Chapter 11: The Hip and Pelvis Flashcards
What are the three joints of the pelvic girdle?
- the hip joint (acetabularfemoral joint)
- the sacroiliac joint
- the pubic symphysis
The ___________ configuration of the hip is designed particularly to fulfill that dual function.
ball-and-socket
This joint may become involved pathologically, but seldom restrict function or cause pain. What are this joint of the pelvic girdle that known as immovable?
Sacroiliac joint pubic symphysis
This joint may become affected pathology, it becomes immediately perceptible during walking as pain or limited motion. What is this joint of the pelvic girdle that known as movable?
Hip joint
Inspection of hip and pelvis: True or False:
While the patient undresses, note whether he performs any particular maneuver that seems painful or inefficient. Quite often, an efficient movement is sacrificed for one that is less efficient but less painful.
True
Inspection of hip and pelvis:
When observed from the side, the lumbar portion of the spine normally exhibits a slight lordosis, neither unduly lordotic nor flat. What condition may result from absence of the normal lordosis?
Paravertebral muscle spasms
Anterior curvature of the spine is known as:
Lordosis
Inspection of hip and pelvis:
If the spine exhibits an _____________ , the anterior abdominal muscles may be weak, since they help to prevent the lumbar spine from becoming increasingly lordotic. Increased lumbar lordosis may also be caused by a fixed flexion deformity of the hip.
Exaggerated curve
The size and depth of the folds increase upon hip _________ and decrease upon hip _______.
Extension
Flexion
Inspection of hip and pelvis:
While observing the posterior aspect of the hip, notice that the lower borders of the buttocks are marked by the __________ . In infants, skin folds are situated symmetrically around the groin and along the thigh.
Gluteal folds
What are the conditions that may result to asymmetrical gluteal folds? may be due to a congenital disloca tion of the hip, muscular atrophy, pelvic obliquity, or a leg length discrepancy.
Congenital dislocation of the hip muscular atrophy pelvic obliquity length discrepancy
Inspection of hip and pelvis: Observe the two discernible dimples which overlie the posterior superior iliac spine directly above the buttocks. They should lie along the same horizontal plane. If they do not, there is evidence of __________.
Pelvic obliquity
What are the anterior aspects of the pelvic girdle?
- Anterior Superior
- Iliac Spines
- Iliac Crest Iliac
- Tubercle Greater
- Trochanter Pubic Tubercles
In Bony palpation, what is the position of the patient?
The patient may either stand or lie down, whichever is more comfortable.
Bony palpation: True or False:
If it is possible, some portion of this examination should be conducted while the patient is standing, since pathology overlooked in a non-weight-bearing position may become patently obvious under the stress of weight bearing.
True
Bony palpation of the anterior aspect: Your first contact should be gentle, yet firm. As you palpate, gauge the __________ and take note of any _________ elicited. It is best to palpate both sides at the same time to facilitate _______________ .
skin temperature
tenderness
bilateral comparison
Bony palpation of the anterior aspect: Stand in front of the patient and place your hands upon the sides of his waist with your thumbs on the _________________ and your fingers on the anterior portion of his iliac crests.
Anterior Superior Iliac Spines
Anterior Superior Iliac Spines: In thin patients, these bony prominences are __________ , but in obese patients, they are covered by and may be somewhat more difficult to find.
Subcutaneous adipose tissue
___________ - is subcutaneous, and serves either as a point of origin or of insertion for a variety of muscles.
Iliac Crest
Bony palpation of the anterior aspect:
To palpate, Keep your thumb upon the anterior superior iliac spine and move your fingers posteriorly along the lateral lip of the iliac crest. About three inches from the top of the crest, you can palpate the ___________ , which marks the widest point on the crest.
Iliac Tubercle
Bony palpation of the anterior aspect:
To palpate, With your thumbs still in place on the anterior superior spines, move your fingers down from the iliac tubercles to the ______________ of the femurs . The posterior edge is relatively uncovered, and, as such, is easily palpable.
Greater Trochanter
What covers the anterior and lateral potions of the greater trochanter?
Tensor fascia lata and the gluteus rnedius muscle
Normally, the trochanters are level. What are the two pathologies that could make the levels of the trochanters unequal?
A congenital hip dislocation hip fracture
Bony palpation of the anterior aspect: With your fingers anchored on the trochanters, move your thumbs along the inguinal creases medially and obliquely downward until you can feel the ____________ .
Pubic Tubercles
Pubic tubercles are hidden under __________ and the ___________ , the pubic tubercles are palpable bony protuberances. Note that they are on the same level as the top of the greater trochanters.
pubic hair
pubic fat pad (mons pubis)
what is the position of the patient on bony palpation of the posterior aspect?
The patient should lie on his side with his hip flexed
What are the posterior aspects of the pelvic girdle?
Posterior Superior Iliac Spines
Greater Trochanter
Ischial Tuberosity
Sacroiliac Joint
Bony palpation of the posterior aspect: These are easily located, for they lie directly underneath the visible dimples just above the buttocks. The spines are subcutaneous and easily palpable. With the patient lying on his side, anchor your thumb upon the upper spine and palpate along the posterior iliac crest to the iliac tubercle.
Posterior Superior Iliac Spines
The entire edge of the iliac crest is ___________ , from the posterior to the anterior superior iliac spines.
Subcutaneous
Bony palpation of the posterior aspect: Keeping your thumb upon the posterior superior iliac spine, move your fingers downward and you can again palpate the posterior aspect of the _____________.
greater trochanter
____________ - is located in the middle of the buttock at the approximately at the level of the gluteal fold.
Ischial tuberosity
The tuberosity is difficult to palpate if the hip joint is __________ , since the gluteus maximus muscle and fat pads cover it.
extended
How to palpate the ischial tuberosity ?
With your fingers in place upon the greater trochanter, move your thumb from the posterior superior iliac spine to the ischial tuberosity.
Which statement is true?
- If the hip is extended, the gluteus maximus moves upward and the ischial tuberosity becomes easily palpable.
- The tuberosities lie in the same horizontal plane as the lesser trochanters of the femurs.
2
This joint is not palpable, due to the overhang of the ilium and the obstruction of the supporting ligaments. It is rarely involved pathologically.
Sacroiliac Joint
Anatomic guidelines in identification of the lumbar spinous processes: The center of the joint, at S2, is crossed by an imaginary line drawn between the _______________ ; a line drawn across the top of the iliac crests crosses the spine between the ____________ .
posterior superior iliac spines
spinous processes of L4 and L5
True or False:
Because the hip joint lies deep and is heavily clothed by muscles, neither its components nor any possible abnormalities, such as a fracture of the proximal end of the femur or acetabulum, are palpable.
However, the combination of a visibly shortened extremity, external hip rotation, and pain upon motion strongly suggest a fractured hip.
True
What are the five clinical zone for soft tissue palpation of the hip and pelvic region?
Zone I - femoral triangle
II - greater trochanter III - sciatic nerve
IV - iliac crest
V - hip and pelvic muscles
___________ - is defined superiorly by the inguinal crease, medially by the adductor longus muscle, and laterally by the sartorius muscle ridge.
femoral triangle
What forms the floor of the femoral triangle?
The floor of the triangle is formed by portions of the adductor longus, the pectineus, and the iliopsoas muscles.
The _________ and __________ are superficial to the iliopsoas muscle, and the psoas bursa and hip joint lie deep to it.
Femoral artery
lymph glands
What is the position of the patient during soft tissue palpation of femoral triangle? This position puts the hip in flexion, abduction, and external rotation.
Most efficiently when the patient is supine, with the heel of the leg being examined resting upon the opposite knee.
___________ - is located between the anterior superior iliac spines and the pubic tubercles. Any unusual bulges along the course of this ligament may indicate an inguinal hernia
inguinal ligament
____________ - passes under the inguinal ligament at about its midpoint. Its pulse is palpable just inferior to the inguinal ligament, at a point halfway between the anterior superior iliac spine and the pubic tubercle .
Femoral Artery
Femoral Artery: Normally the pulse is quite strong, but if the ___________ or _________ is partially occluded, the pulse may be diminished.
common iliac artery
external iliac artery
__________ - lies deep to the femoral artery , but because it is covered by the thick anterior joint capsule (iliofemoral ligament) and the tendon and fibers of the psoas muscle, it is not palpable.
femoral head
___________ - lies lateral to the femoral artery; it is not palpable.
Femoral Nerve
___________ - medial to the femoral artery, is a clinical site for venous puncture. Under normal circumstances, it is not palpable.
Femoral Vein
____________ - which forms the lateral border of the femoral triangle, is the longest muscle of the body. It is palpable at its origin (slightly inferior to the anterior superior iliac spine), and is rarely pathologically involved .
Sartorius Muscle
This muscle is palpable when the legs are abducted away from the midline. It then forms a distinct ridge, extending from the area of the pubic symphysis toward the middle of the thigh. The proximal cordlike terminus of the muscle is particularly prominent.
Adductor Longus Muscle
___________ - is frequently pulled during strenuous activity or athletic endeavor, and may be ten- der to palpation. Occasionally, in spastic children, this muscle must be tenotomized to release the extremity from severe adduction and to prevent possible ____________ .
Adductor longus hip dislocation
The general area within the triangle should also be probed for enlarged lymph nodes, which may be a sign of an _________ ascending from the lower extremity, or of local ___________ .
infection
pelvic problems
What is the most medial structure in the femoral triangle?
lymph nodes
What are included in soft tissue palpation of Femoral Triangle ( zone I )?
Inguinal ligament
Femoral Artery
femoral head
Femoral Nerve
Femoral Vein
Sartorius Muscle
Adductor Longus Muscle
What are included in soft tissue palpation of Greater Trochanter ( zone II )?
Trochanteric Bursa
Gluteus Medius Muscle
What is the position of the patient in soft tissue palpation of greater trochanter?
The patient turn over on his side
____________ - Protects soft tissues that cross the bony posterior portion of the greater trochanter. Any tenderness might indicate trochanteric bursitis. The bursa itself is not palpable unless it is distended or inflamed. If it is inflamed, the area around it feels boggy and may be tender to palpation.
Trochanteric Bursa
This muscle inserts into the upper lateral portion of the trochanter.
Gluteus Medius Muscle
Soft tissue palpation of greater trochanter: When the hip is _________ , ________ , and ___________ , the tensor fascia lata can ride anteriorly over the greater trochanter; an audible and palpable snap becomes perceptible when it returns to a neutral position. This snap usually occurs in activities such as climbing or walking up stairs.
flexed
adducted
bearing weight
A condition that can generate a mild aching sensation or trochanteric bursitis, but rarely a problem of any magnitude.
snapping hip
What are the conditions that may cause tenderness of the sciatic nerve?
herniated disc in the lumbar spine
pyriformis muscle spasm
direct trauma to the nerve itself ( such as misplaced injection)
What is the position of the patient in Soft tissue palpation of Sciatic Nerve (Zone III )?
To palpate the soft tissues in this zone, have the patient remain on his side, with his back to you.
__________ - is located midway between the greater trochanter and the ischial tuberosity.
sciatic nerve
Soft tissue palpation of Sciatic Nerve: When the hip is _______ , the sciatic nerve is covered by the gluteus maximus’ muscle, but when it is ________ , the gluteus maximus moves out of the way.
extended
flexed
Soft tissue palpation of Sciatic Nerve: Palpate the greater trochanter and the ischial tuberosity again to determine the midpoint between them. If you press firmly into the soft tissue depression at that midpoint, you may be able to feel the _________ underneath the ________ .
sciatic nerve
fatty tissue
Note that there is a bursa overlying the ischial tuberosity. Tenderness elicited during palpation of the tuberosity may possibly result from ___________ , a rare finding.
ischial bursitis
__________ - can be easily confused with ischial bursitis and the two structures must be isolated and the precise area of tenderness identified to avoid error.
Sciatic pain
This area is clinically significant, first because the duneal nerves cross it, and second because the gluteus and sartorius muscles originate just below it.
iliac crest
What are included in soft tissue palpation of iliac crest ( zone IV )?
Cluneal Nerves
_________ - supply sensation to the skin over the iliac crest, between the posterior superior iliac spines and the iliac tubercles. When an iliac bone graft is taken, these nerves are often cut, and the crest should be palpated for possible neuromas in this nerve.
cluneal nerves
On occasion, ______________ may be found along the iliac crest. Such palpable enlargements are painful and very tender to the touch.
fibro-fatty nodules
In soft tissue palpation of the hip and Pelvic muscle ( zone V ) The superficial muscles of the hip and pelvic region lie in quadrants, according to their position and function includes:
1) Flexor grouping—anterior quadrant
2) Adductor grouping—medial quadrant
3) Abductor grouping—lateral quadrant
4) Extensor grouping—posterior quadrant
What are the muscles included in flexor group?
Sartorius Muscle
Iliopsoas Muscle
Rectus Femoris
__________ - is the primary hip flexor. It is not palpable, since it lies deep to other muscles and fascia. An abnormal contracture of this muscle may lead to a flexion deformity of the hip.
iliopsoas muscle
_________ - bursa that lies underneath the iliopsoas, and occasionally the iliopsoas contracting over an inflamed bursa causes pain in the inguinal area.
psoas bursa
_________ - is a traplike muscle that runs obliquely down, lie anterior at the aspect of the thigh.
Sartorius Muscle
____________ - crosses both the hip joint and the knee joint, acting as a flexor for the hip and an extensor for the knee . It is the only two-joint muscle in the quadriceps group.
Rectus Femoris
What is the dual origin of rectus femoris?
direct head and an indirect head
_________ , which takes origin from the anterior inferior iliac spine, It is the more commonly avulsed usually from sport injuries.
direct head
Neither head is distinctly palpable, since the muscle disappears proximally in the depression between the ________ and the ___________ . Either head (or both) can be torn from its attachments, and the area should be palpated for __________ .
sartorius tensor
fascia lata
tenderness
True or False:
Although it is difficult to distinguish the rectus femoris from the other quadriceps, it is impossible to detect an obvious deficit or rupture in the belly of the muscle.
False
What are the five muscles included in Adductor Group?
(1) the gracilis
(2) the pectineus
(3) the adductor longus
(4) the adductor brevis
(5) the adductor magnus
_________ - is the most superficial and the only muscle accessible to palpation among adductor group.
Adductor longus
What muscles are included in Abductor Group?
Gluteus medius and minimus muscles
__________ - lies deep to the gluteus medius and is not palpable.
Gluteus minimus muscles
_________- is the main hip abductor. It lies just below the iliac crest. It is most easily palpable when the patient lies on his side with his free leg raised in a few degrees of abduction.
Gluteus Medius Muscle
What condition will results to weakness of the gluteus medius muscle?
gluteus medius lurch
What are the muscles included in Extensor Group?
gluteus maximus hamstring muscles
___________ - a massive, coarse-grained muscle, is the primary hip extensor. Its origin and insertion are difficult to palpate. The outline of this muscle can be roughly estimated by using some of the bony landmarks located during bony palpation.
Gluteus maximus
Trur or False:
An imaginary line drawn from the coccyx to the ischial tuberosity represents the maximus lower border; another line drawn from the posterior superior iliac spine to slightly above the greater trochanter represents the muscle’s upper border; and a third line between the posterior superior iliac spine and the coccyx completes the outline.
True
The gluteus maximus is most palpable when the patient is in the __________ , with his buttocks squeezed together. The muscle also becomes prominent when the patient, while prone, _______ his hip and _______ his knee.
prone position
extends
flexes
___________ - consist of the biceps femoris on the lateral side and the semitendinosus and semimembranosus on the medial side. They are palpable from origin to insertion.
Hamstring Muscles
Both gluteus maximus muscles should be palpated simultaneously to provide instant comparison of _____ , size, ______ , and quality.
tone
shape
What conditions may results to general tenderness and spasm of the hamstring muscle?
Excessive athletic activity (pulled hamstring)
Spasm secondary to a herniated disc in the lower lumbar
spine slippage of one lumbar vertebra on another (spondylolisthesis )
What conditions may results to any tenderness elicited while examining the hamstrings ?
Ischial bursitis the case of a severe injury direct damage to the hamstrings
What are included in Active Range of Motion Tests?
Abduction
Adduction
Flexion
Flexion and adduction
Flexion, abduction and external rotation
Internal and external rotation
Ask the patient to stand and to spread his legs apart as far as he can. He should be able to abduct each leg at least 45° from the midline. What is the range of motion?
Abduction
Instruct the patient to bring his legs together from the abducted position, and alternately cross them, first with the right leg in front, then with the left. He should be able to achieve at least 20°. What is the range of motion?
Adduction
Instruct the patient to draw each knee toward his chest as far as he can without bending his back. He should be able to bring his knees almost to his chest (approximately 135°) . What is the range of motion?
Flexion
Have the patient sit in a chair and ask him to cross one thigh over the other. What is the range of motion?
Flexion and adduction
After the patient cross one thigh over the other, instruct himt to uncross his thighs and place the lateral side of his foot upon the opposite knee. What is the range of motion?
Flexion, abduction and external rotation
Ask the patient to fold his arms across his chest, and, keeping his back straight, to get up from the chair. What is the range of motion?
Extension
True or False:
There are no specific, quick active tests for range of internal and external rotation of the femur; however, these functions have been adequately tested in conjunction with the other tests.
True
On occasion, patient may substitute motion of the pelvis and lumbar spine to compensate for decreased range of hip motion. During the passive range of motion test, what are the range of motion included?
Flexion ( Thomas Test ) 120 °
Extension 30°
Abduction 45°-50°
Adduction 20-30°
Internal rotation 35°
External rotation 45°
___________ - is a specific test designed to detect flexion contractures of the hip, it may also be used to evaluate range of hip flexion.
Flexion ( Thomas Test )
What is the position of the patient during Flexion ( Thomas Test ) ?
The patient should be supine on the examining table, with his pelvis level and square to his trunk so that an imaginary line drawn between the anterior superior iliac spines is perpendicular to the axis of his body.
What to do to stabilize the patient’s pelvis?
Place your hand under the patient’s lumbar spine and flexing his hip, bringing his thigh up onto his trunk.
Normal flexion limits to allow the anterior portion of the thigh to rest against the _________ , almost touching the chest wall.
abdomen
What indicates that the pelvis is stabilized?
The previous lordosis of the lumbar spine is flattened.
Flexion of the hip: If the hip does not extend fully and If he rocks forward, lifting his thoracic spine from the table, or arches his back to reform the lumbar lordosis when he lowers his leg. What condition of the hip is suspected?
fixed flexion contracture
________ and ________ of the back are compensatory mechanisms to facilitate lowering of a contracted hip.
rocking
arching
True or False:
The extent of a flexion contracture can be approximated if you observe the patient from the side and estimate the angle between his leg and the table at the point of greatest extension.
True
Ask the patient to lie prone upon the examining table, and stabilize the pelvis by placing your arm ever the iliac crest and lower lumbar spine. If the hip cannot extend, a flexion contracture is a probable cause. What passive range of motion is done?
Extension
Abduction of both hips can be easily compared if the leg remains in this position while you repeat the same maneuver on the other leg. Hip abduction can be measured accurately by recording the ______________ for each leg, and measuring the ___________ separation during full abduction
Degrees of abduction
intermalleolar
True or False:
Adduction is more often limited by pathology than abduction.
False
With the patient still supine, continue to stabilize the pelvis and, by holding one ankle, guide the leg across the midline of the body and over the opposite extremity. What passive range of motion is done?
Adduction 20-30°
True or False: You can feel the pelvis begin to move at the end point of hip adduction. Note that heavy thighs can offer some soft tissue resistance to a full range of adduction.
True
True or False:
It is important that the range of femoral rotation be tested with the patient’s hip both extended and flexed, since rotation can exist in one position, but be limited in the other. It is perhaps more important that rotation be tested when the hip is extended since hip extension is vital to ambulation.
True
Have the patient assume a supine position, with his legs extended. Stand at the foot of the table, hold his feet just above the malleoli, and rotate the legs externally and internally, using the proximal end of the patella as a guideline to evaluate range of rotation. What passive range of motion is done?
Internal rotation and External rotation
True or False:
Occasionally, the rotation range of an extended hip may differ from that of a flexed hip. To test rotation of the hip in flexion, ask the patient to sit up on the end of the table so that both hips and knees are in 90° of flexion.
True
What is one possible cause of excessive internal or external hip rotation?
femoral neck anteversion or retroversion
Normally the neck of the femur is angled 15° anterior to the long axis of the shaft of the femur and the femoral condyles. Any increase in this anterior angulation (excessive anteversion) results in a greater _____________ .
internal rotation
What condition can limit motion in all planes, but it most often affects internal rotation and abduction.
Osteoarthritis
The neurologic examination of the hip is divided into two parts:
(1) muscle testing
(2) sensation testing
The muscles will be tested in functional groups. This group includes:
Flexors, extensors, adductors, and abductors
This type of testing is important for clinical reasons since each functional group receives innervation from a different peripheral nerve, and, in most instances, from a different neurologic level.
Muscle Testing
Ask the patient to raise his thigh from the table.Place your free hand over the distal end of the thigh and ask him to raise his thigh further, while you offer resistance. What muscle is being tested?
Iliopsoas
The patient to lie prone and to flex his knee to relax the hamstring muscle. With your other hand, offer resistance to his motion by pushing down on the posterior aspect of the thigh just above the knee joint. This muscleshould be palpated for tone during the test . What muscle is being tested?
gluteus maximus muscle
What is the Primary extensors muscle of the hip?
Gluteus Maximus
What is the Secondary extensors muscle of the hip?
Hamstrings
What id the innervation of Gluteus Maximus?
Inferior Gluteal Nerve, S1
What is the Primary Abductor muscle of the hip and what is the innervation?
Gluteus Medius ; Superior Gluteal Nerve, L5
What is the Secondary Abductor muscle of the hip?
Gluteus Minimus
What is the Primary Adductor muscle of the hip and what is the innevation?
Adductor Longus : Obturator Nerve, L2,3,4
Have the patient lie on his side and abduct his leg. Then place your hand on the medial side of his knee, and ask him to try to pull his leg back toward the midline of the body against your resistance. What range of motion is done?
Adduction
The strip approximately level with the umbilicus is supplied by _____: The strip immediately above the inguinal ligament is supplied by _____ , and the area in between is supplied by _____.
T10
T12
T11
__________ is supplied to the hip, pelvic region, and thigh by nerves taking origin from roots in the lower thoracic, lumbar, and sacral spines.
Sensation
The sensory area of ____ lies immediately below the inguinal ligament and parallel to it on the upper anterior portion of the thigh. An oblique band immediately above the kneecap represents ____ , and the area between is supplied by ____ .
L1
L3
L2
What are the orthopedic testing for hip?
Trendelenburg Test
True and apparent leg length
Hibb’s test
Allis’ sign
Ober’s modified
Thomas test
This procedure is designed to evaluate the strength of the gluteus medius muscle.
Trendelenburg Test
To determine, first place the patient’s legs in precisely comparable positions and measure the distance from the anterior superior iliac spines to the medial malleoli of the ankles.
True Leg Length Discrepancy
Establish that there is no true leg length discrepancy. Apparent shortening may stem from pelvic obliquity or from adduction or flexion deformity in the hip joint. During inspection, pelvic obliquity manifests itself as uneven anterior or posterior superior iliac spines while the patient is standing.
Apparent Leg Length Discrepancy
