HIP JOINT HISTORY & EXAMINATION
HISTORY
PAIN
Onset
Duration
Character
Diurnal variation
•
•
•
•
§
§Pain at first step-
arthritis
§After exertion – early Osteonecrosis
§Pain localised to
groin – hip
§Anterolateral aspect of thigh- Lumbar spine
§Laterally above trochanteric
region in C Fashion-femoroacetabular impingement
•
LIMP
1st
symptom to appear in TB Hip even before Pain
Painless limp : congenital (DDH, Coxa vara,
Dysplastic disorder)
d/t healed disease with deformity( healed infection with ankylosis or
AS)
Neuromuscular disorder (polio, CP)
•
STIFFNESS( LIMITATION OF MOVEMENT)
Indicates spasm secondary to inflammatory
disorder or enthesopathy
or cartilage eburnation
Morning stiffness – noninfective inflammatory disorder
•
DEFORMITY
•Shortening
•Asso. With
pain, progression
•
SWELLING
•Small swelling- mask by muscle bulk
•Large progressive swelling- TB Hip, Acute pyogenic
infection
•Old unreduced dislocation
•
•PAST H/O
qTB
& treatment
qRespiratory,
renal, dermatological
qNeurological
disorder
q
Haematological
disorders, connective tissue disorder
qOrgan
transplantation
q
Liver disorder
qTrauma
& treatment
qCongenital/
development disorder & Treatment
qSurgery
around hip
qDiabetes,
HTN
•PERSONAL HISTORY
ØOccupation
ØDiet
ØSmoking
ØAlcohol
intake
ØAddiction
•FAMILY HISTORY
vDysplasia
vInflammatory
disorders
vStorage
disorders
•GENERAL EXAMINATION
q
qClubbing
qLymphadenopathy
– external/ internal iliac, paraaortic
qAbdomen for psoas abscess
qHaemophilia
qDysplasia
qHypermobility
syndrome
•LOCAL EXAMINATION
ØExpose
from below the nipples
ØCover
the private parts
•STANDING
GAIT
1.Trendelenberg’s gait( abduction lurch gait)
2.Short
limb gait
3.Antalgic gait
4.Waddling
gait
5.Gluteus
maximus gait(
extension lurch gait)
6.Gluteus
medius gait
7.Stiff
hip gait
•Inspection
STANDING
From
front
Knee flexion, foot pointing out/in, equinus at ankle
•
From side
•
From
behind
•
•
vAt all the sites: SEADS
v
vS: swelling
v
vE: erythema
v
vA: atrophy
v
vD: discoloration
v
vS: suppuration( scars &
sinuses)
•PAPLATION
Mark all bony points –
•
•
•
Anteriorly
ütemperature,
üASIS
Level,
ügroin
tenderness at base of scarpas triangle (2cm below & lateral to midinguinal
point)
üFemoral
pulsation (inferolateral
to midinguinal
point)
üSwelling
& abscesses,
üpalpate
femur along length
•
From side
üTrochanteric upriding
üTederness
üBroadening
üThickening
üLevel
of iliac crest
•
From back
üTenderness over SI Jt (just
distal to PSIS)
üGluteal tenderness (Short ER underlying gluteus
cause of pain)
üCoccygeal tenderness( coccycodynia)
üTenderness over ischial tuberosity
(bursitis)
üGluteal fold tenderness ( gluteus maximus
tendinitis)
üFeel for swelling
(spherical, smooth, bony hard of head
femur in dislocation) soft tissue swelling & abscesses
•
Medially
üAdductor
spasm
ü
ludloff’s sign(
tenderness over AM aspect of thigh at base of scarpa’s triangle – LT affection
•
SUPINE
CONFIRM above findings
Percussion
Firm pecussion at heel elicits pain at hip in inflammatory
condition (Anvil’s test)
•DEFORMITIES
•Fixed flexion deformity: Thomas test
Prerequisites
1.U/L
Deformity
2.No
bony ankylosis in
other hip & knee
3.Other
hip should be painless
4.Ipsilateral hip should not be very painful
5.No
fixed pelvic/ spinal deformity
•THOMAS TEST
ØStand on right side of
couch
ØPass hand behind volar side
up
ØAsymptomatic limb to flex
hip & knee to fullest obliterating lumbar lordosis
ØAsk pt to hold limb in same
position
ØPassively gently
extend affected limb at thigh to correct
overcorrection.
ØMeasure angle after
reconfirming obliteration of lordosis.
•THOMAS TEST
BILATERAL DEFORMITY
Do the test in prone position
Both lower limbs hanging off the couch
Support both thighs
Obliterate lumbar lordosis in
direct vision
Mesure
flexion deformity from imaginary horizontal parallel to floor
•THOMAS TEST
Drawbacks
Coexisting abduction/adduction deformity
Painful hip
Obese & uncooperative pts
Difficult to do prone test
Principle
•Fixed sagittal plane deformity is compensated by pelvic
extension & vice versa
•
•DEFORMITIES
Fixed adduction &
abduction deformity: by squaring pelvis
•Squaring is done to remove effect of
compensation by body by reversing
deformity prooduced d/t
compensation.
•Abducting the limb in fixed abduction
deformity & vice versa
•DEFORMITIES
Fallacies of squaring pelvis
•
•Fixed rotational deformities : has to be
measured by using goniometer
•Center of heel to 2nd toe as reference
•MOVEMENTS
•Hold the pelvis firmly with left hand with
thumb at the ASIS & fingers embracing trochanter
•FLEXION
•1st
reveal deformity by THOMAS test & then passively move limb further &
measure range taking couch as reference
•ADDUCTION /ABDUCTION
•First square the pelvis
•Measure range of respective movement taking
body midline as reference
•20° abduction means 20° abduction beyond
deformity
•Rotational movements
•Measure both in extension & flexion at
hip
•Extension : measure from zero position
(patella horizontal to ceiling)
•In flexion: hip flexed at 90° & leg
parallel to midline
•EXTENSION
•In prone position
•MEASUREMENTS
APPARENT LENGTH
• in unsquared pelvis
•Limbs lying parllel
•Xiphisternum
to medial malleolus
•
TRUE LENGTH
• square pelvis
•Limbs in mirror image (flexion at hip)
•Measure from ASIS to MM
•
WASTING
•Thigh circumference 15 cm from medial knee
joint line
•
•Femoral & tibial length
•Galleazi sign & Allis test
•
BRYANT TRIANGLE
•Square pelvis
•Draw a line from ASIS Laterally horizontal
(Perpendicular to midline)
•Line joining tip of trochanter to
ASIS
•Tip of trochanter to intersect
joint 1st line(base)
•
•Femoral anteversion:
•Craig’s test, Ryder method
•Special tests
•Qualitative assesment of supratrochanteric shortening
o Nelaton’s line: lateral position
Affected side up
Flex hip to 90°
Join ischial tuberosity to ASIS
Supratrochanteric shortening: if tip of GT crosses this line
•
oShoemaker’s line
•Supine
•Join tip of trochanter to ASIS & extend it to abdomen crossing umblicus
•Similar line to opposite side
•Normally crosses at or above umblicus in
midline
•In suprotrochanteric shortening, line misses umblicus &
lies below on opposite side.
•
oChiene’s line
Lines joining both ASIS & Both trochanter –
parallel
Converge on side of upriding
•TESTS FOR STABILITY
•Active SLRT (Stinchfield’s test): indicates dislocation/ fracture of neck or
hip joint instability
•Trendlenberg test
•Telescopy
•Ortolani & barlow’s manoeuver
•TRENDLENBERG TEST
•To check integrity of abductor mechanism
comprising of head & acetabular socket as fulcrum, neck & trochanteric
region as lever
•Abductor as power
Prerequisites
•Not to be very painful hip
•No abduction/ adduction deformity
•Quadratus lumborum
–normal (affected in polio)
•Obese pt- pseudopositive
•Sacroilitis
– positive
•TRENDLENBERG TEST
•Stand behind pt
•Observe angle b/w pelvis (line joining iliac
crest) & ground
•Stand on unaffected side 1st
•Lifting affected side foot & flexing hip
b/w neutral & 30° & knee to
clear .
•Raise affected side as high as possible
•Repeat on affected side
•Normally (negative test): able to lift other
side without losing balance for at least 30 sec & lift is equal to
abduction possible at that hip.
•TRENDLENBERG TEST
Positive test
üMaximal
elevation not achieved
üSustained
elevation not achieved
üIliac
crest not elevated
üPelvis
drops down
ü
•TRENDLENBERG TEST
Gluteus medius
paralysis
Polio, L5 radiculopathy, girdle muscle dystrophy, CP
Failure
of lever
Trochanteric
avulsion, fracture neck femur, coxa vara
Failure
of fulcrum
Dislocated hip, DDH, perthes, osteonecrosis
Gluteal
inhibition
Painful hip d/t arthritis/ infection, sacroilitis
•
Ober’s test : for ITB contracture
Gauvain sign: spasm of abdominal muscle on initiating rotatory
movements of hip in active tuberculosis, seen in stage of synovitis
•
Ely’s test (rectus phenomenon)
ØTight
rectus
ØPassive
flexion of knee leads to flexion of hip
•
Noble compression test
For iliotibial band friction
Yeoman’s test
•Active hip extension
•Against resistance
•To test gluteus maximus
tendinitis
•
•
•
Phelps test
•Gracillis
tightness
•Prone position
•Abduct limbs
•flex 90° (relaxing grracillis)
•Further abduction- contracture
•
Tripod sign
•Hamstring tightness
•In sitting position
•Passively extend knee
•Patient leans back & support himself with
both hands & extension at hip
•
Piriformis test (FADIR)
•Flexion, adduction & IR
•Lateral postion stretches piriformis
•Pain in piriformis tendinitis/ syndrome.
•If pain occurs in groin- femoroacetabular impingement
•
Patrick’s test (FABER)
•FLEXION, ABDUCTION & ER at hip putting
Lateral malleolus at
patella – apin at SI
Joint
•Pain at groin - FAI
•
ERICHSON’S PELVIS
COMPRESSION TEST
•Press iliac crest together
•Pain at SI joint
Yeoman’s test for Sacroilitis
•Passive hyperextension of thigh in prone
position
•
•
Fulcrum test
•Stress fracture of femur
•Forearm below midthigh & press knee
•
Alli’s sign
•Relaxation of fascia between trochanter &
iliac crest
•Fractures of hip
Gill’s sign
•Swollen hip due to effusion feels thicker
than other hip felt with thumb at base of scarpa’s triangle & four fingers over buttocks
•
•
Ludloff’s test
•Inability to raise thigh in sitting postion
specially against resistance
•Lesser trochanter avulsion fracture
Gear stick
sign
•Limitation of abduction in extension
•improves with flexion of hip
•
•
Sectoral sign
•Osteonecrosis
•Reduced internal rotation in extension
•Improves when check in flexion
Figure of
“4” sign
•Click felt on making fig of 4 in osteonecrosis
d/t collapse of subchondral bone & left over shell of cartilage
•
•
Schober test
•Mark 2 pts
•One pt 10 cm above & other 5 cm below LS
junction
•Measure distance before & after Forward
flexion
•Increase > 5 cm normally
•
Mc Farland’s test
During flexion hip points to opposite
shoulder
In SCFE & ON – ipsilateral
shoulder
•
Per rectal
examination
•Central fracture dislocation,
•Otto pelvis
•
Distal
neurovascular examination
Sciatic nerve distribution, reflexes &
sensation
Peripheral pulses (popliteal,
anterior & posterior tibial, dorsalis pedis)
•
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