Hip examination

HISTORY It is important to bear in mind the following points when performing a hip examination:

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Age of the patient o Younger patients - traumatic injuries, osteonecrosis and developmental dysplasia of the hip are more prevalent o Older patients - hip fractures and osteoarthritis are more common Mechanism of injury Duration of problem CLINICAL EXAMINATION

Follow the scheme below:

Inspection Palpation Measurment Movement

Before starting

Introduce yourself Explain what the examination entails Ask permission to perform examination Expose the patient appropriately - from waist down exposing both the lower limbs, but leaving the underwear on Preserve dignity by using a blanket appropriately Tell the patient to let you know if anything you do is uncomfortable Remember - always watch the patients face

Inspection

General observation o Does the patient look well? o Is there a walking stick? Frame? o Is there a shoe raise? o Hands (Rheuamtoid arthritis?)

Patient Standing

Remember to inspect from all sides (front, laterally and from behind): o Skin Scars (previous injuries or surgical scars) Sinuses (secondary to TB or infected hip replacements) Colour - discolouration? o Deformity Abduction / adduction contracture Fixed flexion deformity Limb shortening

o o o

Limb rotation Scoliosis Lumbar lordosis Swelling (the hip joint is deep and thus swelling is not generally seen) Muscle wasting - look at the gluteal folds gluteals? quadraceps? Pelvic obliquity (anterior superior iliac spines (ASIS) not horizantal) Is there a leg length discrepancy? Is there a fixed deformity?

Patient Walking

Observe the patient walking. o Gait pattern. There are different types of gait: Stiff hip (pelvis swing) Antalgic (short stance phase) Short leg Trendelenburg (Lurching gait, watch the shoulders) Drop foot gait Broad based gait (ataxia) o Stride length o Use of a walking aid

Patient Lying down - supine with one pillow under the head

Observe the patient climb onto the examination couch Deformity o Rotational deformity is common in osteoarthritis (observe the position of the patella and foot on either side) o Fixed flexion deformity (look at the angle between the thigh and the bed). Perform Thomas's test at this stage (see below) o Abduction / Adduction deformity (adduction deformity - tilted pelvis and apparent shortening of that leg) Detailed check: o Skin - scars

Palpation Ask the patient.."Does it hurt anywhere?"

Skin temperature (use dorsal surface of your hand to compare temperatures over both hips) Is there tenderness over the bony landmarks? o Anterior and posterior superior iliac spines o Ischial Spine o Greater Trochanters (trochanteric bursitis) o Iliac crests o Ischial tuberosity (hamstring tear) o Pubic Tubercle Is there tenderness of the soft tissues? o Muscles o Femoral triangle Joint line tenderness (beneath the mid inguinal point)

Measurement

Before measuring, if a fixed deformity of one leg has been observed, the unaffeted leg should be placed in the same position as the one affected to make them identical. The different types of measurements to be taken are:

Apparent length - the distance between the xiphi-sternum (a fixed point) and the medial mallelous. True length - the distance between the ASIS and the medial malleolus Circumference of the quadriceps at a fixed point (from the tibial tuberosity).

If a difference has been observed in true leg length measurements, it is important to determine whether the shortening is above (femoral) or below (tibial) the knee:

Having asked the patient to bend their knees, keeping their ankles together, compare the position of both knees.

Movement These should be performed both actively and passively for both legs. When assessing hip movements, it is important to fix the pelvis and prevent any movement taking place at this anatomical structure. This is done either by dropping one leg over the edge of the couch and assessing movements of the other leg, or by placing one forearm between the ASIS's. Active movement

Flexion (0-130o)- "Can you bring your heel to your bottom?" Extension (0-10o) - Having asked the patient to lie prone, ask them to raise each leg off the bed with the knee straight. Abduction (0-45o) - "Can you move your leg away from the bed?" Adduction (0-30o) - "Can you move your leg across your other leg"

Passive movements Repeat the above movements but additionally testing for hip rotation.

Rotation - With each leg in turn, flex both hip and knee to 90o , and having stabilised it with one hand, move the heel first outwards (internal rotation - 0-45o) and inwards (external rotation - 0-45o) with the other hand.

Special Tests There are two special tests: Trendelenburg test - test of abductor function (gluteus medius weakness)

Stand behind the patient and identify the iliac crests Have another person in front of the patient for balance Ask the patient to stand on the normal and then the affected leg by flexing the knee rather than flexing the hip. This is for testing the abductors on the opposite side. Watch for the patients' response in terms of balance (truncal position) and pelvic tilt Negative test (normal) o If pelvis stays level or rises slightly, with the trunk staying over the pelvis (i.e. staying over the centre of gravity), AND can be maintained for 30 seconds. Positive test (abnormal) o The patient is unable to hold pelvis level and maintain this for 30 seconds.

The patient leans over to the affected side, in order to keep their centre of gravity over their foot

For further information about performing a Trendelenburg test, please Click Here. Thomas' test - test for fixed flexion deformity

Finally

With the palm up, place your hand beneath the lumbar spine Passively flex the unaffected hip until the hollow of the lumbar spine is eliminated The affected leg rises up from the bed, if there is a fixed flexion deformity present. Repeat for the other side

Check distal neurovascular supply.