1. بسم الله الرحمن الرحيم

3. SYMPTOMS
Pain
Stiffness
Deformity
limping

4. How to Start IPEEP INTRODUCE. PERMISSION. EXPLANTION. EXPOSURE.
POSITION.

5. The Apley System All joint examinations follow this system: Look Feel
Move : Active then Passive
Special Tests
Radiograpgy.

6. Steps in clinical examination
Setting the pelvis square
This is an important preliminary step.
Determine from the position of
the anterior superior iliac spines whether Or not the pelvis is lying
Square.
adduction or abduction at one or other hip If this is impossible it means that there is in correctible
in that event the fact that
the pelvis is tilted should be noted and borne in mind during the
subsequent steps of the examination.

9. 1. LOCAL EXAMINATION OF THE HIP REGION

10. (Patient recumbent)

11. Inspection look Bone contours and alignment Soft-tissue contours
Colour and texture of skin
Scars or sin uses

12. Front and back of pelvis/hips and legs:
any ischaemic or trophic changes
Swelling (e.g. lipoma)
Scars (previous surgery)
Sinuses (infection/neuropathic ulcers)

13. Wasting
(old polio, Carcot-Marie-Tooth) or
hypertrophy
(e.g. calf pseudo-hypertrophy in muscular dystrophy)
Deformity
(leg length inequality, pes cavus, scoliosis)

14. Palpation feel Skin temperature Bone contours
Soft-tissue contour (Assess any swellings
Assess pelvic tilt by palpating iliac crests
Local tenderness

15. Measurement of limb length

16. Real or true length
Measure from anterior superior iliac spine to medial malleolus.
(Angle between pelvis and limbs to be equal on each side)
If discrepancy found, determine site of shortening

17. Ideally it would be desirable to measure from the nor111al axis of hip movement-that is, the centre of the femoral head-but since there is no surface landmark at that point it is impracticable to do so. The measurement is therefore taken from the nearest convenient landmark namely, the anterior superior spine of the ilium. Distally, measurement is usually made to the medial malleolus.

20. to obtain an accurate comparison of their true length
measurement the two limbs must be placed in comparable positions relative to the
pelvis.
Thus if one limb is adducted and cannot be brought out to the
neutral position the other limb must be adducted through a corresponding angle by crossing it over the first limb before the measurements are Taken.

21. Similarly, if one hip is in fixed abduction the other
must be abducted through the same angle before the measurements of true length are made.

22. If there is a true leg length discrepancy
, determine which bone/segment of the lower limb is short.
It may be below or above the knee (See Galeazzi test below). .

23. Ask the patient to flex hips to about 45 o and knees to about 90 o
Ask the patient to flex hips to about 45 o and knees to about 90 o . Make sure the heels are together on the couch, with medial malleoli touching.
Look at the knees from the side to see if they are at the same level.
If one is proximal to the other, there is femoral shortening;
if one is distal to the other there is tibial shortening.

26. (a) Above trochanter
(Bryant's triangle;)

27. With the patient lying supine a
perpendicular is dropped from the anterior superior spine of the ilium
towards the couch.
A second line is projected upwards from the tip of the greater trochanter to 'meet the first line at a right angle.

28. Bryant's triangle

29. If above the knee, it may be above or below the greater trochanter.
Drop a perpendicular from the side of the ASIS and measure distance from greater trochanter to this line.
If above the trochanter,
it may be the femoral neck (varus/valgus neck)
or head (DDH):
Don't forget to ask yourself "Is the hip in joint?" as a dislocated hip will cause a positive

30. (b) Below trochanter
measure each bone

31. 'Apparent' or false discrepancy

32. 'Apparent' or false discrepancy
IT IS EQUAL TO
PELVIC TILIT +REAL LIMB LENGHT
Measure from xiphisternum to medial malleolus.
(Limbs to be parallel and in line with trunk)

36. Examination for fixed deformity
Including Thomas's manoeuvre for detection
and measurement of fixed flexion deformity

41. Technique of the maneuver
: One hand is placed behind the lumbar spine (between it and
the couch) to assess the degree of lumbar lordosis.
If there is no lordosis
when the affected limb lies flat on the couch there can be no fixed flexion deformity and there is no need to proceed with the test.
If there
is excessive lordosis, as indicated by arching of the back, it is corrected in the following way:

42. The sound hip is flexed to the limit of its range.
The limb is then pushed further into flexion, thereby rotating the pelvis on a horizontal transverse axis until the arching of the spine is
obliterated.
During this manaouvre the disordered limb, if in fixed
flexion, is automatically lifted from the couch as the lumbar lordosis is reduced .
The angle through which the thigh is raised from
the couch is the angle of fixed flexion deformity.

43. Movements

44. Movements (active and passive) Flexion Abduction; abduction in flexion
Adduction
Medial rotation
Lateral rotation

45. flexion

46. flexion

47. EXTENSION

48. ABDUCTION

49. ABDUCTION-ADDUCTION

50. ABDUCTION-ADDUCTION

51. INTERNAL ROTATION

52. Power (tested against resistance of examiner)
Estimate strength of each muscle group

53. POWER FLEXOR
ILIOPSOAS

54. POWER
EXTENSOR OF THE HIP

55. Examination for abnormal mobility
Test for longitudinal (telescopic) movement
Click test (in new-born)

56. (Patient standing) Examination for postural stability
(Trendelenburg's test)

61. Gait

62. EXAMINATION OF POTENTIAL EXTRINSIC SOURCES OF HIP SYMPTOMS
This is important if a satisfactory explanation for the symptoms is not found on
local examination. The investigation should include:
I) the spine and sacro-iliac joints
2) the abdomen and pelvis; and
3) the major blood-vessels.

63. 3. GENERAL EXAMINATION General survey of other parts of the body.
The local symptoms may be only one
manifestation of a widespread disease.

64. CLASSIFICATION OF DISORDERS IN THE HIP REGION ARTICULAR DISORDERS OF THE HIP

65. CONGENITAL DEFORMITIES
(DEVELOPMENTAL HIP DYSPLASIA)

66. ARTHRITIS Transient synovitis of children Pyogenic arthritis
Rheumatoid arthritis
Tuberculous arthritis
Osteoarthritis

67. OSTEOCHONDRITIS
Perthes' disease

68. MECHANICAL DISORDERS
Slipped upper femoral epiphysis

69. EXTRA-ARTICULAR DISORDERS IN THE REGION OF THE HIP

70. DEFORMITIES
Coxa vara

71. INFECTIONS
Tuberculosis of the trochanteric bursa

72. MECHANICAL DISORDERS
Snapping hip

73. Age at Time of Diagnosis Disease
(Years)
0 to Congenital dislocation
2 to Tuberculous arthritis; transient synovitis
5 to Perthes' disease; transient synovitis

74. 10 to 20 Slipped upper femoral epiphysis
20 to Osteoarthritis (secondary to previous Injury
or disease)
50 to Osteoarthritis (primary)