Hip Examination

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Hip Examination

• Marc Quinn

2
Introduction

• Orthopaedics (Greek)
• Ortho Straight
• Paedia Child
• Always remember
• Look
• Feel
• Move
• Special tests

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Background Skeletal Anatomy
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Background Skeletal Anatomy
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Background Hip Flexors

• Hip flexors include
• Psoas (assisted by iliacus)
• Also
• Tensor fasciae latae
• Sartorius muscle
• Pectineus muscle
• Adductor longus muscle
• Adductor brevis muscle
• Rectus femoris muscle

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Background Hip Extensors/Abductors/Adductors

• Hip Extensors
• Gluteus Maximus
• Hamstrings
• Hip Abductors
• Gluteus Medius and minimus
• Hip Adductors
• Adductor Brevis, longus and magnus

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Please examine this patients hip

• Introduce yourself
• Hello my name is.. Im a fourth year
  medical student.
• Consent the patient for examination
• The doctor has asked to examine your hips. This
  will involve me doing some measurements and
  asking you to do some hip movements. Is that OK
  with you?
• Expose the patient
• The whole lower limb should be exposed ask
  patient to remove any trousers but to keep
  underwear on. Use a blanket to preserve dignity

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Inspection

• Ive not seen this patient walk into this
  cubicle, therefore I am unable to comment on any
  pain this patient maybe experiencing or on this
  patients gait
• From the end of the bed
• Look for clues eg. walking stick, Delta
  Rollator

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Inspection

• Scan patient from head to toe
• Does patient look well or unwell?
• Any obvious conditions eg. a recent surgical
  scar
• Patient is comfortable and looks well
• There is no obvious deformity or leg length
  discrepancy (Fixed flexion deformity)
• No obvious external rotation (NOF)
• No obvious muscle wasting (Quadriceps)
• Show the examiner that you are looking for scars
  There are no obvious scars from surgery to the
  hip (Look for arthroscopy scars aswell!!)

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Measurements

• True leg length
• Measure from A.S.I.S to inferior border of medial
  malleolus

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Measurements

• True Shortening
• In true shortening the affected limb is
  physically shorter than the other and this may be
  caused by pathology proximal or distal to the
  trochanters.
• True shortening from causes distal to the
  trochanters most frequently results from previous
  fractures of the femur or tibia or growth
  disturbance (e.g. from polio or epiphyseal
  trauma). Proximal to the trochanters causes
  include femoral neck fractures, OA and hip
  dislocation.

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Measurements

• Apparent leg length
• Measure from tip of xiphoid process to inferior
  border of medial malleolus
• Apparent Shortening
• In apparent shortening the limb is not altered in
  length, but appears shortened. This may be as a
  result of an adduction contracture of the hip
  joint, which has to be compensated for by tilting
  of the pelvis, or SIJ pathology causing pelvic
  rotation.

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Palpation

• Now ask the patient
• Do you have any pain in your hips? (if
  so, find out which one could be both!)

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Palpation

• The hip joint is very deep hence unusual to get
  localising tenderness.
• Feel for
• The Anterior Superior Iliac Spines (A.S.I.S)
• Ischial Spines
• Also check Temperature Check for heat over
  the anterior surface of the hip joint (??Septic
  arthritis)
• Greater Trochanter
• Identify the inverted horseshoe shaped bony
  prominence over the lateral aspect of the thigh

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Palpation

• Check for tenderness over the greater trochanter
  Trochanteric bursitis (area of inflammation
  over the trochanteric bursa)
• Symptoms include deep, boring pain in the gluteal
  region.
• The cause is usually repetitive trauma or
  pressure (and OA)

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Movement

• Expected Range of Movement
• Flexion 0-130 Degrees
• Abduction 0-45 Degrees
• Adduction 0-30 Degrees
• MR 0-45 Degrees
• LR 0-60 Degrees
• Extension 0-20 Degrees

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Movements

• Thomas test
• Place your left hand in hollow of lumbar spine
• Flex hip and knee of unaffected side
• Look to see if hip of the affected side lifts
  from bed
• Flexion
• Flex hip and knee of affected side and note ROM
  (130)

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Movements

• Abduction
• Stabilise pelvis and hold ankle with other hand
• Abduct and note ROM (45)
• Adduction
• As above and note ROM (30)

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Movements

• Rotation
• Flex hip and knee to 90 degrees, externally and
  internally rotate
• Note ROM (45)
• Abnormal Movement (telescoping)
• Alternately push and pull leg along its long axis
  demonstrates marked instability

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Stand

• If time and patient condition permitting
• Inspect again for
• Anteriorly Rotational deformity
• Laterally Increased Lumbar Lordosis
• Posteriorly Scoliosis, Gluteal Wasting

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Trendelenberg Test

• Used to assess the ability of the hip abductors
  to stabilise the pelvis on the femur.
• A positive test demonstrates that the hip
  abductors are not functioning.
• Causes
• Disturbance in pivotal mechanism dislocation or
  subluxation of hip, shortening of femoral neck
• Weakness of the hip abductors e.g. myopathy,
  neuropathy

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Trendelenberg Test

• The test is performed with the patients back to
  the examiner. The model stands on the normal leg
  and flexes the knee of the other leg to a right
  angle.
• The pelvis should remain level or tilt slightly
  upwards on the unsupported side.
• The model then stands on the affected leg and
  flexes the knee of the other leg.
• If the pelvis tilts downwards on the unsupported
  side, then this confirms a positive Trendelenberg
  sign.

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Trendelenberg Test
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Complete Examination

• Thank the patient and make sure they are
  comfortable
• Turn to the examiner and say
• To complete the examination I would like to do
  the Trendelenberg test, analyse this patients
  gait, examine this patients Lumbar spine knee
  and assess functional aspects in more depth. I
  would also like to request an AP and lateral
  X-ray of the hip joint
• Then Present your findings.

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Differentiating Hip Pain
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The Osteoarthritic Hip on examination

• Inspection
• limp with a positive Trendelenburg sign
• the patient lies with affected leg adducted and
  in external rotation
• apparent leg shortening on measurement
• Movements
• restriction of movements at the hip joint
• flexion deformity may be present - positive
  Thomas' test

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Questions Osteoarthritis

• Q What is the first movement to become affected
  in osteoarthritis of the hip?
• A Internal rotation of the hip
• Q What is the difference between true and
  apparent leg shortening
• A True due to joint or bony abnormality.
  Apparent due to pelvic tilting (as occurs in
  fixed flexion / adduction deformity)

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Questions Osteoarthritis

• Q Describe radiological appearances of OA and RA
• OA asymmetrical narrowing of the joint space
  with sclerosis of subcondylar bone, cysts close
  to the joint surface and osteophytes at the joint
  margin.
• RA periarticular osteoporosis, marginal bony
  erosion, narrowing of joint space. At later
  stages, destruction and deformity, with
  subluxation of the joint surfaces

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OA X-Ray
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Questions Osteoarthritis

• Q How would you manage a patient with arthritis
  of the hip
• A Analgesia/ Physiotherapy / walking aids/
  Surgery
• Q What are the operations available for a
  patient with osteoarthritis of the hip
• A Total Hip Replacement (THR) in older patients
  / Birmingham Hip Resurfacing (BHR) in younger
  patients (approx. less than 60 years old)

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Hip Replacements
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Questions Osteoarthritis

• Q What are the complications of a THR
• A Chronic infection in 1 / Acute dislocation
• Q What are the contraindications to a THR
• A Young patients who are active / when there is
  doubt to the origin of the hip pain / mild
  disease / obesity

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Painful Paediatric Hips

• Perthes disease
• Aseptic necrosis of the upper femoral epiphysis
• Aged 3-10, Boys affected more often, aetiology
  unclear, bloods normal, X-Ray, conservative Mx
• Slipped Upper Femoral Epiphysis
• Slip of the upper femoral epiphysis on its
  metaphysis
• Often occurs during puberty (? Hormonal
  imbalance) following trauma in obese or very
  tall/thin
• Refer for internal fixation

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Painful Paediatric Hips

• Irritable Hip (Transient Synovitis)
• Common and sudden cause of painful hip and limp
  mild presentation to severe difficulty WB
• Follows viral illness e.g. URTI
• Pyrexia, increased WCC/ESR/CRP suggest infection
• Discharge with NSAID unless significant physical
  signs orthopaedic referral