACTIVE
PASSIVE

FL 130, EX 10, ADD 30, ABD 45, IR30, ER45,

also check whether this rom is associated with pain(SYNOVITIS, OA,TB,), spasm(TB), crepitus (OA), mechanical block(foreign body), Differential rotations (in prone and supine position)(PERTHEs, SCFE)

DEFORMITY ASSESMENT:( what to asses and how to asses )

Saggital plane: –FFD, EXTN Deformity

Coronal plane :–ABDN & ADD Deformity

Axial plane : –ER & IR deformity

plane: – FFD, EXTN Deformity Coronal plane :– ABDN & ADD Deformity Axial plane : –

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Page 4 Deformity ; ‐ Do Thomas test, to find FFD at hip. (read and by

Deformity ;Do Thomas test, to find FFD at hip. (read and by heart Thomas test )

Pearls –what determines deformity In paralytic conditions; the overpowering muscles determines the deformity,

In non paralytic conditions; Innate tendency of postural fixity in possible position of walking that determines the deformity.

look for FFD, ADD def, ABD def, rotational def,

FIXED FLEXION DEFORMITY :PLS DO THOMAS TEST (in unilateral cases)

PRONE TEST (STAHELI TEST) (B/L hip cases)

HAMSTRING SHIFT TEST (IN CP cases) (Difference in popliteal angles )

ADDUCTION DEFORMITY : Square the pelvis firstmeans if ASIS is at higher level, implies, adduction deformity. So further Adduct the affected limb so that the ASIS of the affected limb is brought to the same level as the normal hips ASIS,

Draw a vertical line from ASIS of affected hip downward , and angle subtended between the imaginary vertical line and the line along the long axis of the thigh is the adduction deformity .(IF there is adduction deformity don’t speak about abduction anywherecos there will be no abduction at all ok)

In adduction deformity there will be

1. Apparent shortening

2. (TS<AS)(True shortening less than apparent shortening )

3. Scoliosis—convexity to the opposite side.

ABDUCTION DEFORMITY : square the pelvis first, means if ASIS is at Lower level, implies, Abduction deformity. So further Abduct the affected limb so that the ASIS of the affected limb is brought to the same level as the normal hips ASIS,

Draw a vertical line from ASIS of affected hip downward , and angle subtended between the imaginary vertical line and the line along the long axis of the thigh is the abduction deformity.

(IF there is abduction deformity don’t speak about adduction anywherecos there will be no adduction at all ok)

In Abduction deformity there will be

1.Apparent Lenthening ,

2.(TS>AS )(true shortening more than apparent shortening ),

3. Scoliosis—Convexity to the same side.

Both adduction and abduction deformities are assessed by

shortening ), 3. Scoliosis—Convexity to the same side. Both adduction and abduction deformities are assessed by

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PERKINS METHOD (standard method ) – Limbs not parallel.

KOTHARIS PARALLELOGRAMLimbs brought together (InB/L hip cases not useful)

Limbs brought together (InB/L hip cases not useful) ROTATIONAL DEFORMITY: ‐ Examination should be done

ROTATIONAL DEFORMITY: Examination should be done in supine and prone position, and Axis deviation test(in scfe)

Differential rotation is seen in perthes, AVN hip,OA hip.

MEASUREMENTS ;‐‐‐ Done with a measuring tape, expressed in centimeter, or using wooden block

1.

Linear measurement ( apparent length, true length, segmental measurement )( screening test for segmental shortening is Allis gallezi sign)

2.

Segmental measurement

Asses (femur)

Supratrochanteric shortening – bryants , nelatons, shoemakers line

Infratrochanteric shortening tip of trochanter to lateral knee joint line .

Asses (Tibia) In tibia medial knee joint line to tip of medial malleolus gives tibial length,

Elaboration of tests in segmental measurements

BRYANTS TRIANGLE ;–Not useful in bilateral hip cases, fig

,

ASIS

;–Not useful in bilateral hip cases, fig , ASIS TIP OF TROCHANTER An imaginary line from

TIP OF TROCHANTER

An imaginary line from ASIS vertically down, and A line from tip of greater trochanter to ASIS, connect the tip of greater trochanter to imaginary vertical line,

Impression;it’s a triangle now ,

1.if horizontal line ‘ X ’ is short, there is upriding of trochanter means supra trochanteric shortening

,2.

2.

If vertical line ‘ Y ’is short , there is internal rotation in the limb, seen in post dislocation of hip,

3.

if obtunese line ‘ z ’is short , then there is internal migration of hip as seen in protrusio acetabuli.

NELATON LINE – Useful in bilateral hip

ASIS

NELATON LINE – Useful in bilateral hip ‐ ASIS * (Tip of troch graces this line

* (Tip of troch graces this line )

ISCHIUM

A line drawn from ischial tuberosity to ASIS, it grazes the tip of greater trochanter,

Impression ;

1.Usually meets in the centre above the umbilicus,

2. in upriding trochanter it meets below the umbilicus

; 1.Usually meets in the centre above the umbilicus, 2. in upriding trochanter it meets below

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Page 6 CHIENE S LINE ; ‐ A Line joining both ASIS,and a second line joining

CHIENE S LINE ;A Line joining both ASIS,and a second line joining both tips of gr trochanter,it should be parallel, if not there is a upriding of trochanter.

ASIS…………………………………ASIS

TRO………………………….……….TRO

MORRIS BI TROCHANTERIC LINE ;Distance between tip of trochanter to pubic symphisis, using a caliper.

Circumferential measurements:( At the thigh at a fixed point from greater trochanter,where there is maximum muscle bulk, and In the calf at a fixed point from knee joint line where there is maximum muscle bulk, )‐‐‐ this is to check wasting of muscles

Quadriceps muscle is very sensitive and tell tale sign of any pathology in hip and knee it gets wasted first, of the four muscles, vastus medialis is wasted first,

Quadriceps wastingfixed point on thigh where there is maximum muscle bulk, and for calf muscle wasting –fixed point on leg from knee joint line where there is maximum muscle bulk,

CONCLUSION IN MEASUREMENTS; PLS say whether it’s a supra trochanteric or infratrochanteric shortening in cms.

SPECIAL TESTS :(ADD WHICH EVER IS RELEVANT FOR THAT PARTICULAR CASE)(e.g.; in #NOF, add telescopic, trendlenburg,)

1. SLR

2. TELESCOPIC TEST in #nof,

3. TRENDLENBURG TEST eat dring and swallow trendlenburg test

4 .ORTOLANI , GALLEZI SIGN,BARLOW TEST done in DDH

5. GAUVAINS SIGN; In early TB, on rotation of hip, abd muscles will go into spasm.

6. NARATH SIGN ( done in #NOF)

7. PATRICK TEST (FL+ABN+ER)pathology in SI.

8. CRAIG TEST for anteversion

9. ELYS TEST to detect rectus femoris contracture

10. OBER TEST( done in ITB contracture)

11. HART SIGNin CDH

12. AXIS DEVIATION TEST( seen in scfe, )

13.SECTORAL SIGN (AVN)

14.ANTERIOR IMPINGEMENT TEST (FADDIR)(FL, ADD,IR)

AXIS DEVIATION TEST( seen in scfe, ) 13.SECTORAL SIGN (AVN) 14.ANTERIOR IMPINGEMENT TEST (FADDIR)(FL, ADD,IR)

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15.POSTERIOR IMPINGEMENT (HEABER)(HYPEREXTN,ABDN,ER)

16. PIRIFORMIS TEST (FAIR)(FL,ADD, IR) (DONE IN PIRIFORMIS SYNDROME ).

TEST (FAIR)(FL,ADD, IR) (DONE IN PIRIFORMIS SYNDROME ). EXAMINATION OF OTHER JOINTS; ‐ examine ,OPPOSITE HIP,

EXAMINATION OF OTHER JOINTS;examine ,OPPOSITE HIP, it might me B/L affection. SI JOINT .

EXAMINATION OF PERIPERAL BLOOD VESSELS,NERVES, AND REGIONAL LYMPH NODES:

DIAGNOSIS:IT’S A MILLION DOLLAR QUESTION, IT CAN BE ANYTHING, SO DON’T LOOK AT THE X RAY, BEFORE HAND, U WILL GET POSSESED BY THE X RAY(MOHINI).AND U START MAKING A CASCADE OF MISTAKES TO MATCH UR FINDINGS TO THE X RAY AND U WILL DELEBRATELY FAIL IN THE EXAM, DON’T DO IT.MAKE A DIFFERENTIAL DIAGNOSIS,WITH YOUR EXAMINATION FINDINGS

1. MAKE A ANATOMICAL DIAGNOSIS : Means to which anatomical part your finding is related eg, hip , neck, trochanter ,subtrochanter, etc

2. PATHOLOGICAL DIAGNOSIS :It can be either a SYNOVITIS, ARTHRITIS, OR ANKYLOSIS, DISLOCATION, OSTEOMYELITIS, malunion, Nonunion.

PEARLS; If shortening is minimal eg of about 0.5 to 1 cm, it makes sense to give a diagnosis of an arthritis,

If the shortening is of about 2 3 cms, it makes sense t o give a diagnosis of malunion, protrusion depending on associated findings,

If the shortening is more than 5 cms, it makes sense to give a diagnosis of CDH, septic sequeale hip.

INVESTIGATIONS;

1.LABORATORY; Hb, Wbc, TcDc, Esr,CRP.

2.RADIOLOGICAL ;–A plain x ray of pelvis with both hip, and lat view

3.SPECIAL INVESTIGATIONS; MRI (in AVN hip)

;–A plain x ray of pelvis with both hip, and lat view 3.SPECIAL INVESTIGATIONS; ‐ MRI

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SELF NOTES

Page 8 SELF NOTES
Page 8 SELF NOTES