MSK - Hip Flashcards
What position should the patient be in for hip examination?
Start with patient lying on bed as flat as possible
What do you look for?
1) Look for scars, swellings and muscle wasting
2) Deformity and symmetry
3) Look for leg length discrepancy
N.B. Less likely to see swelling as it is a deep joint
How may a leg look if the neck of femur is fractured?
May be shortened and externally rotated if neck of femur fractured
What kind of leg discrepancy are there?
True and apparent
An apparent leg length discrepancy occurs when both legs are of equal length but they lie in different positions relative to the pelvis, e.g. with fixed flexion or abduction deformity of the hip.
How do you measure leg discrepancy?
For both apparent and true leg length, measure with the patient lying supine on the bed.
1) Apparent leg length discrepancy - measure from xiphisternum to medial malleollus using tape measure.
2) True leg length discrepancy - start with pelvis square. Measure from the ASIS to medial malleolus.
1) Apparent leg length is measured from a point in the patient’s midline, either the umbilicus or xiphi-sternum, to the medial malleolus of the ankle of each leg. If there is a difference, it may be due to a spinal or pelvic deformity or an adduction or abduction contracture of the hip.
When taking the measurement, identify both right and left anterior superior iliac spine (ASIS) and imagine a line drawn between them. To obtain an accurate true length, the limbs must be placed in comparable positions relative to the pelvis (the ASIS line) which may mean one has to be abducted or adducted to match the position of the opposite leg.
2) True leg length (difference in bony components) is measured from the Anterior Superior Iliac spine (ASIS) to just below the ipsilateral medial malleolus. The metal end of tape should be placed immediately distal to the ASIS and measured to immediately distal to the medial malleolus.
What do you feel for?
1) Palpate for tenderness over the greater trochanter
N.B. The hip joint itself is too deep to feel any temperature difference.
What movements do you carry out?
1) THOMAS’ TEST. Check for a fixed flexion deformity.
2) FLEXION. With knee flexed to 90°, check full flexion of hip. (n.120°)
3) ROTATION. With hip and knee both flexed to 90°, assess both internal and external rotation of hip and compare sides.
4) ABDUCTION. Place hand on contralateral ASIS and abduct leg. The end point is when pelvis starts to move (n.45°).
5) ADDUCTION. Place hand on ipsilateral ASIS and the end point is when pelvis starts to move (n.25°) or alternatively place forearm across both Anterior Superior Iliac Spines and test both abduction and adduction.
6) TRENDELENBURG TEST. Assessment of hip and proximal gluteal strength of the side they are standing on.
What is Thomas’ Test?
Assessment of fixed flexion deformity.
1) Lie the patient supine on examining couch.
2) If there is a fixed flexion deformity, patients usually compensate by increasing their lumber lordosis so you MUST ensure that lumbar lordosis is obliterated by placing one hand under the patient’s lumbar spine.
There are two variations on performing this test.
- Fully flex the normal hip until you feel the lumbar lordosis flatten on your hand. Observe the opposite leg. If the leg is lifted off the bed, then there is a fixed flexion deformity of that hip.
- The other method is to ask the patient to flex both hips until you feel the lumbar lordosis flatten on your hand. Ask the patient to extend one leg at a time, starting with good leg. In a positive test, the bad leg will lie partially flexed and there is a block to full extension. This is only possible in young patients.
What is the Trendelenburg test/sign?
Assessing weak or paralysed abductor muscles of the hip or where the hip joint is abnormal e.g. dysplasia.
1) Stand the patient in front of and facing a mirror.
2) Stand behind the patient with your
hands on the patient’s iliac crests. If your patient is frail or unsteady, you should stand in front of the patient with their hands resting on your forearms and you will be able to feel any pressure change.
3) Ask the patient to lip their foot to flex their knee - you must demonstrate this
4) The test is positive if the pelvis dips on the side of the non-weight bearing leg. In a normal test, the pelvis will remain level or may rise.
What are the abductor muscles of the hip?
Gluteus minimus and gluteus medius
What is essential for the Trendelenburg test to work?
1) It is essential to demonstrate how the patient should lift the leg. That is by flexing only the knee to bring the foot off the ground. Do not allow the patient to flex the hip joint, as the iliopsoas muscle will then be able to stabilise the pelvis and prevent the sign.
2) If your patient is frail or unsteady, you should stand in front of the patient with their hands resting on your forearms and you will be able to feel any pressure change.
What happens if you allow to the patient to flex their hip joint in the Trendelenburg test?
The iliopsoas muscle will then be able to stabilise the pelvis and prevent the sign.
What functions do you test?
1) Gait
2) Examination of spine and knee (joint above and below)
What are you looking for when testing gait?
Limps:
1) Antalgic - pain on weight bearing.
2) Trendelenburg dip - weak abductors which gives a
waddling gait
3) Ataxic gait – wide based and marked clumsiness
4) High stepping gait – presence of foot drop
