Rashed Dawabsheh

Hip joint
Ball and socket joint Weight bearing joint Stable joint between the

femur acetabulum of the pelvis

and

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Anatomical Components:
1. Articular Capsule 2. Acetabular labrum 3. Ligaments:

Iliofemoral Pubofemoral Ischiofemoral Ligament of the head of the femur Transverse ligament of the acetabulum

Anterior view

Posterior view

Medial view with acetabular floor removed

Anterior view with capsule removed

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Bursae
thin sac of tissue that contains fluid to lubricate

the area and reduce friction that occurs between muscles, tendons, and bones

E.g. greater trochanteric bursa

can get inflammed(trochanteric bursitis) producing Lateral Superficial hip pain that may radiate down the lateral aspect of the thigh, Usually aggravated when lying on the side at night

Femoral neck angle

Surrounding Vital Structures:

Nerves:

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All of the nerves that travel down the thigh pass by the hip. The main nerves are thefemoral nervein front and thesciatic nervein back of the hip. A smaller nerve, called theobturator nerve, also goes to the hip

Blood Vessel & Blood Supply of the Joint

femoral arterypasses by the front of the hip area, and has a deep branch, called the profunda femoris. The profunda femoris sends two vessels that go through the hip joint capsule. Lateral & Medial femoral circumflex arteries These vessels are the main blood supply for the femoral head, the ligamentum teres (Ligament of the head of the femur) contains a small blood vessel hat gives a very small supply of blood to the top of the femoral head.

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Hip Joint Movements:

Flexion = 0 - 120 Extension = 0 - 20

Hip Joint Movements:

Abduction = 0 - 45 Adduction = 0 - 25

Hip Joint Movements:

Internal Rotation = 0 - 45 External Rotation = 0 - 45

History
Hip Joint Pain:

- Groin pain that may radiate to the Ant. Thigh & knee - Usually increased with activity (OA) - Pain over the greater trochanter is typically trochanteric bursitis -The buttock is not the hip! Buttock pain is typically from the sciatic nerve or lumbar spine

History
Limping can be due to:

- Pain (as in antalgic limp). - Shortening of one of the limbs. - Weakness in abductors (as in trendelenburg gait).

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History
Age:

in >70 or postmenopausal woman, there is an increased chance of neck fracture Important Questions: - How did this affect your daily activity? - How Long/Far can you walk? - Do you use any Walking Aid?

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Examination
Before Examination: 1.Introduction 2.Privacy 3.Position: for most of the exam the patient should be supine lying
4.Privacy 5.Exposure:

on a flat table. patient's hands should remain at his/her sides with the head resting on a pillow. The knees and hips should be in the anatomical position
patient's hips should be exposed so that the quadriceps muscles and greater trochanter can be assessed

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Examination
Look . Feel . Move.
Look:

- Gait (while ptn is standing) - Masses / Scars / Lesions / Signs of trauma or previous surgery - Bony alignment (rotation, leg length) - Muscle bulk and symmetry at the hip and knee

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Examination
Feel:

- Tenderness over the greater trochanter (Trochanteric Bursitis) - Assessing for fractures & Injuries look for Tenderness over: ischial spine, Pubic Rami, Lesser trochanter & ischial tuberosity

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Examination
Move:

- Internal/External Rotation:
using with leg in full extension with rolling the leg on the couch & the foot to indicate the range of rotation, and then test with knee (and hip) flexed at 90

with your hand under the back (to detect any masking of hip movement by the pelvis or lumbar spine)

- Flexion:

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Examination
your left hand on the pelvis

(Move Cont.)

- Extension: with ptns face down on the couch & with place

- Abduction/Adduction:
iliac crest to stabilize the pelvis place your left hand on the opposite

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Examination
Movement Flexion Extension Abduction Adduction External Rotation

(Move Cont.)

- Check in several positions - Compare with the contralateral side

Normal Range 0 - 120 0 - 20 0 - 45
(up to 90 in infants)

0 - 25 0 - 45 0 - 45

- Neurovascular exam

Internal Rotation

Special Tests
Thomass Test Measures fixed flexion deformity (incomplete extension) - place your hand under ptn lumbar spine - passively flex both legs (hips & knees) as far as possible - you should feel that lumber spine lordosis got eliminated - now ask the ptn to extend the test hip - Incomplete extension indicates fixed flexion deformity

Special Tests
Shortening (Leg Length Discrepancy)
Ask the ptn to lie spine and stretch both legs as

possible Measure with tape:

From Umbilicus to medial malleolus: the apparent length From ASIS to medial malleolis: the true length

In hip fractures the affected leg is often . shortened and externally rotated

Special Tests
Trendelenburg Sign - Ask the ptn to stand on one knee for 30 seconds - Repeat with the other leg - Watch the iliac crest on each side if it moves up or down The Trendelenburg sign is said to be positive if, when standing on one leg, the pelvis drops on the side opposite to the stance leg.

Special Tests
Trendelenburg Sign
The weakness is present on the side of the stance leg. The body is not

able to maintain the center of gravity on the side of the stance leg. Normally, the body shifts the weight to the stance leg, allowing the shift of the center of gravity and consequently stabilizing or balancing the body. However, in this scenario, when the patient/person lifts the opposing leg, the shift is not created and the patient/person cannot maintain balance leading to instability.
It is positive in:

Weakness / paralysis in hip abductors. Marked proximal dislocation / subluxation of the hip. Shortening of femoral neck. Any painful disorder of the hip.

Imaging
X-ray CT scan MRI Sonography Others.