Transcript Evaluation of the Hip & Pelvis

Evaluation of the Hip & Pelvis
Outline of Presentation
• Anatomy
• Steps in evaluation of the Hip
• References
Anatomy
• The os coxa (hip bone) initially begins life as
three individual bones:
– Ilium
– Ischium
– Pubis
Overview
• The hip articulation is formed between the
head of the femur and the acetabulum of the
pelvic bone
• Due to its location and function, the hip joint
transmits truly impressive loads, both tensile
and compressive. In addition, the hip
provides a wide range of lower limb
movement
Anatomy
• Ilium
– The ilium is the largest of these three bones
– It is composed of a large fan-like wing (ala), and an
inferiorly positioned body
– The body of the ilium forms the superior twofifths of the acetabulum
Anatomy
• Ischium
– The ischium is composed of a body, which
contributes to the acetabulum, and a ramus
– The ischium forms the posterior two-fifths of the
acetabulum. Together, the ischium and the ramus
form the ischial tuberosity
Anatomy
• Pubis
– The pubis is the smallest of the three bones, and
consists of a body, and inferior and superior rami.
The pubis forms the anterior one-fifth of the
acetabulum
Anatomy
• Acetabulum
– The ilium, ischium and pubis fuse together within
the acetabulum
– While the majority of acetabular development is
determined by the age of 8, the depth of the
acetabulum increases additionally at puberty, due
to the development of three secondary centers of
ossification
Anatomy
• Femur
– The femur is the strongest and the longest bone in the
body
– The proximal end of the femur consists of a head, a neck,
and a greater and lesser trochanter
– Approximately two thirds of the femoral head is covered
with a smooth layer cartilage except for a depression, the
fovea capitis, which serves as the attachment of the
ligamentum teres
Anatomy
• Femur
– The trabecular bone in the femoral neck and head is
specially designed to withstand high loads
– The design incorporates both primary and secondary
compressive and tensile patterns. However, within this
trabecular system, there is a point of weakness called the
Ward triangle, which is a common site of osteoporotic
fracture
Anatomy
• Femur
– The greater trochanter serves as the insertion site for
several muscles that act on the hip joint
– The lesser trochanter, located on the posterior-medial
junction of the neck and shaft of the femur, is created from
the pull of the iliopsoas muscle
– The angle that the femoral neck makes with the
acetabulum is called the angle of anteversion/declination
Anatomy
• Extra-articular ligaments
– Three extra-articular ligaments help provide
stability at the hip joint:
• Iliofemoral ligament of Bertin/Bigelow
• Pubofemoral ligament
• Ischiofemoral ligament
Anatomy
• Muscles
– Iliopsoas
• Comprised of iliacus and psoas major
• The most powerful of the hip flexors
– Pectineus
• An adductor, flexor and internal rotator of the hip
– Rectus femoris
• The rectus femoris combines movements of flexion at the hip and
extension at the knee
Anatomy
• Muscles
– Tensor fascia latae (TFL)
• Assists in flexing abducting and internally rotating the
hip
– Sartorius
• Responsible for flexion, abduction, and external
rotation of the hip, and some degree of knee flexion
Anatomy
• Muscles
– Gluteus maximus
• Largest and most important hip extensor and external rotator of
the hip
– Gluteus medius
• The main abductor of the hip
– The anterior portion works to flex, abduct and internally rotate the
hip
– The posterior portion extends and externally rotates the hip
– Gluteus minimus
• The major internal rotator of the femur
Anatomy
• Muscles
– Piriformis
• An external rotator of the hip at less than 60° of hip flexion
• At 90° of hip flexion, the piriformis reverses its muscle action
becoming an internal rotator and abductor of the hip
– Small external rotators
• Include obturator externus and internus, superior and inferior
gemelli, and quadratus femoris
Anatomy
• Muscles
– Hamstrings. The hamstrings muscle group consists
of the biceps femoris, the semimembranosus and
the semitendinosus
• The biceps femoris, extends the hip, flexes the knee
and externally rotates the tibia
• The semimembranosus and semitendinosus extend the
hip, flex the knee and internally rotate the tibia
Anatomy
• Muscles
– Hip adductors. The adductors of the hip include
the adductor magnus, longus, and brevis, and the
gracilis
Anatomy
• Bursa
– There are more than a dozen bursae in this region
• The iliopsoas (iliopectineal) bursa is located under the
inguinal ligament, between the iliopsoas tendon and
the iliopectineal eminence of the superior pubic ramus
• The subtrochanteric bursa is located between the
greater trochanter and the TFL
Anatomy
• Femoral triangle
– The femoral triangle is defined superiorly by the inguinal
ligament, medially by the adductor longus, and laterally by
the sartorius
– The floor of the triangle is formed by portions of the
iliopsoas on the lateral side, and by the pectineus on the
medial side
– A number of neurovascular structures pass through this
triangle. These include (from medial to lateral) the
femoral vein, artery, and nerve
Anatomy
• Neurology
– The posterior gluteal region receives cutaneous
innervation by way of the subcostal nerve, the
iliohypogastric nerve, the dorsal rami of L1, L2, L3 and the
dorsal primary rami (cluneal nerves) of S1, S2, and S3
– The anterior region of the hip has its cutaneous supply
divided around the inguinal ligament.
• The area superior to the ligament is supplied by the iliohypogastric
nerve
• The area inferior to the ligament is supplied by the subcostal
nerve, the femoral branch of the genitofemoral nerve, and the
iliolingual nerve
Examination
• History
– The hip is a common area of local and referred pain
– A pain diagram and a medical history questionnaire should
be completed by the patient. The history should
determine the patient’s chief complaint and the
mechanism of injury, if any
– The patient should be encouraged to describe the type
and location of the pain
Examination
• Systems Review
– Pain may be referred to the hip region from a number of
sources
– Weight loss, fatigue, fever, and loss of appetite should be
sought out because these are clues to a systemic illness
– Other examples include an insidious onset of symptoms,
evidence of radiculopathy, bowel and/or bladder changes,
night pain unrelated to movement, and severe pain
Examination
• Tests and Measures
– Observation
• The patient is observed from the front, back and sides
for general alignment of the hip, pelvis, spine and lower
extremities
• Walking – analysis of the gait and supine
• Pain may be referred to the Hip joint from the lumbar
spine and the sacroiliac joint. These must be assessed
Palpation
• Iliac crest, Anterior Superior Iliac Spine
• Tensor fascia lata
• Posterior superior iliac spine, SI jt,ischial
tuberosity, hamstrings, lumbosacral jts
• Greater trochanter
Active movements
• The most painful ones are done last
• Some movts are tested with the patient in
supine & others in prone position
• Hip Extension done in prone
Active movts.
• Flexion/extension
• Abduction/Adduction ( supine or Side lying)
• Hip internal/ external rotation (sitting or
supine)
Passive movements
• As in active movts. if necessary
Resisted isometric
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Hip Flexion/Extension
Hip Abduction/Adduction
Hip medial Rotation/lateral
Knee flexion/extension
Special tests
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Use only tests that are necessary
Faber
Tests for Leg length – true , functional
Proprioception/balance
Thomas test – used to assess hip flexion
contracture.
• Sign of the buttock- to assess whether pain is
from Sciatica OR hamstrings
• Trendelenburg test- hip abd weakness
Functional tests
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Squatting
Going up and down stairs
Running straight ahead
jumping
Suggested text
• Orthopaedic Physical Assessment by David
Magee
• Orthopaedic Medicine by Monica Kesson and
Elaine Atkins
• Living Surface Anatomy by Philip Harris and
Craig Ranson