By Q. Benito. Western States Chiropractic College.
The anterior part of the incision is now deepened and one of the two muscles internal oblique cut along the line of the incision to protect the peritoneum from being incised 250 mg lariam sale. The neurovascular bundle comprising the 12th thoracic nerve and accompanying subcostal vessels are found passing downwards and forwards within the deeper layers of the internal oblique at right angle to its fibres discount lariam 250 mg fast delivery. The lumbar fascia is now incised just in front of the lateral border of the quadratus muscle to expose the retro-peritoneal fat 250 mg lariam overnight delivery. Two fingers are inserted through this opening and used to separate the peritoneum from the under-surface of the transversus muscle generic lariam 250mg fast delivery. As this separation continues with one hand, the transversus muscle is divided with a pair of scissors throughout the extent of the incision. So five muscles are incised for this exposure :— Latissimus dorsi and serratus posterior-inferior posteriorly and the three lateral muscles of the abdominal wall anteriorly. To do this, the quadratus lumborum and associated fascia are detached form its lower border. By a little gauze dissection, the renal fascia is identified in the posterior part of the wound. This incision on the fascia is extended anteriorly as fas as required but care should be taken to safeguard the peritoneum in the anterior part of the wound. In the upper pole, the kidney may be anchored by fibrous bands which traverse from the capsule of the kidney to the diaphragm. The adrenal gland is carefully separated by the dissecting finger from the kidney. On the anterior surface of the kidney the peritoneum is adherent and must be detached with care. Other adhesions, if there be any, should be looked for and divided to mobilise the kidney properly. Care should be taken to include all the muscles which have been divided Drainage of the retro-peritoneal space should be provided either by a corrugated rubber sheet or by a suction drainage (Redi-vac). In case it happens, a water-seal drainage should be introduced through the 10th inter space and the pleura is closed. The incision starts a little medial to the lateral border of the erector spinae muscle at the level of the 12th rib. The incision is carried forwards along the line of the 12th rib and is continued beyond its tip as far as required. The Latissimus dorsi and serratus posterior-inferior are come across in the medial part of the wound and these are divided. The bed of the rib comprising of the periosteum and the fibres of the diaphragm are cautiously incised to get into the retro-peritoneal space. The lower reflection of the pleura is identified at the medial part of this incision and is carefully pushed upwards. The incision along the 12th rib is carried forward into the loin, while the medial end of this incision is extended upwards vertically upto just above the neck of the 10th rib. The upper vertical portion is deepened and 2 to 3 cm segments ofthe 11th and 10th rib are excised. This approach will give a very wide exposure, highly suitable for upper pole tumours. In case of hypernephroma, intra-peritoneal approach is preferred as the extent of the growth along the renal vein to the inferior vena cava is assessed and the renal vein is first ligated before the hypernephroma is mobilised. A long upper paramedian incision with a transverse extension at the level ofthe umbilicus, dividing the rectus and the lateral abdominal muscles is mostly employed. The peritoneum on the posterior wall is incised along the lateral side of the flexure of the colon. The colon is then mobilised and displaced medially to expose the anterior surface of the kidney and its vessels. At the end of the operation the peritoneum which was incised is sutured back and the retro-peritoneal space is drained through the loin. Gravity and peristalsis both contribute to spontaneous passage into and down the ureter. Stones with other composition have smooth surfaces and are often passed through the ureter without being impacted. A ureteral stone is only detected when it causes some symptoms due to its presence in the ureter or any pathological changes to the kidney or ureter. If the stone remains for weeks or months irrepa rable damage to the renal parenchyma may occur. There are 3 sites of anatomical narrowing of the ureter where a stone may be arrested. These are — (i) pelviureteral junction, (ii) when the ureter crosses the iliac artery and (iii) where it enters through the bladder wall. Occasionally a stone may remain lodged in a ureter for many months without harming the kidney. When the stone has impacted patient may complain of dull ache which gets worse during walking and exercise. Pyelitis, pyelonephritis and pyonephrosis (from hydronephrosis) may occur due to infection. Diverticulum in the wall of the ureter may occur when the stone gets impacted and ulcerates the epithelium of the ureter. With the formation of diverticulum pain totally goes off with false belief of the patient that the stone has passed away. It is repeated at longer or shorter intervals till the stone is ejected into the bladder or becomes impacted in the ureter. This colic becomes severe when the stone becomes arrested at the anatomical narrowings of the ureter. In case of ureteric colic there is radiation of pain the position of which suggests the position of arrest of stone in the ureter. When the stone is arrested high in the ureter the pain passes from the loin to the groin along the distribution of the iliohypogastric and ilioinguinal nerves. When the calculus is in the lower-third of the ureter, colic starts at a lower level and radiates to the testicle in the male or labium majus in the female and to the medial aspect of the thigh as the pain is referred along the two branches of the genitofemoral nerve. This is due to common segment of innervation of the lower ureter and the genitofemoral nerve. When the stone enters the intramural part of the ureter, the pain is referred to the tip of the penis in the male and strangury’ in both sexes. The position of this dull ache depends on the position of impaction of the ureteric calculus Such pain is due to capsular tension and distension of the renal pelvis. This pain is aggravated by exercise, movement and jolting and is relieved by rest. The ureteric stone often gets impacted in the pelvic part of the ureter and at that time dull ache is complained of at the iliac fossa. When this pain passes off, it is due to the stone has formed a false diverticulum due to pressure necrosis at the point of impaction. When the pain becomes gradually severe for 1 or 2 days and then gradually subsides, it suggests complete obstruction of the ureter by the stone. Even in the absence of infection symptoms of urgency and frequency of urination may be complained of when the stone is very near the bladder. This may mimic intraperitoneal pathologies like peptic ulcer, cholelithiasis or acute appendicitis. This often gives difficulty in differentiating this condition from acute appendicitis when the right ureter is involved. On many cases no radio opaque stone may be seen due to its small size or presence of intestinal gas shadows in front of the stone. Sometimes the shadow may be of phlebolith or some other intra-abdominal calcification and not of ureteric calculus. It must be remembered that ureter starts at the level between the first and second lumbar vertebrae, somewhat higher on the left side and traverses in front of the tips of the transverse processes of the lumbar vertebrae. It then runs in front of the sacro iliac joint and then in front of the tip of the ischial spine after which it turns medially and forwards to enter into the bladder. But even in these cases a nephrogram may be seen without a good visualisation of renal pelvis or ureter. This also indicates ureteric obstruction with good reasonable renal function In excretory urography the following findings help in the diagnosis :— (a) The stone lies in the ureter with some dilatation of the ureter above the stone.
Low-density generic lariam 250mg on-line, nonenhancing cystic areas Note the mild peripancreatic inflammation and extensive within an enlarged spleen generic lariam 250mg amex. Although the etiology of this generally asymptomatic condition is unknown buy lariam 250mg with visa, it may be associated with malignant hemato- logic diseases (Hodgkin’s disease order lariam 250 mg mastercard, myeloma), disseminated malignancy, tuberculosis, the use of anabolic and contraceptive steroids, prior Thorotrast injection, and certain viral infections. Contrast-enhanced scan in an asymptomatic man obtained during the hepatic parenchymal phase shows multiple discrete nodules throughout the spleen. Multiple rounded, low-attenuation lesions of different sizes to local deposits of glucocerebroside in reti- throughout the splenic parenchyma. The hemoperitoneum (*) occurred secondary to trauma and was unrelated to the splenic peliosis. Infarction Perfusion defect on delayed contrast-enhanced A typical feature is the rim sign of capsular images enhancement that is caused by blood supply from capsular vessels. They usually do not show peripheral enhancement in the acute stage because of the immunocompromised state of these patients, or in the chronic stage because of fibrotic changes. Contrast T1-weighted image shows a huge homogeneous, nonenhancing mass that causes lateral displacement of the normal splenic parenchyma. Smaller T1-weighted images and usually hyperintense hemangiomas may show homogeneous en- on T2-weighted images. Characteristic peri- hancement on immediate postcontrast images, pheral enhancement with centripetal, delayed remaining enhanced on delayed studies. Contrast T1-weighted, fat- saturated image shows peripheral enhancement of a huge cyst-appearing lesion in a man with endocarditis. Axial T2-weighted image shows a round, hypointense mass in the anterior portion of the spleen, representing an old, healed hematoma. T2-weighted, fat-saturated image shows multiple, round, hyperintense lesions in the liver and spleen (arrowheads) representing Candida microabscesses. By the final image, the nodules have become almost completely isointense to the splenic parenchyma. Contrast T1-weighted image shows a sub- capsular multilocular mass with hypoitense (arrowheads) and hyperintense (arrow) nonenhancing areas, revealing their cystic nature. Lymphoma Multiple focal lesions, diffuse splenic involve- Most common splenic malignancy. Generally be hypointense on T2-weighted images, unlike isointense to splenic parenchyma on both metastases, which rarely exhibit this appearance. Immediate post- contrast images show hypovascular nodules, which usually become rapidly isointense to the spleen. Coronal fat-saturated T2-weighted image shows a heterogeneous hyperintense mass in the inferior pole of the spleen. Immediate postcontrast T1-weighted image (A) shows multiple small hypovascular nodules that are not detectable on a delayed scan (B). Angiosarcoma Multiple nodular heterogeneous masses with Rare primary malignancy of the spleen. T2-weighted image shows a heterogeneous mass with central hyper- intense areas representing regions of necrosis. Sagittal unen- hanced T1-weighted image shows a bilob- ulated mass surrounding and extending to the spleen (*). Note the presence of a fluid- fluid level within the superior component of the mass with hyperintense signal of the de- pendent compartment, indicating its hemor- rhagic content. Immediate postcontrast T1-weighted image in a patient with disseminated tuberculosis shows a multicystic mass (arrows) with septal and peripheral enhancement. Note the several liver lesions with peripheral enhancement (arrowheads), which were not detectable on the unen- hanced image (not shown). Ascites is present in more originate from the ovary, stomach, pancreas, colon, than 70% of cases. Hematogenous metastases specific for peritoneal carcinomatosis and can frequently develop from malignant melanoma, as be seen in other diffuse infiltrative lesions. Malignant peritoneal Variable appearance that may include ascites, Unusual condition that accounts for 12% to 30% of mesothelioma irregular or nodular peritoneal thickening, a mesotheliomas. Large amount of semination of malignant melanoma causes multi- ascites with even peritoneal thickening (arrow- ple nodules in the peritoneal space, including the head) and diffuse omental infiltration (arrow) omentum (arrows), retroperitoneal spaces, and the without associated lymphadenopathy. Diffuse platelike mass in the greater omentum (arrows), massive ascites, and peritoneal thickening. Scalloping of visceral appendix, ovary, pancreas, stomach, colon, or surfaces, especially the liver, is diagnostic. Omental involvement the appearance closely mimics peritoneal carci- causes smudging and caking rather than a nomatosis and tuberculous peritonitis. There is curvilinear or punctuate calcifications of the seeding nodules; scalloping of the liver, spleen, and stomach; and small bowel adhesions from mesenteric infiltration. Innumerable seeding nodules in the peritoneal cavity and omentum (white arrow) with evidence of ascites. Multiple enlarged lymph nodes with conglomeration (black arrows) are seen in the retroperitoneal spaces. The appearance varies from a mild infiltrative haze to the presence of mass-like lesions with discrete margins. Solid/cystic mass lesions Primary neoplasm Benign tumors are usually well circumscribed, Must less common than secondary processes. Both types can appear complex, with fibrous histiocytoma, hemangiopericytomas, leio- cystic and solid elements. Extensive peritoneal soft-tissue infil- 194 volving the mesentery, omentum, and parietal tration and multifocal coarse calcifications. Predominantly cystic/ Single or multiloculated fluid-filled mass with a Cystic lymphangioma, enteric duplication cyst, developmental lesions thin wall and occasional septa. Large lobulated mass (arrows) in mass in the mid-abdomen, inferior to the the left upper quadrant of the abdomen stomach. The thickened peritoneum (arrow) representing an exophytic carcinoma ex- adjacent to the mass is suggestive of a tending directly from the greater curvature of malignant lesion, which in this case was an the stomach. As an abscess or secondary to an adjacent inflammation matures, the surrounding peritoneal membrane (pancreatitis, pericholecystitis) or surgery. Common thickens and shows marked contrast enhance- locations include the right subphrenic space, the ment. A gas-fluid contrast is often necessary to differentiate a fluid- level indicates fistulization to the intestinal containing intestinal loop from an abscess. Paragonimiasis can produce multiple, small, often densely calcified nodules scattered in the peritoneal cavity. Frequently occurring on the right, resemble infiltration from more ominous the nonspecific clinical appearance may be difficult causes. A pattern of whirling fatty tissue around to distinguish from acute appenditicits or a vascular structure may be a specific finding. Multifocal ill-defined cystic a lobulated cystic mass in the greater omentum lesions and several nodules (arrow) in the inferior to the gastric antrum. Large, well-circumscribed mass with dense tion and congestion with a secondary mass calcification in the anterior mid-abdomen, an appearance suggestive of (arrow) in the right lower aspect of the anterior a foreign-body granuloma or organizing hematoma. The patient had a palpable mass for 10 years that developed soon after a Caesarian section. An exudative response may lead to com- plications of fistula or abscess formation. Sclerosing encapsulating Dilated small bowel at the center of the Rare benign cause of acute or subacute intestinal peritonitis abdomen, encased within a thick fibrocol- obstruction. Sagittal scan shows herniation of omental fat through a defect (arrow) in the anterior abdominal wall. Focal ill-defined lesions with increased attenuation (arrowheads) in the omental fat adjacent to the abdominal wall defect are suggestive of omental fat infarction secondary to vascular compromise. However, this may be reduced in a patient with anemia (decreased serum hematocrit level) or in a hemorrhage that is more than 48 hours old. The sentinel clot sign is valuable for identifying the dominant source of hemoperitoneum in patients with multiple injuries from trauma.
If the tumor presses on an area of the brain associated with a particular function generic lariam 250 mg on line, deficits of that function may be evident generic 250 mg lariam with visa. Infectious problems have a timetable of days or weeks purchase 250 mg lariam with amex, and often an identifiable source of infection in the history 250mg lariam visa. The specific symptoms depend on the area of the brain affected, which is in turn related to the vessels involved. The most common origin is high-grade stenosis (≥70%) of the internal carotid or ulcerated plaque at the carotid bifurcation. Carotid endarterectomy is indicated if the lesions are found in a location that explains the neurologic symptoms. Except for very early strokes, ischemic stroke is no longer amenable to revascularization procedures. An ischemic infarct may be complicated by a hemorrhagic infarct if blood supply to the brain is suddenly increased. There is a current movement to reeducate physicians to recognize very early stroke and treat it emergently with clot busters. Subarachnoid hemorrhage can be caused by rupture of an intracranial aneurysm as well as trauma or even spontaneous bleeding. The amount of pressure the free blood exerts on the brain determines the severity of symptoms and resultant outcome. With significant pressure exertion, especially when caused by an aneurysm, patients complain of severe, sudden onset headache—“the worst of their life. Treatment for a cerebral aneurysm is either open clipping of the aneurysm or endovascular coiling with good results. If leaking from an aneurysm results in minimal pressure exertion on the brain, patients are not very symptomatic and do not necessarily seek medical attention. Many such patients tend to represent in a delayed fashion, usually 7-10 days after the “sentinel bleed. Accordingly, a very high index of suspicion at initial presentation can be life-saving. While awaiting surgical removal, treat any increased intracranial pressure with high-dose steroids (i. Clinical localization of brain tumors may be possible by virtue of specific neurologic deficits or symptom patterns. For example, the motor strip and speech centers are often affected in tumors that press on the lateral side of the brain, producing symptoms on the opposite side of the body (people speak with the same side of the brain that controls their dominant hand). Other classic clinical pictures include the following: Tumor at the base of the frontal lobe produces inappropriate behavior, optic nerve atrophy on the side of the tumor, papilledema on the other side, and anosmia (Foster-Kennedy syndrome). Craniopharyngioma occurs in children who are short for their age, and they show bitemporal hemianopsia and a calcified lesion above the sella on x-rays. Transnasal, trans-sphenoidal surgical removal is reserved for those who wish to get pregnant, or those who fail to respond to bromocriptine. Acromegaly develops from the effects of excess growth hormone from a pituitary tumor. It is recognized by the height and the presence of large hands, feet, tongue, and jaws. Additionally, there is hypertension, diabetes, sweaty hands, headache, and the history of wedding bands or hats that no longer fit. Pituitary apoplexy occurs when there is bleeding into a pituitary tumor, with subsequent destruction of the pituitary gland. The history may have clues to the long-standing presence of a pituitary tumor (headache, visual loss, endocrine problems), and the acute episode starts with a severe headache, followed by signs of increased compression of nearby structures by the hematoma (deterioration of remaining vision, bilateral pallor of the optic nerves) and pituitary destruction (stupor and hypotension). Steroid replacement is urgently needed, and eventually other hormones will need to be replaced. Tumor of the pineal gland produces loss of upper gaze and the physical finding known as “sunset eyes” (Parinaud syndrome). It produces cerebellar symptoms (stumbling around, truncal ataxia) and the children often assume the knee-chest position to relieve their headache. Brain abscess shows many of the same manifestations of brain tumors (it is a space-occupying lesion), but develops much more quickly (a week or two). There is fever, and usually an obvious source of the infection nearby, like otitis media or mastoiditis. Patients often describe that the pain feels “like a bolt of lightning” brought about by touching a specific area, and lasts 60 seconds. The only finding on physical exam may be an unshaven area in the face (the trigger zone, which the patient avoids touching). Reflex sympathetic dystrophy (causalgia) develops several months after peripheral nerve injury (e. There is constant, burning, agonizing pain that does not respond to the usual analgesics. A successful sympathetic block is diagnostic, and surgical sympathectomy is curative. There is severe testicular pain of sudden onset, but no fever, pyuria, or history of recent mumps. The testis is swollen, exquisitely tender, “high riding,” and with a “horizontal lie. This is one of the few urologic emergencies, and immediate surgical intervention is indicated. After the testis is untwisted, an orchiopexy is done to prevent recurrence; simultaneous contralateral orchiopexy is also indicated. It is seen in young men old enough to be sexually active, and it also starts with severe testicular pain of sudden onset. There is fever and pyuria, and although the testis is swollen and very tender, is in the normal position. Acute epididymitis is treated with antibiotics, but U/S is typically performed to avoid missing a possible diagnosis of testicular torsion. The combination of obstruction and infection of the urinary tract is the other condition that is a urologic emergency. Any situation in which these two conditions coexist can lead to destruction of the kidney in a few hours, and potentially to death from sepsis. A typical scenario is a patient who is being allowed to pass a ureteral stone spontaneously, and who suddenly develops chills, fever spike 40–40. This should be accomplished by the quickest and simplest means (in this example, ureteral stent or percutaneous nephrostomy), deferring more elaborate instrumentations for a later, safer date. Patients have frequency, painful urination, with small volumes of cloudy and malodorous urine. Pyelonephritis, an infection involving the kidney, produces chills, high fever, nausea and vomiting, and flank pain. Acute bacterial prostatitis is seen in older men who have chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender prostate on rectal exam. Gentle catheterization can be done to empty the bladder (the valves will not present an obstacle to the catheter). Voiding cystourethrogram is the diagnostic test, and endoscopic fulguration or resection will get rid of them. The urethral opening is on the ventral side of the penis, somewhere between the tip and the base of the shaft. Circumcision should never be done on such a child, inasmuch as the skin of the prepuce will be needed for the plastic reconstruction that will eventually be done. Vesicoureteral reflux and infection produce burning on urination, frequency, low abdominal and perineal pain, flank pain, and fever and chills in a child. The patient feels normally the need to void, and voids normally at appropriate intervals (urine deposited into the bladder by the normal ureter); but is also wet with urine all the time (urine that drips into the vagina from the low implanted ureter). Thus the classic presentation is an adolescent who goes on a beer- drinking binge for the first time in his life and develops colicky flank pain. Most cases of hematuria are caused by benign disease, but any patient presenting with this condition should get a work-up to rule out cancer (the one exception is the adult who has a trace of urine after significant trauma who needs a work-up but not to identify cancer). Renal cell carcinoma in its full-blown picture produces hematuria, flank pain, and a flank mass. That full-blown picture is rarely seen today, since most patients are worked up as soon as they have hematuria. Surgery is the only effective therapy and may include partial nephrectomy, radical nephrectomy, or even inferior vena cava resection.
Abduction is corrected by tilting the pelvis downwards and scoliosis of the lumbar spine with convexity towards the affected side generic 250 mg lariam with visa. This is called the stage of apparent lengthening buy lariam 250 mg low price, as the pelvis is tilted downwards and the affected limb Fig discount 250mg lariam amex. This 2 (Arthritis) — the effusion subsides will flex the affected thigh to the extent of ‘fixed flexion’ deformity discount lariam 250 mg fast delivery. This leads to spasm of the powerful adductors and flexors of the hip to protect its movements, which is very painful. So the attitude becomes one of the slight flexion, slight adduction and medial rotation (Fig. Adduction is corrected by tilting the pelvis upwards resulting in scoliosis of the lumbar spine with convexity towards the sound side. This is called the stage of apparent shortening, as the pelvis is tilted upwards and the affected limb looks shorter than its fellow. The attitude is more or less similar to that of stage 2 except for the fact that deformities are exacerbated at this stage. In this context one should remember the various causes of pathological dislocation. In adolescent coxa vara, the attitude is one of marked external rotation with slight adduction possibly due to eversion of the femur resulting from upper epiphyseal separation. In congenital dislocation of the hip, the attitude is one of lordosis, which is particularly marked in bilateral cases with undue protrusion of the abdomen anteriorly and the buttock posteriorly. In unilateral cases the grooves between the labia (girls are more often affected) and the thigh are Fig. Note the deformity of of flexion, abduction and flexion, adduction and can be noticed. It must be remembered that flattening of the buttock and loss of gluteal fold may be brought about by flexion of the limb besides muscular wasting. Tenderness — of the hip joint is elicited by applying steady pressure inwards over the two greater trochanters (Fig. Tenderness over the joint a little below the midinguinal point can be elicited in any arthritis. Palpation of the greater trochanter is important to note whether it is broadened or tender and whether it is displaced upwards or not. As the hip joint lies in its socket and is heavily clothed with strong muscles all around, this joint is almost inaccessible. The deformity is one of marked finger is pressed deep to detect if there is any tenderness or not. For cold abscess one should search the following regions : (a) in front of and medial of the greater trochanter, (b) on the medial side of the femoral vessels, (c) posteriorly in the gluteal region and (d) rarely in the pelvis from perforation of acetabulum. Such abscess may gravitate towards the ischio-rectal fossa and may burst to form fistula-in-ano. This artery passes over the head of the femur and this bony support helps its palpation. In congenital dislocation the head of the femur is dislocated and this bony support is missing. During examination the clinician must always compare the range of a certain movement of the affected joint with that of the sound counterpart. This is because of the fact that the range of each movement varies according to the individuals. Simultaneous steady pressure Flexion — with the knee extended cannot be done inwards over the two greater trochanters elicits more than 90° due to the tension of the hamstring pain on the affected side. Extension — is permitted to about 15°; Abduction — to about 40°; Adduction — to about 30°, that means the limb can be made to cross the middle third of the other thigh. Internal rotation — is possible to about 30° and external rotation — to about 45°. During testing the movements (both active and passive movements) one must make sure that the pelvis does not move. When there is a "fixed feel in congenital dislocation of hip because flexion deformity", the exact range of free flexion present of loss of bony support. The thigh of the sound side is held and the patient is asked to make an attempt to flex the affected hip. Any bending of the thigh beyond the position of "fixed flexion" is the range of free flexion permissible to the joint. When there is no fixed flexion deformity, extension of the hip joint is best tested by lying the patient ■“■■■■ ■ in prone position on the table and asking him to lilt allected limb (fig. In case of children the thumb and the middle finger of the left hand of the clinician are used to touch the two anterior superior iliac spines so that any movement of the pelvis will be detected Fig. It may be noted that the abduction is the first movement to be restricted in tuberculous arthritis. It is noted whether the limb crosses the sound thigh at its upper third or middle third or lower 5. Note that the clinician touches the two anterior clinician places the Hk superior iliac spines to detect any flat of his hand upon movement of the pelvis. Rotatory movement can also be tested by flexing both the hip and the knee joints of the affected side to the right angles and then rotating the thigh internally and externally Fig. These movements are also method of testing the abduction move tested by asking the patient to lie on his face to flex the ment with acutely flexed knees. The restriction of different movements depends upon the nature of affection of the hip joint. In any arthritis, including tuberculous variety, restriction of all the movements is the characteristic feature. In adolescent coxa vara, there will be limitation of abduction and internal rotation, but adduction and external rotation are not only be free but often exaggerated. In congenital dislocation of the hip, abduction and rotations are limited to varying degree, flexion and extension are free whereas adduction is excessive. So testing rotations of the hip joint the following three tests are performed when this condition keeping both the hip and knee joints is suspected. The hip is now flexed to 90° and the knee is grasped with the other hand of the clinician, who pushes the thigh downwards along the axis of the thigh with this hand, while the other hand notes Fig. This test can be performed in ‘fixed flexion’ defor telescopic test" is seen in performed in ‘fixed flexion’ defor mity of the hip. The lower limbs are now completely adducted and pressure is exerted downwards along the bony axis of the femur while the little fingers of both the hands are placed on the greater trochanters. The little fingers on the greater trochanter are now pushed inwards simultaneously. When only length of the thigh is measured, measurement is taken from anterior superior iliac spine to the joint line of the knee. It must be remembered before taking the measurement that the interspinous line is brought to the horizontal Fig. While comparing the length of the affected limb with that of the sound limb, the sound limb must be placed in the same position as the affected one. This mark is made on both the limbs and circumferences of the limbs at that level are compared. The greater trochanter is raised in dislocation of the hip, separation of the upper femoral epiphysis (adolescent coxa vara) and to a slight extent when the head of the femur eroded e. Rectal examination should be undertaken in tuberculous arthritis if an intrapelvic abscess is suspected. The thigh of the normal side has of the femur becomes obvious this line will be been adducted the affected hip is deformed in adduction. The neck is anteverted and is not properly seen in X-ray due to super imposition. When the dislocation is of mild nature, the following lines are drawn to detect the pathology. On the right side which is affected by Perthes’ disease, and a vertical line is drawn down if this line is drawn it will not correspond with the upper curved from the outer edge of the acetabulum border of the obturator foramen. The upper femoral epiphysis normally lies medial to the vertical line and below the horizontal line. But in congenital dislocation of the hip the epiphysis will lie on the outer aspect of the vertical line and above the horizontal line.