Orthopedic surgery pptx - طلاب المرحلة الخامسة

بسم الله الرحمن الرحيم

SYMPTOMS

Pain
Stiffness
Deformity
limping

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

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The Apley System

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

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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.

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1. LOCAL EXAMINATION OF THE HIP REGION
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(Patient recumbent)

Inspectionlook

Bone contours and alignment
Soft-tissue contours
Colour and texture of skin
Scars or sin uses

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Front and back of pelvis/hips and legs:

any ischaemic or trophic changes

Swelling (e.g. lipoma)

Scars (previous surgery)
Sinuses (infection/neuropathic ulcers)

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Wasting

(old polio, Carcot-Marie-Tooth) or

hypertrophy
(e.g. calf pseudo-hypertrophy in muscular dystrophy)

Deformity

(leg length inequality, pes cavus, scoliosis)
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Palpation feel

Skin temperature
Bone contours
Soft-tissue contour (Assess any swellings

Assess pelvic tilt by palpating iliac crests

Local tenderness

Measurement of limb length

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

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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.

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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.

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.

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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).
.
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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.

(a) Above trochanter

(Bryant's triangle;)

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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.

Bryant's triangle

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
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(b) Below trochanter

measure each bone
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'Apparent' or false discrepancy

'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)

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Examination for fixed deformity

Including Thomas's manoeuvre for detection

and measurement of fixed flexion deformity

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:

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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.

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Movements

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

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flexion
45

flexion

EXTENSION

ABDUCTION

ABDUCTION-ADDUCTION

INTERNAL ROTATION

Power

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

POWER FLEXOR

ILIOPSOAS
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POWER

EXTENSOR OF THE HIP
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Examination for abnormalmobility

Test for longitudinal (telescopic) movement

Click test (in new-born)

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

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.
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3. GENERAL EXAMINATION

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

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CLASSIFICATION OF DISORDERS IN THE HIP REGIONARTICULAR DISORDERS OF THE HIP
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CONGENITAL DEFORMITIES

(DEVELOPMENTAL HIP DYSPLASIA)

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ARTHRITIS

Transient synovitis of children
Pyogenic arthritis
Rheumatoid arthritis
Tuberculous arthritis
Osteoarthritis

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OSTEOCHONDRITIS

Perthes' disease
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MECHANICAL DISORDERS
Slipped upper femoral epiphysis

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EXTRA-ARTICULAR DISORDERS IN THE REGION OF THE HIP

DEFORMITIES

Coxa vara

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INFECTIONS

Tuberculosis of the trochanteric bursa

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MECHANICAL DISORDERS

Snapping hip

Age at Timeof Diagnosis Disease

(Years)
0 to 2 Congenital dislocation
2 to 5 Tuberculous arthritis; transient synovitis
5 to 10 Perthes' disease; transient synovitis

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10 to 20 Slipped upper femoral epiphysis

20 to 50 Osteoarthritis (secondary to previous Injury
or disease)
50 to 100 Osteoarthritis (primary)

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