examination of hip

flow of events

1. GIEP
2. Handwashing
3. gait inspection
4. inspection
5. palpation
6. measurements
7. movements
8. special tests

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You may start your examination by gait inspection.

in a hip problem, the 2 commmonest presentations are;

• pain
• deformity

so take note of any limping due to the above 2 reasons-

how do we recognize an antalgic gait (painful limping)?

• patient is reluctant to walk.
• slow movement

what do we observe in a gait?

• 2 phases of walking 
• stand phase
• swing phase

stand phase is reduced in antalgic gait. - the leg which the patient spends the least time standing on independantly, is the painful leg.

stand phase is normal and equal in both legs if ONLY deformity is present with absence of pain.

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inspection

firstly, comment that in a proper inspection, you would expect the patient to be in minimal clothing e.g. just a brief in male patients.

look for any

• swelling
• redness
• obvious deformities
• scars
• nodules (rheumatoid nodules etc)
• symmetry and difference in length (you may look from the bottom of the bed)

you can turn the patient over to observe the above from the back. or let the patient stand if no complains of instability.

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palpation

*please note general rules of palpation

• start from the normal limb
• warm hands
• warn patient
• ask for any pain

first, palpate generally for

• temperature difference - inflammatory arthritis and infections are warm.

then palpate specifically

• ASIS
• Greater trochanter of femur
• head of femur
• insertion of adductor longus (not compulsury)

also, these are the things that you MAY palpate (but not on syllabus i think)

• PSIS (dimple of venus)
• Ischial tuberosity

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measurements

there are 2 main measurements;

• apparent lower limb length shortening
• true limb shortening.

the difference between those two is that "apparent" limb shortening may be due to ORIENTATIONAL difference - hence the limb is actually not deformed or shortened. it can be seen in dislocations etc. in "true" shortening, the limb shortening is due to the STRUCTURAL defect- hence, there is shortening in the actual length of the limbs, e.g. fracture, growth deformities etc.

so, here's what to do to measure those 2 measurements.

apparent limb shortening

1. square the pelvis. (marking criteria)you *square* the pelvis by making sure the hips exactly 90deg from your side- and you also go to the foot end of the bed to ensure the 2 legs are equal distant from the center line.
2. start from the xiphisternum, or sternal notch (Umbilicus is NOT recommended - because it is relatively mobile.
3. put the zero (inch) part of the tape measure at the xiphisternum
4. extend the tape towards knee
5. when you reach knee, try and follow the curvature of the leg (the leg may be a little bent - so show that you're following that and not straight from umbilicus to the medial mallulus.)
6. extend tape until the lower border of the medial mallulus. (I choose the lower border because the tip of medial mallulus may be not clear - may produce biased readings, same goes for the upper border)
   Specify where you take your reading to the examiner.
7. read the inch measure part, put a finger there
8. turn the tape measure over to read the cm measurement
9. repeat 1-8 in the other leg

you may be wondering why the *inch - flip over - cm* business. its so that we reduce bias. if we use cm straightaway, lets say one limb length was 88cm. you would register that in the mind and when you do the other limb, you might stop measuring at 88cm when the limb is actually longer... this can be avoided if the reading was in inch where each inch is further away from each other - so what you'd most probably do is point somewhere in between 34 and 35 inch *if limb is 88cm long* and flip over - oh its 88cm. after that, you point somewhere in between 34 and 35 again, but this time it may be 86cm. something like that.

when examiner ask you why you do it, just tell them "to reduce bias". they will nod, and you will continue.

next, TRUE limb shortening.

repeat the above step, except you do not start from the umbilicus - you start from the ASIS.

*remember to SQUARE the Pelvis*

IF you find any limb shortening, you need to find out WHERE the actual shortening is. is it at the hip joint? neck of femur? body of femur? knee joint? below knee?

there are several things you could do;

• bend patient's knees - put ankle-to-ankle. if the height of the knee is different, there is some shortening above the knee. - Galeazzi's sign
• Bryan's triangle - measure the horizontal and vertical distance between the ASIS and the greater tuberosity. they should be the same in both side. if not -e.g. if one is longer than the other, there may be dislocation.
• actual measurement - measure the true length from ASIS to knee, then knee to Medial Mallulus.

what if the patient has a fixed deformity?

• move the patient's normal leg to make the pelvis symmetrical, square the pelvis and measure the lengths.

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movements

there are 6 movements you'd have to do.

• abduction
• adduction
• external rotation
• internal rotation
• flexion
• extension

simple - just remember to

• fix the pelvis during abduction adduction, by placing your arm over the pelvis while movement. shall the pelvis move, that is the Max ROM.
• keep knee at 90 deg for rotations (if you intend to do the bend-knee technique)

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special tests

2 special tests

• Thomas's test
• trendelenburg's test

thomas' test is rather difficult to explain - but basically it is a test to detect Fixed-Flexion-Deformity. which means a deformity where you cannot fully straighten your leg from flexion.

so, people with FFD *Fixed Flexion Deformity* will have to compensate by their lumber lordosis - by bending their backs towards their belly. imagine a proud person - sticking out its belly. something like that.

so, to check if a person has FFD, one can do thomas's test. - do this before checking the Range of motion.

pathophysiology of FFD - could be bony pathologies - malunion after fracture, childhood deformity e.g. SUFI, septic arthritis causing ankylosing hip, patients with rheumatoid arthritis soft tissue involvement.

this is the procedure (suspected FFD at RIGHT leg)

1. lie patient supine on bed
2. put hand into patient's back (lumber part) lumber lordosis
3. ask patient to flex his/her LEFT leg
4. at one point, you should feel the lumber lordosis obliterating (your hand will be squashed between the bed and the patient's back)
5. at that point, look at the patient's RIGHT leg - is it lifting from the bed?
6. if it is lifting, the test is positive - patient has FFD on its RIGHT leg.

think of it this way - if you have FFD, you either have to flex your hip, or bend your back. you cannot straighten both of them - so this thomas's test enables us to purposely straighten the patient's back so the patient will be forced to flex the hip - if s/he has FFD.

Trendelenburg's sign (not trendelenburg test)

in IMU, you will elicit trendelenburg's sign like this.

1. ask patient to stand up
2. instuct the patient
   "I would like you now to stand with one leg in the air, I will be of assistance shall you feel unstable, so don't worry" 
3. approach patient from the back
   "I will hold your hips from behind"
4. clutch the pelvis on the same level - ensure it is parallel to the ground
   "I will gently touch on the pelvis so that the tilt can be observed clearly.
5. ask patient to lift up the leg that is NOT BEING TESTED.
6. look at the pelvic tilt. if the pelvis tilts UP on the side the leg is lifted, it is a negative sign.
   If the pelvis tilt UP on the side the leg is on the ground / patient loses balance, it is positive.
7. report.

postitive trendelenburg sign suggests...

• incompetent gluteus medius / minimus / both
• fracture of femur
• dislocation of hip

*Credits to Joe for correct description of squaring of pelvis and trendelenburg:s sign