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That's part of the trauma Orthopedic series teaching can You got all my screen, by the way? Yeah. Problem. You see this larger? Yeah. Like I'm gonna see if we can also use, like, any question that you have. Just drop them into the chat bucks on. Hopefully I'll crying out that I go down to the end. Uh, so with hep a couple of things that you need to know. Firstly, to understand anything out of the pathology surgical perspective, you need to obviously understand the anatomy on. So with the happy, as most of you will know, the ball and socket joint to the boulders the femoral had on the market is a tablet on this located in the pelvis. But obviously, you have to You want to decide? Um, one of the main functions after hip joint is allow you to wait there. Um, provide stability to the lower level, because if you think about it, amount of force that go through your body is equally divided between the right leg and the left leg, so the hip has to be stable. Don't Teo, even to distribute the forces. Um, front. So the articulation is between the femoral head on the uh after tablet. The after tablet is have the labrum around the outside off the stream, if you remember from your anatomy lectures back in preclinical years, and that actually increases the surface area for the head to articulate with the tandem on sort of aggressive vacuum effect. Teo, make sure that it's stable. I have with any joint that's coming with articular cartilage. No, there's if you have been to any trouble meetings quite often, when consultants or senior distrust be a medical student, one of the question attention ask is in terms of fracture is about. Is the capital attached? Now? Most of automatically say that it's attached, you know, right about here at the InterTrust and tear it land, which is correct. They're only for the anterior part of the capital. So unti, really the capsule goes from the after tablet, um, and extends on rooted in two trochanter IQ line the posteriorly. When you have a look at the hip, you haven't tried Concerta Crestor, 70 really? Because it into a truck and Terek Line and Posteriorly, it's called intertropical tired crashed, and the Crestor is actually slightly more proximal. So when you look on the hip when you look at the hip anterior capsule in here posterior. It's slightly higher up, tricked out when they when they ask you that question in your hospital, does that make sense? Okay, The way that the hip provide stability, it's mainly due to a number of ligaments. There are three main ligament on a couple of smaller ligaments that you don't need to know as much about the different main ones that I would, um, probably advise. You just have a quick really, quite You don't need to know anything in detail about Just know that they're there. And that's what increases the stability of the hip joint, divided into into intracapsular extracapsular liquor ribs. So, anything I think when it comes orthopedic, anything that you do try it e that categorized things, which makes it much easier. So with fractures, intracapsular extracapsular fractures on with the ligaments with it, we got intracapsular you miss it, extracapsular. That just makes it easier for you to remember things as well. Intracapsular you've got a small ligament between the head of the fever on the tablet. To those of you that have been too, uh, thirties and have seen a hip replacement afternoon. If you want to take the head out that there's a ligament, that attack is it to the tablet, which makes it difficult to remove enough from what they do. They just cut it to get it to get the femoral head out on within. That ligament is a small African, the operator artery, which probably very small supply to the femoral head. You have extra captured a ligament, so the main one is in your femoral ligament, which hopefully I'll be, um, anterior until your superior iliac spines on insert into the truck and Terek line interior of the unique features off. This is if you look at the ligament, it's after way it shaved. They call it a y shaped structure, so stopping there beautiful instruction and it divides into a while, you know, upside down and the way that the fibers run quite spirals in its nature. That's the reason why the hip it's stable because five is running in the spiral. My nose opposed to a straight longer Uh huh, The other two ignorant people often mentioned are you people femoral ligaments and as the name of the best ones from the superior pubic cream I to the InterTrust entire line. And we've got the issue of femoral ligament, which is behind posteriorly that runs from the issue, interpreted a greater trochanter. It's often did the main really glad that you need to be aware of your level. You don't need to know much in detail except for the fact that the spiral in nature and that spiral helical shape confessed stability to the hip joint. Does that make sense? Find the main structure that provide the greatest rent is the issue femoral iliofemoral ligament that awful for if you ever do get half who knows what the blood supply to the femoral head. Okay, there will just go back to basics sent. So you have your femoral artery that come from your back artery. I come from the orders. They order the echo artery temporal artery. Femoral artery divides into your deep party off, or the profunda Femara, which is what some people are vascular surgeons called it in the profunda Femara, which is a green color in this picture, and give left the medio circumplex several artery and the lateral complex femoral artery, the lateral one, actually goes behind the femur laterally and the media goes, Auntie, really medially the one that supplies the most fertile off these two arteries. The media second flex. It's a supposing majority of the block the block And what happens with the CT are treated as a circle around the base of the feed. The femoral neck deformity enough to most it. More often you get is a super small branches or retinacular arteries that go Uh huh. Along the femoral had along the same room, like supplying the femoral red so that the main blood vessel that you need to be aware of There are other small structures that can't that do supply blood. And they're young traitor artery which are describing really around the park, the ligamentum terrorist that is in the ligamentum terrorist on the superior and inferior gluteal arteries as well. In terms of nerve supply, you have, the three main is they have a static now, which supplies the posterior compartment I on majority of the lower limb the, um, Tibby. Oh, the tibial muscle. Eventually on you have the femoral nerve supplies. The anterior compartment start on the objective, which supplies the medial compartment of the That's as much as you really need to know. You don't need to know, you know, in great detail. So that was a medical student. Which individual muscle their supplies, usually because of the nature of the nerve supply to the sciatic nerve going from the back or read out of the leg pain in the back enough and then be referred to the news or the ankles, which is like some patients when they complain of pain in the knee. Actually, the pathology Micheal in the hip and nothing the itself, as we mentioned earlier on the primary function on the hip, is teo possibility on to allow you to wait there as an individual. Uh huh. The first doctor that does this is the tablet, um, on the way we describe the other tablet from the orthopedic perspective. Is it deep concave on with the labrum surrounding the tablet? It increases the depth of it, increasing the vacuum effect. I'm printing dislocations from occurring. And then we've mentioned Ligament earlier, after the Eylea ephemeral the people femoral on the issue of femoral elements, which, because it's viral orientation, um, confirm stability that we often get with, um mobilization, uh, business life, but just going back to basics, the movement to happen at the hip flexion. So if you occupation to lie down, lift in the leg of this election, just him to turn over left in the leg extension, abduction is bringing the leg out to the side. A D deduction is bringing the leg in from the side to board the midline on naturally rotation. Media rotation is, but with the leg extended, but you're rotating it 35 and there are number of missiles that allows these movements to happen. Now the main thing to remember it, brother and remembering individual muscle groups. For flexion to happen, the muscle has to originate slightly approximately the hip so rather than originated from the hip joint itself. Most of these flexor muscle of the original from the anterior superior early explain all from the vegetable body on it, then attach it to the medial side of the knee. So that's how it last flashing after me on the hip. Yeah, with extension majority of the muscles, your gluteal muscles, a new hamstring muscle, um, and everything with flexion is when when you're asking a patient to reflect their head Often they're disruptive tightness in the in the car if he often to bend their the interest is the degree of flexion. That's primarily due to the relaxation of the hung string. Uh, the the the method, of course, the various movements. You can probably have a look in your in your own time, so definitely the best. But I often tend to remember muscle that rather than remembering the words on, you know, reading a carriages and in searching by word, I actually look at the images. So, uh, your hip flex is your start aureus. You're active, the more you're packed in years on your so a major, All these. Actually, they crossed me to allow the flexion after the under him on. Then, if you look at your hip abductors, do you have your gluteus maximus media on minimum on the way? I tend to remember that this is small, medium and large. They essentially stopped in top of each other. Just so it's the way of remembering something, um, addictive muscle. So you have your eye doctor Magnus longer on brother and again, the way I tend to remember it. Madness is big a sheet like no, that longer. Not as big a magnificent on top of magnets and brevis is the time. It's smaller ones. That's the book that longest. But for your anatomy stations were anatomy questions in finals? Don't they Don't often after you buy the origin are getting that long that you can identify the muscles that hold that they really care about, even for your postpartum exam. So the quick fire through the anatomy and your vascular supply that you really need to be aware of for these, uh, you need to be able to do a hip examination. I'm not going to go into the history of hard to take, you know, half take a history for those that preservative pain. But our focus more mainly on the examination side. So going back to basics again, all examination when it comes to joints should be look for you and me, and then you do a number of specialty. In terms of looking, you do a better examination first. Actually, just before this, in terms of your office, is you always introduce yourself explained to the patient exactly what you're doing. Make sure that they're paid for. If there aren't any pain. You would always have. You come in that I'd like to give the patient some pain relief at this time. Don't give you one point and then explained to the patient exactly what you're doing gained econd that make sure that they're comfortable. So if they're standing up passing to sit down or lie down in the bed, particularly for this exam, you probably want the patient to be stuck up initially, Um, your general inspection that actually starts when the patient walked into the room. So from here in the clinic, you know, if you're over there, Consultant, he's a hip surgery congested that monitor. The patients are going to have hip pain. You examine your general infections as they could walk through that room. Have a lot of walking a day. What their body habit. It's like, what is there gate like limping on any particular side. They got any previous scar from surgery. You can gather all the information before you even spoken to the patient at all of this and equipment there walking in. And any prescription medications, often wheat. When we talk about a description medications, we talked about the pain that the patients are taking or whether there's been referred to the pain team or whether they're finally started injections for that pain into the direct. Uh huh. So that was your general inspection that you can do a straight away on, then moving on to your closer inspection for joint examination. You want to try and make a little slick as possible? Well, actually, for the exam that you've done the examination several times before, and in fact, a revolving medical students before, we tend to just do the examination once before the exam. I hope for the best and from. So when you are examining them closely, you always ask the patient to turn around rather than your stuff. Maybe around the patient. It just makes it easier for you. And it's slightly clicker for the timer as well. So starting in the front, there are better to turn 90 degrees to death. Died left. All right. And the 90 degrees again. Please have a look at the back of that, um, posterior chain. Yeah. Instance. You're looking for any obvious deformities, anything that you met, anything that you see that fairly obvious you mention it. So if you see a scar. Don't work from the end of your checklist before you say that. Oh, there's a scar there might indicate a previous joint replacement. So that's really because that was, automatically switch off the Examiner and show them that you know what you're talking about. You're actively looking at things as opposed to really things. That checklist, common things to comment on would be scarred, which typically would be a hip replacement. They often you get that on the lateral collateral side if they've had a neck, a femur fracture for which defined urgent surgery or if they've had an elective procedure and they will have a scar on the posterior. So I just give you better exposure access, and they should have a little tip, replacement person, that sort of approach. Other thing to note. If they do, you have a scar. There's any readiness and the bruising and swelling, which may indicate an infection on, particularly if this is the first presentation of joint pain over the come in the muscles on both on the wasting the Congress, that muscle. I wish my indicated patient is not using the joint or they may have neurovascular on your muscular disorders. Um, have a look at their gait. How are they walking into the room on also leg length discrepancy. Uh huh. We're going into a bit more detail with regard to leg length discrepancy later on victims. What I mean by power to it is, um, your hip abductors, if you had abducted, they're not functioning well. You can get a drop in your pelvis, a Z, your walking and they're going. We're going to a bit more detail later on at the occupation, to me, not to degrees, to look from the file in the back again. You're looking for the exact same thing. But just for your examination, respect with examination purposes always mentioned the things that you're looking forward getting again. Just said about dinner that you're looking for it. Uh huh. From a lateral that, specifically looking at any effect flexion deformities that essentially means you're unable to. The patient is unable to fully extend the Factive joins. In this case, they will be a nail to extend their hip current completely from the back again. You're looking that muscle wasting and God's, which may indicate previous spinal surgery is oh, any questions so far. Okay, so moving on to So at this point, the patient is stuffed up. You did a general inspection. That's what you want to do is ask patient to walk. And the reason why I preferred to ask him to walk at this stage is it gives you a lot of information before you actually even touch the patient. You've probably got your diagnosis in most cases. Uh, when you are a seven day gait, Alberto station is, you know, walk to the end of the room, turn around slowly and walk back a negative. That we're only Pakistani in gait or in the trendelenburg skate or a world waddling gait. Um, and also, you can affect how the speed at which they're walking, whether the brain is shuffling on a limp, any particular side. Um, the other thing is always a destination foot where when they walk back to you, But it may indicate this issues with their feet in terms of diabetes, which they may require specific. But where for Charcot, for example? Good. So you've done all the generalist actually reverse after gate that you may want to your look feel on me. Um, when you're looking over the last patient, Teo, lie down on the bed. I don't expect a hit drink from above and from the side of the family patient bedside and each instance you're looking for scars, swelling, bruising, wasting any of the muscles and you decide many extraction deformity. And again, there's nothing that you will be looking for when you do your general infections. But you're off for the Communist. Did you need to mention these again and again that each stage extraction deformity? Yeah, you can look at that when the patient stood up. Actually, you get You can only really identify when the patient is lying down on the bed. Um, moving on t uh, feel so well, you're feeling attention to try. Try not to use the palm of your hand over. Use the dorsum or the back of the hand. Um, only because they're the palm of your hands and get 1/4 impression that the patient drop Maybe you want. But actually, it's 200 things that you're feeling for our temperature. There's not many things that you can actually, if you're in that in the in the joint examination, see the tenderness, temperature on, basically, for the hip itself. They may have tried anti right bursitis feel around the hip or the greater trochanter, and usually the bump on the side of the hip that you can feel yourself. It's really only mentioned leg length discrepancy. Okay, yeah, the leg length discrepancy. There is true leg length discrepancy on Apparent like a discrepancy with crude leg left discrepancy. You're actually measuring from the interior superior on the X fine down to 2 m valueless. Be inside of the foot or the ankle. The parent leg left discrepancy. You're measuring from the umbilicus. Some people that measure from the different process, often more commonly, definitely umbilicus down to the medium. I'll be on this tells you whether there the problem is with hip. So if you go difference in your true leg left. Definitely very crude. Leg left. Difference in the pathology you're lacking in the head. If your leg doing crew Legoland distractedly the same and you destroyed. But it's different with your current leg left leg measurement. Then the problem is elsewhere. Higher ups, a gambling not in the hip joint itself. Does that make sense. So if you have equal crew leg left measurement on left hip pathology. Whereas if you have differing apparent leg measurements, leg length measurement and pathologist language something else and not necessarily fine. And then finally you move Auntie the meeting part off the examination. So always I said it. Any anyone, any student come across always examined the normal side here. So when you're you know, you know whether that's a shoulder examination handed examination, you always have the normal side to see what the patient's baseline is. Because someone that in 10 years you don't know you know the amount of ablation is getting is whether, whether that normal for them or not for elderly patient, it may have restrictive range. You've been anyway. So if you're starting off with the affected try, you don't know whether that's the baseline again. This dictation didn't any paid mention to the Examiner that you would like them to offer patients in pain relief before trying to me. They're they're affected. Limb movement is divided into activism and passive me. When active movement is for the patient death without any support from yourself, passive movement is abort essentially duty without the patient. Um, putting much effort. Okay, Um, okay, but now how to do each individual movement, The one that you probably I probably highlight, is hip flexion. When you're flexing the head, what patients often tend to do it This straight leg raise on that thing, you know, they get paid as they got to united degrees. Actually, your normal hip flexion is between 0 to 1.2 degrees, which is a lot. So the way to after patient reflect their head is after him to bend any and bring them into the chest and that remove the tightness that you get in the hamstring near the way to do also do. This is my place in your hand below the patient's lumbar spine, which removes and the you know, if they're masking the fixed flexion deformities, that really is it. But yeah, we always tell patients you bring them, you just close the chapter they can, because naturally, with when you say that they bend in any way. Um, when you're affecting like a head extension, you always ask the patient a turnaround. For from a mask in perspective, I would always be interested. Definitely the end, because you look more liquor. You want to be a difficult action abduction, abduction, internal external rotation and then our special to flip over, opposed to do in flexion and ask them to turn over in Africa to turn over again to review the reason. It's just that it makes a little bit awkward, fine, passive movements, most of them. Even though we've just probably could be, I could leave it all to the only one that patients tended to actively a flexion and extension. Passive ones are quite important, as they tell you, whether there's been any earlier on the arthritis exactly on the hip, on go one that tends to be affected. Usually it is internal rotation, so the way you would internally rotate it back in the hip and the new to 90 degrees, um, using it right inside for internal rotation. You would move the ankle afterwards for the hip protest inward. And if you have early on, if you have arthritis, early stage of arthritis and the patient, uh, from describe paid on internal and external rotation for your for your level, you don't need to know the degree off movement at each individual joint, probably saying that the pain has a good range of movement. It's probably adequately, I think, for passing your ask you I know when I was a student, I never expected you to remember the exact figures. Uh, for those of you are are interested in orthopedics but the figures of the range of movement that we typically expecting patients on the slide for you to read. Okay, so we've covered Looking for feeling part of the meat mint part, actually, don't even special test really for the hip, there's only two sessions test You got the Thomases test, which is better for flick collection deformity, and you've got the trendelenburg contestants. It'll talk about that in a short while. Um, Thomas is tested a number of ways that people you people after patient Teo, bring their need into their chest whether they put their hand below the patient fine on, then they need themselves, which ever attacked you're comfortable with. Go with that because there's 100 ways of doing example. You can come to your shoulder exam in this special test that you can do pick the one that you're comfortable with. Just make that like a possible. So that's what I would do. I always place my hand behind for the Thomases. Test yourself for the next election deformity. Are you to lie flat on the bed? Uh, and I always place my hand below the patient numbers They radical the ability to mask of extraction deformity because they can't bend there than birth find anymore. And then don't grab the patient me on our flex it and bring it up all the way to the chest. No, if I'm elected their right hip big dump, okay? And they have a fixed flexion deformities in the left hip and the left hip would bend slightly. So to start off with both legs will be extended completely. Put my hand, deliver the patient lumber spine and then I'll bend. The patients will write me. I have to have a fixed flexion deformities in the left knee. The left knee will bend slightly off the table that you won't be fully extended to that Make sense on the same for the write that for a fixed flexion deformities in the right leg, the banding patients left knee and the right leg will bend slightly from the table. Um, it's only positive, like it initially like this and then assuming he banded patients, other need the like the contract with attention. Okay, the only time you shouldn't do this is in those I had a hip replacement because you just look at it. I'm the bottle, not be happy. Good trendelenburg test you can I personally, I would do from telling the test in the beginning of many examination, as opposed to the M because naturally, the patient instead of Aricept and they gave the next national thing for me to do would be to you know, whether the hip hop doctor that working no, some people get from doesn't big test confused because they confused which side it refers to you. So you think you've had a patient stood in front of you? You get down in front of them. Put your hands in the patient now what you want to do first after patient to lift one of the leg after floor. So far gone that let's say the patient is standing on the left leg. So that means that the right foot it up off the floor. Now what usually happens is your pelvis would go upward because you're abducted on the left side. are working now. If the hip abductors on the left side is not working, when you after you open your left leg, your parents in the right side won't go over. And what happens with the deficient? Abducted Is your pelvis dropped to floor? So if you're still on your right leg on your pelvis connections that mean that the problem isn't a direct link, but actually, it's on your left hip. Abductors. People can often get that confused thinking that the problem is on the safe side. The actually, it's under control. Lateral hip object, you know, on the leg that yours not standing on. Okay, it's a bit more clear over the description. I've got him slide for you guys. Any any questions that you got to do that. Okay, so that's your trendelenburg attacked. So hands under patients television for us to purposes, obviously you get quite yet mark for empathy for patient interaction for fashion is, um so I would I would always after patient either hold my forearm for my show that now, if you ask them to lift the left leg up, not really have it would totally because these hip abductors on the right side are working now after hip abduction in the right side of not working and the toes had dropped down. Okay, so the problem isn't on the left that actually the problem is under right hip. Object it. You know, every time you have been stand up, it contralateral publix is that are not working. And then finally you would I think, the patient as you would do normally, um, present your findings. Tell the patient work. You know what you found. If there's anything concerning on what you would do next and because we're in 2020 because of covert, I would always also just to put this in order to contact that was also mentioned, you know, disposed differently a ppd and washing my hands appropriately and at the end, just in the last two. The examiner. So you don't want to start talking about all the negative finding? Just mentioned the positive finding. For example, you know, you met this patient has this many years old, understand? When I found this, there's no perfect stick matter of muscular skeletal disease. Um, my differential diagnosis is you know, for example, osteoarthritis. Triamterene, breast out is septic arthritis um, so too exclude. Different facilities are black toujeo a number of investigations starting afterward. Basic bedside investigation and going on to more invasive investigations. I would phrase thing that supposed to go into each individual Negative. Finding further assessment on investigations that you can do would be that make sure you've been in your vascular exam. So when I did my off 50 and med school, I had a lower limits emulation with the baton hip examination. But you can keep my examination. I have to mention I would do in your vascular exam because you're doing your vascular examination in itself is a separate examination to complete your exam. Is this scenario always have to mention your vascular status as a medical legal requirement of the wall to document your vascular status? Um, examination of the joint that both on below. So in this case, it would be your lumber spine on your knee joint and and finally investigation that we've mentioned to going from bed. It's like two more invasive investigations. So, um, make sure you put your investigation into contact. If it's someone in an elective clinic, you know you don't have to mention the fact that you want to do observation. You want to be blood there. And then because the patient is actually well in themselves, they're not having the operation. Any time soon we're in and pay any scented set setting with, um, over the hip paid that. That would mention better observations. Blood, which would include your inflammatory market, Um, e g and chest X ray to rule out for the source of infection. And then you you would always do a joint X rays. So they always make sure that you put in a P in the natural of you as well. On depending on what you're looking for, uh, can have a MRI, a CT scan of some cases. Well, any questions? No. Of the quick fire, you know, do you, um, for for what you would expect to see. And you're asking if I don't go to two mosquito? But if you don't want more, if you do want to ask any questions, you're free to often down. Thank you so much for that talk was really good. I just need to put in the feedback link. So there's a feedback link in the chat there. So guys make sure that you feel that in so that you can get your certificates and so that we can provide a good feedback as well. And yeah, I don't if you can see the chat, Um, let me have a look. There's there's no question the moment, but if there are people want to write them in the chat or on your just helps, that's fine. Eso The next lecture will be on Monday. It'll either be the Fractures lecture or the spine lecture. It's part of our specialty, Siris. So makes you guys come back on Monday for that as well. Yes, I think it's any if you are interested in orthopedics than the I'm on 22. Happy to answer any questions with regards to her career related questions at the question on the hip joint, um, their default. Be interested if you want any career focused advice. I don't think there's any question, so thank you again So much for sorting this out and I'll get your certificate on the feedback that we collect for you in the next week or so. Perfect. Thank you. Thank you very much. I