Hip Exam Flashcards
What are the stages in the examination?
- INTRODUCTION
- GENERAL INSPECTION
- INSPECTION OF BOTH HIPS (PATIENT STANDING)
- PALPATION
- ACTIVE and PASSIVE MOVEMENT OF THE HIP JOINT
6.SPECIAL TESTS - FOR COMPLETENESS
- CONCLUSION
Instead of the standard inspection, palpation, percussion and auscultation format, how are joint exams done?
LOOK, FEEL, MOVE + SPECIAL TESTS.
So when examining a joint one inspects for deformity, skin changes, muscle wasting, etc. then feels for temperature, tenderness, deformity, etc. and, finally, one moves the joint to assess both the range of normal movements and special tests.
Both active and passive movement should be examined i.e. the patient’s ability to move the joint itself (active) and the examiner’s ability to move it (passive).
How should you compare joints from one side to another?
Perform each part of the examination on one side then the other rather than examine the joint completely on one side then the other
If there is a pathology in a joint what else should be done?
Pathology from one joint can be experienced as pain in another joint, therefore it is essential that you complete any musculoskeletal examination by examining the joint above and below.
e.g Arthritides (pleural of arthritis) more often than not affect more than one joint. Hip pathology can often present as knee pain.
What is involved in the Introduction?
A. Wash hands with water or alcohol gel
B. Introduce self
C. Confirm patient’s name and date of birth
D. Explain procedure and seek informed verbal consent to examine the hips
E. Ensure patient is comfortable and pain-free and ask if they have had hip surgery
F. Fully expose the patient’s legs but allow the patient to maintain their modesty
It is very important that you ask if the patient has had any hip surgery, particularly a hip replacement (arthroplasty) because moving the hip in a particular direction can cause a dislocation of the hip. Moreover, old scars will not be immediately obvious.
What is involved in the General Inspection?
A. Observe for signs of pain/discomfort
B. Observe for signs of systemic disease relevant to the musculoskeletal system
- Adapt your inspection to the clinical scenario and listen carefully to what the examiner tells you in an OSCE.
- Start the exam with the patient lying on the couch. Observe them in that position, looking for any general signs of discomfort such as grimacing or holding a limb or joint.
- One should also be looking for any clues from other systems that may suggest pathology that could be involving the musculoskeletal system (eg. orthoses, walking aids).
- Look for signs of fever such as sweating, flushed skin and shivering (rigors) which could be associated with bone and joint infections.
- Look for signs of rapid weight loss which could be associated with metastatic bone and soft tissue tumours. Also look for signs of rheumatoid arthritis such as hand and finger deformities, and look for skin rashes (such as psoriasis).
What is involved in the Inspection?
INSPECTION OF BOTH HIPS (PATIENT STANDING)
A. Look for any mal-alignment of the legs
B. Look for any wasting of the gluteal muscle bulk
C. Look for any swelling, redness, deformity or scars around hips.
D. Remember to inspect from the front, side and back
- Note that the patient can stand comfortably with both feet flat on the ground, the hips in the neutral position and the knees in full extension.
- Compare the alignment of one leg to the other in the standing position from the front and from behind and note any tilting of the pelvis. Observed for any limb length discrepancy.
- The gluteal muscle is the best place to look for muscle wasting as it is quick to atrophy and even relatively small changes are fairly easily noted due to its large size. Then inspect the hip region itself for swelling or redness which may indicate inflammation, but please remember that the hip is a deep-seated joint and so external signs of inflammation are rare.
- Scars may indicate previous trauma or surgery and are most likely to appear on the lateral aspect of the joint. Note that scars (especially old ones) might be difficult to see – therefore, adequate exposure of the patient is paramount.
What is involved in the Palpation?
A. Ask if the patient is currently experiencing any pain
B. Feel the greater trochanter
PALPATION WITH THE PATIENT LYING COMFORTABLY AND HIPS FULLY EXTENDED
- Before you start palpating, ask the patient if they currently have any pain and where that is (be extra cautious when examining these areas and remember to watch the patient’s face for signs of distress). Start your examination with the non-affected side.
- Palpation over the greater trochanter will detect inflammation of the overlying bursa (trochanteric bursitis or greater trochanteric pain syndrome.)
- Feel the temperature (although any changes are difficult to detect as the hip is a deep- seated joint).
What is involved in the Active and Passive movement of the Hip?
A. Flexion
B. Abduction/adduction
C. Internal/external Rotation in neutral and 900 flexion D. Extension
Crepitus of the hip joint, a sign of degenerative joint disease, may be felt as the hip is moved by the examiner.
A FLEXION: With the patient supine on the couch ask the patient to bring the knee as far as possible towards the head, flexing the hip, and assess the angle made between the new position of the femur and where the femur lay in the neutral (extended) position (00). Normal angle of maximum flexion is about 1100. (Note that flexion of the lumbar spine and pelvis may add to the appearance of hip flexion. If in doubt you can place a hand under the lumbar spine and check that there is no loss of lordosis.)
B ABDUCTION/ADDUCTION: To assess the lateral movements of the hip in isolation one must exclude the tilting of the pelvis. This is best done by placing your left hand on the patients left ASIS (anterior superior iliac spine) and your left forearm on the patient’s right ASIS. Your left forearm is keeping the pelvis still while leaving your right hand free to passively move the limb you are testing. Abduct the hip by bringing the limb away from the midline until the pelvis starts to tilt and measure the angle made from the midline. Repeat for adduction by bringing the limb across the midline in front of the other limb. Normal abduction is 450 and adduction is 300.
C INTERNAL/EXTERNAL ROTATION: First check internal and external rotation actively in the neutral position by asking the patient to rotate the foot internally and externally, and then repeat with gentle passive rolling of the thigh internally and externally. While the hip is flexed to 900 you can gently internally and externally rotate the hip passively using the distal lower limb and measure the angle of rotation.
(Normal range of movement is 400 of internal and 450 external rotation.
D EXTENSION: This is done most accurately with the patient prone. Alternatively you could use Thomas’ test (see special tests below) as it is also a test of extension.
What is involved in the Special Tests?
A. Thomas Test – This is a test for flexion contracture of the hip seen in arthritis and in
neuromuscular disorders – ie. the joint capsule or elevated muscle tone pulls the hip into forced flexion.
- The patient lies supine on the examination couch and the examiner places one hand, palm uppermost, under the patient’s lumbar spine. This helps the examiner assess when the flexion movement is no longer at the hip joint, but due to the lumber spine.
- Ask the patient to bring one knee towards the chest (flexing that hip), while the other hip remains extended. The test ends when the examiner can feel movement at the lumbar spine. The Thomas test is said to be positive if the patient cannot keep the opposite hip extended during the test (ie. the opposite leg lifts off the couch).
B. Limb Length – With the patient supine and the pelvis level. To measure the apparent length of a limb, record the distance from the umbilicus to the medial malleolus. To measure the true length of a limb measure the distance from the ASIS to the medial malleolus.
C. Trendelenburg Sign -This sign is positive if, when standing on one leg, the pelvis drops on the side opposite to the standing leg. If this occurs, the most likely reason is weakness of the hip abductors on the side of the stance leg as the abductors are not able to maintain the centre of gravity on the stance side. Normally, the body shifts the weight to the stance leg, allowing the shift of the centre of gravity and consequently stabilising or balancing the body. However, in patients with weak hip abductors, when the patient/person lifts the opposing leg, the shift is not created and the patient/person cannot maintain balance leading to instability.
What is involved in for completeness?
To complete your examination you should also offer to
Offer to examine the knee below and the lumbar spine above.
Offer to examine the lower limbs neurologically and
Offer to assess the gait of the patient.
(If the examination of only one hip has been done in OSCE conditions, offer to test the contralateral hip).
What is involved in the Conclusion?
CONCLUSION
A. Thank patient
B. Wash hands
C. Be prepared to orally summarise your findings
