DR. (PROF.) ANIL ARORA MS

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1 Hip Examination DR. (PROF.) ANIL ARORA MS (Ortho) DNB (Ortho) Dip SIROT (USA) FAPOA (Korea), FIGOF (Germany), FJOA (Japan) Commonwealth Fellow Joint Replacement (Royal National Orthopaedic Hospital, London, UK) Senior Knee and Hip Replacement Surgeon Associate Director Department of Orthopaedics and Joint Replacement Max Superspeciality Hospital, Patparganj, Delhi (India)

2 Background Skeletal Anatomy

3 Background Hip Flexors Hip flexors Ilio-psoas Accessory M.

4 Background Hip Extensors: Gluteus Max Hamstrings Abductors: Medius, Minimus Adductors: Brevis, longus and magnus

5 Hip Examination Introduce yourself Take Consent for Examination Expose the patient

6 Always remember Inspection Palpation Movements Measurements Special tests Introduction

7 Inspection Scan patient from head to toe

8 Inspection Pre - requisites Flat bed / couch Adequate exposure Comfortable painless position

9 Standing- from front Level of shoulders Trunk ASIS level, Pelvic Tilt Iliac fossae Groin fold, Scarpa s Attitude of limb as a whole Knee, ankles, feet.

10 Standing- from front Scars Sinuses Fullness / swelling Muscle wasting Abnormal position / pulsations

11 Standing- from sides Iliac crest- level Supra-trochanteric depression Infra-trochanteric depression Lateral thigh mass Level of GT in relation to ASIS Knee, ankle, feet

12 Standing- from back Imaginary plumb line Shoulders, trunk, spine PSIS Gluteal folds- level Back of thigh Knee, ankle, feet

13 Standing- from back Posterior thigh muscle wasting Swelling Sinuses Scars Contractures

14 Note the scar

15 Gait Use of support Walk without support Swing phase Stance phase Time spent in each phase Level of shoulders, trunk. Hip, knee, ankle, feet

16 Gait Antalgic Short Limb Trendelenburg Waddling Stiff hip In-toeing Out-toeing

17

18 Trendelenberg Test Patient s back to the examiner Patient stands on the normal leg Opposite hip extended Opposite knee flexed Shall stand for 30 seconds. The pelvis should remain level or tilt slightly upwards on the unsupported side.

19 Standing on normal side

20 Trendelenberg Test Patient then stands on affected leg Opposite Hip extendedd, Knee flexed If the pelvis tilts downwards on the unsupported side, then this confirms a positive sign.

21 Trendelenberg Test

22 Indirect Trendelenberg

23

24

25 Trendelenberg Test Assess the ability of the hip abductors to stabilise the pelvis on the femur. Causes of positive test- Disturbance in pivotal mechanism Dislocation or subluxation of hip Shortening of femoral neck

26 Trendelenberg Test Disturbance in effort Myopathy, neuropathy- abductors Disturbance in effort (lever) arm Fracture neck femur, I/T #

27 Trendelenberg Test Fallacies Bear wt on affected extremity for at least 30 seconds Bilateral cases- difficult to interpret Grotesque deformity (Mainly fixed abduction deformity)

28 Sitting Squatting Sitting cross-legged ( For functional assessment)

29

30 Inspection-lying down-supine Exaggerated lumbar lordosis ASIS level Swelling/ scar/ sinuses in Iliac fossae Attitude of limb

31 Attitude

32 Inspection-lying down-supine Swelling/scars/sinuses/abnormal pulsations in Scarpa s triangle Wasting of Quads. Level of patella Tibial Tuberosities Level of medial malleolus

33 Level of patellae, tibial tuberosities

34 Patella : assess rotation of the limb

35

36 Foot Size

37 Inspection-lying down-side Iliac crest Lumbar lordosis Trochanteric region

38

39 Increased lumbar lordosis

40 Inspection-Sides

41 Inspection from Side

42 Inspection-lying down-prone Level of PSIS Gluteal folds Wasting of glutei Swelling, scar, sinuses, MASS?? Wasting of hams Popliteal fossa Calf wasting

43

44

45 Popliteal Fossae

46 Gluteal Wasting

47 Palpation

48 Lumbar Lordosis

49 Iliac Fossae

50 Iliac crest

51 ASIS

52 Temperature

53 Tenderness

54 Narath s sign

55 Greater Trochanter

56 GT Palpation

57 GT Palpation

58 Gluteal palpation

59 Femur

60 Knee

61 Tibial Tubercle

62 Tibia

63 Medial Malleolus

64 Palpatory Bryant s

65 Palpatory Bryant s

66 Deformities

67 Performing Thomas test

68 FFD- Alternative method Alternative Method

69 Fallacies of Thomas test Hurts an already painful hip Difficult in obese patient Inaccurate in Bilateral FFD Falters with Ankylosed Knee

70

71 Squaring the pelvis- Revealing the deformity

72 Kothari s Angle

73 Kothari s Angle

74 Movements

75 Hip Flexion

76 Flexion

77 Hip Abduction and Adduction

78 Extension

79 Movements- Rotations

80 ROTATIONS- in extension

81 ROTATIONS- in flexion

82 ROTATIONS- in prone

83 ROTATIONS- in sitting

84 Measurements

85 Apparent Length

86 Apparent Measurements

87 Compare with opposite side

88 TRUE LENGTH

89 True Length

90 True Length

91 True Length

92 True Length- Alternative method

93 True Length- normal limb

94 True Length-normal limb

95 Where is the shortening

96 Bryant s Triangle

97 Bryant s Triangle

98 Supratrochanteric shortening

99 Pelvis should be square

100 Supratrochanteric Shortening..? Has the Trochanter gone up

101 Schoemaker s line

102 Schoemaker s line

103 Chiene s test

104 Nelaton s Line- Lateral position

105 ALLEN S TEST

106 Special Tests

107 Guavain s Test

108 FABER Test

109 Others. Opposite Hip SI joints Spine Both Knees Distal Neurovascular status Per Rectal Examination

110 Chest Expansion

111

112 Thank You

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