Hip

Question 1

What is the overall format of the hip exam

Answer 1

Look
Feel
Move
Special tests (Trendelenburg’s and Thomas’ tests)

Question 2

How do you perform the inspection part of the hip exam

Answer 2

Ask the patient to stand and turn in 90 degree increments so you can inspect the anterior, lateral, and posterior aspects

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait

Inspection of hip when patient is lying down

Question 3

What should you inspect for on the anterior aspect of the hip

Answer 3

Scars
Bruising
Quads wasting
Leg length discrepancy
Pelvic tilt

Question 4

What can cause the following:
a) Leg length discrepancy
b) Pelvic tilt

Answer 4

a) may be congenital or acquired (e.g. fracture, degenerative joint disease, surgical removal of bone, trauma to the epiphyseal endplate prior to skeletal maturity).

b) lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.

Question 5

What can cause the following:
a) Leg length discrepancy
b) Pelvic tilt

Answer 5

a) may be congenital or acquired (e.g. fracture, degenerative joint disease, surgical removal of bone, trauma to the epiphyseal endplate prior to skeletal maturity).

b) lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.

Question 6

What should you inspect for on the lateral aspect of the hip

Answer 6

Flexion abnormalities: fixed flexion deformity at the hip joint may suggest the presence of contractures secondary to previous trauma, inflammatory conditions or neurological disease.

Question 7

What should you inspect for on the posterior aspect of the hip

Answer 7

• Scars
• Muscle wasting: inspect for any asymmetry in the muscle bulk of the posterior compartment of the thigh and the gluteal region suggestive of disuse atrophy or a lower motor neuron lesion.

Question 8

Name 2 special gaits you should look for in the hip exam

What is another key thing to look at that is suggestive of an abnormal gait

Answer 8

Trendelenburg’s gait: an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior gluteal nerve lesion or L5 radiculopathy.

Waddling gait: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with myopathies (e.g. muscular dystrophy).

unequal sole wearing

Question 9

What does Trendelenburg’s gait look like

Answer 9

Trendelenburg’s gait refers to the gait in an individual with unilateral hip abductor weakness, which is typically described as ‘lurching’ in nature. As the pelvis sags towards the unaffected side, the trunk lurches towards the opposite side in an effort to maintain balance.

Question 10

If Trendelenburg’s gait refers to the gait of a person with unilateral hip abductor weakness, what does bilateral weakness look like

What is this typically associated with

Answer 10

bilateral hip abductor weakness typically presents with a waddling gait, caused by the overuse of circumduction to compensate for gluteal weakness.

myopathies (e.g. muscular dystrophy).

Question 11

What should you do in the Feel part of the hip exam

Answer 11

Temperature

Palpation of hip joint (Palpate the greater trochanter of each leg for evidence of tenderness, which may suggest trochanteric bursitis.)

Leg length assessment

Question 12

How do you assess leg length

Answer 12

Leg length should be formally assessed to differentiate between a true leg length discrepancy and an apparent discrepancy caused by other abnormalities (e.g. a leg appears shorter secondary to lateral pelvic tilt).

Apparent leg length - measure and compare the distance between the umbilicus and the tip of the medial malleolus of each limb.

True leg length - measure from the anterior superior iliac spine to the tip of the medial malleolus of each limb.

Question 13

What are the active movements you should ask the patietnt to do in the hip exam

Give the normal range of movement and the instructions

Answer 13

Active hip flexion
- Place your hand under the lumbar spine to detect masking of restricted hip joint movement by the pelvis and lumbar spine.
- Normal range of movement: 120°
- Instructions: Ask the patient to flex their hip as far as they are able – “Bring your knee as close to your chest as you can.”

Active hip extension
- Normal range of movement: the leg should be able to lie flat (180°).
- Instructions: Ask the patient to extend their leg, so that it is flat on the bed – “Straighten your leg out so that it is flat on the bed.”

Question 14

What passive movements should the patient do in the hip exam

Answer 14

Flexion
Internal Rotation
External Rotation
ABduction
ADduction
Extension

Question 15

How do you test passive hip flexion

what is the normal range of movement

Answer 15

Instructions: Whilst supporting the patient’s leg, flex the hip as far as you are able, making sure to observe for signs of discomfort.

Normal range of movement: 120°

Question 16

How do you test passive hip internal rotation?

What is the normal range of movement?

Answer 16

Normal range of movement: 40°

Instructions: Flex the patient’s hip and knee joint to 90° and then rotate their foot laterally.

Question 17

How do you test passive hip external rotation?

What is the normal range of movement?

Answer 17

Normal range of movement: 45°

Instructions: Flex the patient’s hip and knee joint to 90° and then rotate their foot medially.

Question 18

What is the normal range of movement for passive hip ABduction?

How do you test this?

Answer 18

Normal range of movement: 45°

Instructions:

1. With the patient’s legs straight and flat on the bed, use one of your hands to hold the ankle of the hip being assessed and place your other hand over the contralateral iliac crest to stabilise the pelvis.
2. Move the patient’s ankle laterally to abduct the hip until the pelvis begins to tilt.

Question 19

What is the normal range of movement for passive hip ADduction?

How do you test this?

Answer 19

Normal range of movement: 30°

Instructions:

1. With the patient’s legs straight and flat on the bed, use one of your hands to hold the ankle of the hip being assessed and place your other hand over the contralateral iliac crest to stabilise the pelvis.
2. Move the patient’s ankle medially to adduct the hip until the pelvis begins to tilt.

Question 20

What is the normal range of movement for passive hip extension?

How do you test this?

Answer 20

Normal range of movement: 10-20°

Instructions:

1. Ask the patient to lie in a prone position.
2. Use one hand to hold the ankle of the leg being assessed and place the other hand on the ipsilateral pelvis.
3. Lift the leg to extend the hip joint and assess the range of hip joint extension.

Question 21

What are the hip exam special tests?

Answer 21

Thomas’ test

Trendelenburg’s test

Question 22

What is Thomas’ test used to assess

Answer 22

Thomas’s test is used to assess for a fixed flexion deformity (i.e. an inability for the patient to fully extend their leg).

1. With the patient positioned flat on the bed, place a hand below their lumbar spine with your palm facing upwards (this helps to prevent the patient from masking a fixed flexion deformity by increasing lumbar lordosis).
2. Passively flex the hip of the unaffected leg as far as you are able to and observe the contralateral limb.
3. Repeat the assessment on the contralateral hip.

Interpretation
The test is positive (abnormal) if the affected thigh raises off the bed, indicating a loss of hip joint extension. This would suggest a fixed flexion deformity in the affected hip.

This test should not be performed on patients who have had a hip replacement as it can cause dislocation.

Question 23

How do you interpret Thomas’ test

Answer 23

The test is positive (abnormal) if the affected thigh raises off the bed, indicating a loss of hip joint extension. This would suggest a fixed flexion deformity in the affected hip.

This test should not be performed on patients who have had a hip replacement as it can cause dislocation

Question 24

What is Trendelenburg’s test?

How do you perform it?

How is it interpreted?

Answer 24

used to screen for hip abductor weakness (gluteus medius and minimus).

1. With the patient upright, stand in front of them and ask them to place their hands on your forearms or shoulders for stability.
2. Position your fingers on each side of the patient’s pelvis at the iliac crest.
3. Ask the patient to stand on one leg and observe your fingers for evidence of lateral pelvic tilt.
4. Repeat the assessment with the patient standing on the other leg.

Interpretation
If the patient’s hip abductors are functioning normally the pelvis should remain stable or rise slightly on the side of the raised leg.

Question 25

What is Trendelenburg’s sign

Answer 25

After performing Trendelenburg’s test:
If the pelvis drops on the side of the raised leg it suggests contralateral hip abductor weakness (this is known as Trendelenburg’s sign).

(If the patient’s hip abductors are functioning normally the pelvis should remain stable or rise slightly on the side of the raised leg.)

Question 26

What further tests would you want to do after a hip exam

Answer 26

Neurovascular examination of both lower limbs.
Examination of the joints above and below (lumbar spine and knee joint).
Further imaging if indicated (e.g. X-ray and MRI).

Question 27

Give some risk factors for developmental dysplasia of the hip (5)

Answer 27

female sex: 6 times greater risk
breech presentation
positive family history
firstborn children
oligohydramnios

Question 28

How frequently is developmental dysplasia of the hip bilateral? Is one hip more common?

Answer 28

DDH is slightly more common in the left hip. Around 20% of cases are bilateral.

Question 29

Describe screening for developmental dysplasia of the hip

Answer 29

the following infants require a routine ultrasound examination:
first-degree family history of hip problems in early life
breech presentation at or after 36 weeks gestation, irrespective of presentation at birth or mode of delivery
multiple pregnancy

all infants are screened at both the newborn check and also the six-week baby check using the Barlow and Ortolani tests

Question 30

What is the management of developmental dysplasia of the hip

Answer 30

most unstable hips will spontaneously stabilise by 3-6 weeks of age
Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
older children may require surgery

Question 31

Give the causes (4) and presentation (2) of avascular necrosis of the hip

Answer 31

Causes
-long-term steroid use
-chemotherapy
-alcohol excess
-trauma

Features
-initially asymptomatic
-pain in the affected joint

Question 32

What investigations would you do for avascular necrosis of the hip(2)

How is it managed

Answer 32

1) plain x-ray findings may be normal initially. Osteopenia and microfractures may be seen early on. Collapse of the articular surface may result in the crescent sign
2) MRI is the investigation of choice. It is more sensitive than radionuclide bone scanning

Management: joint replacement may be necessary