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Examination of Hip

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Bryant’s triangle
 Nélaton’s line
Schoemaker’s Line
Telescopy Test

Thomas test
Trendelenberg test

Measurement of Supratrochanteric Shortening

Shortening of limb length produced above the level of trochanter (due to femoral head, neck and hip joint lesions) is known as supratrochanteric shortening. And it is measured by follwing tests.

Qualitative Assessment

  1. Patient lies supine & hip is extended
    1. Schoemaker’s Line
      1. A line joining tip of trochanter and ASIS, when prolonged on both side, should meet in the central line at or above the umblicus.
      2. In case of proximal migration of greater trochanter the line on that side will meet its counter part below the umblicus and on the opposite side.
    2. Chiene’s Parallelogram
      1. The lines joining the two ASIS and two tips of trochanter should be parallel.
      2. In case one of the greater trochanter has moved proximally the lines will converge on that side.
    3. Morris’s Bitrochanteric Test
      1. The distance from the tip of the trochanter to the pubic symphysis should be equal.
      2. If trochanter is externally rotated or displaced back distance will increase on that side & viceversa.
  2. Patient lies on the normal/opposite side of the limb with preferably 90° flexion at hip.
    Nelton’s Line
    1. A line drawn from ischeal tuberosity to ASIS should pass through the tip of greater trochanter.
    2. In case of supratrochenteric shortening the trochanter will be above this line.

Quantitative Measurement

  1. Bryant’s Triangle
    1. The patient lies supine & tips of trochanter and ASIS are marked on both sides.
    2. A perpendicular is dropped from each ASIS on to the bed. From tip of greater trochanter another perpendicular is dropped on to the first one, (base of the triangle). Now join the tips of greater trochanter to ASIS on respective side. Each side of this right angled triangle is compared with its counter part on the normal side.
    3. Any shortening of the base ie DC (i.e. more or less femoral axis continuation line), which may be due to shortening in the neck, head, joint or dislocation of joint can be measured.
  2. Trendelenburg’s test 
    1. When both feet are supporting the body weight, the pelvis (anterior superior iliac spine) on the two sides lies in the same horizontal plane.
    2. When only the right foot is supporting the body weight, the unsupported side of the pelvis is normally raised by the opposite gluteal medius and minimus.
    3. If the right gluteal medius and minimus are paralysed, the unsupported left side of the pelvis drops. This is a positive Trendelenburg’s test.
    4. Patients walk with positive trendelenbrug sign on
      One hip- Lurching/Trendelenburg Gait
      Both hip- Wadding Gait
    5. Trendelenberg’s test is done to assess the integrity of abductor mechanism. It is positive in the conditions in which any of the three — fulcrum, lever or power is affected eg. dislocation of hip, fracture neck femur and abductor paralysis due to polio or superior gluteal nerve palsy
    6. Trendelenberg’s test may be positive in TB hip only in late stages when the head of femur is destroyed.
    7. Causes of Positive Trendelenberg Test
      1. Paralysis of abductor muscles
        • Superior gluteal nerve palsy (supply gluteus medius and minimus)
        • Polio
        • Iliotibial tract & quadratus lumborum palsy.
    8. False positive Trendelenberg Test
      1. Genu varum
    9. Abductors of hip are –
      1. Gluteus medius and minimus (main)
      2. Tensor fascia lata & sartorius (accessory)
      3. In cases of fracture intertrochanteric femur both gluteus muscles become ineffective as these are inserted in greater trochanter. Tensor fascia lata (TFL) which is inserted through the iliotibial tract on to the lateral condyle of tibia will still be in a position to affect some abduction thereby causing a negative trendelenberg test.
    10. Decreased lever arm due to upward displacement of greater trochanter causing abductor muscles slack
      1. Fracture neck femur
      2. Dislocation of hip
      3. Severe coxa vara
    11. Absence of stable Fulcrum & lever arm about which the abductor muscles can act
      1. Dislocation of hip
      2. Destruction of femoral head as in Perthe’s disease, AVN, late stages of TB hip & septic arthritis
    12. Shenton’s line
      Shenton’s line is an imaginary semicircular line joining the medial cortex of femoral neck to the lower border of superior pubic ramus. It is breeched in fracture neck femur, head femur, superior pubic rami and dislocation of hip.
    13. Telescopic Test
      In supine position, hip & knee are flexed as much as 900 and thigh is pulled up & pushed down. Even in normal condition a slight amount of excrusion of trochanter can be felt by other hand. If excrusion is more, then this indicates instability of hip joint such as:  
      1. Old unreduced posterior dislocation
      2. Loss of neck & or head in old fractures neck femur
      3. Paralytic hip
    14. Managment Options For Fracture Subtrochanteric Femur
      1. Conservative
        Traction on Thomas knee splint (in abduction & external rotation)
      2. Operative
      3. External Fixator
        1. Plate & Screw fixation
          a. Sliding hip screw
          b. Dynamic condylar screw (DCS)
          c. Condylar blade plate
        2. Intramedullary Fixation
          a. Intramedullary hip screw
          b. Russell Taylor reconstruction nail
          c. Short cephalomedullary nails eg Gamma nail
          d. Standard interlocking nail.
          e. Enders nail in children. 
    15. Displacements In Fracture Shaft Femur
      1. Proximal Third fracture
        1. Proximal fragment flexes, abducts and externally rotates because of gluteus medius & iliopsoas
        2. Distal fragment is adducted due to adductors (adductor longus, minimus, magnus & pectineus)
      2. Middle Third fracture 
        1. Proximal fragments abducts relatively less due to balancing effect of gluteus medius & adductors; but flexion and external rotation by iliopsoas persists.
        2. Distal fragment is adducted d/t adductors.
      3. Distal Third fracture  
        1. Proximal Fragment adducts (because adductor over power gluteus medius due to long lever arm).
        2. Distal fragment is hyperextended by gastrocnemius.
  1. Management Plan
    Different available modalities of treatment are
  1. Gallow traction less than 2 years of age and <12 kg of weight. < 2 kg of weight should be used as traction.
  1. Hamilton Russell’s traction skeletal traction on Thomas knee splint and skeletal traction with out splint (Perkins traction) are more suitable for older children & adolescents.
  1. Immediate or early spica casting is the treatment of choice in children 6 months to 6 years of age for femoral fractures with <2 - 3 cm of initial shortening, and stable fracture pattern.
  2. Femoral fractures with > 2 - 3 cm of shortening or marked instability (i.e.) high probability of slipping of reduction and tight thigh swelling in 6 months to 6 years age group, who cannot be reduced with immediate spica casting, require 3 - 10 days of skin or skeletal traction before casting.
  3. Skeletal fixation by TENS (Titanium elastic nailing system) intramedullary flexible rods & plating can be used in children with multiple trauma, head injury, vascular compromise, floating knee injuries or multiple fracture, preferably in children > 6 years of age. It is important to understand that TENS is more useful in stable fracture pattern & plating in unstable fracture pattern.
TENS in Children ILN in Adults
  1. External fixator is used in open fractures (compound injuries)
  2. Intramedullary fixation with interlocking nail is treatment of choice for most fracture shaft femur in adults.
  3. Nonunion is treated by exchange nailing (i.e. introduction of large diameter reamed interlocking nail) and bone grafting.
  4. Delayed union is treated by dynamization of nail (removal of proximal or distal screws or both) and bone grafting.
  5. It is said that a fractured shaft femur should unite in 100 days, plus minus 20 (3 - 4 months).

Fat Embolism Syndrome

Fat embolism refers to the presence of fat globules in lung parenchyma and peripheral circulation after fracture of a long bone or other major trauma. And fat embolism syndrome reflects a serious systemic manifestation as a consequence to these emboli .Discussed in general consideration of fracture.
Gurd’s criteria for the diagnosis of fat embolism syndrome
Major criteria
  1. Axillary or subconjuctival petechia. This occurs transiently over 4 - 6 h in 50% - 60% of patients
  2. Hypoxemia (PaO2 <60mmHg; FiO2 <0.4)
  3. Central nervous system depression disproportionate to hypoxemia, and pulmonary edema
Minor criteria
  1. Tachycardia (>110 beats/min)
  2. Pyrexia (>38.5°)
  3. Emboli in the retina on fundoscopic examination
  4. Fat present in urine
  5. Sudden unexplained drop in hematocrit or platelet values
  6. Increasing erythrocyte sedimentation rate
  7. Fat globules in the sputum
  8. Symptoms within 72h of skeletal trauma
  9. Shortness of breath
  10. Altered mental status
  11. Occasional long tract signs and posturing
  12. Urinary incontinence
At least two major symptoms or signs or one major and four minor symptoms

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