OSCE - MSK Hip Flashcards
What are the 5 components (In order) of a MSK hip examination?
How is this order different?
Look
Special tests
Feel
Move
Measure
Special test is done whilst the patient is standing - Trendelenburg sign
What are the 6 components required in an introduction
Introduce self (name, role, purpose)
Hi, my name it Steve, I’m a 2nd year medical student and I’ve been asked to conduct an hip examination on you today, is that ok?
Brief summary
This will involve me observing your posture and gait whilst standing, then we’ll get you onto the bed to perform some movements of your legs to assess the hip joints
Duration
This examination will take about 10 minutes to complete
Level of discomfort
Before I start, are you in any pain at the moment? This examination should not cause you any pain throughout, however if you do feel pain at any time please let me know and I will work around it
Exposure
I will need you to take your shoes off and be exposed from the hip joint to the foot
Wash hands
**
“Look”
What are the key aspects to this?
Examine standing first
- General observation
(Patient is Alert)
Distress
(No obvious distress is noted)
Posture
(standing posture appears normal, feet are not turned in or out) - Equipment to aid walking/standing?
- Gait assessment
Ask the patient to walk forwards for 5 steps and then back again
What is looked for in a gait examination?
Check for:
1. Limp
- Hurrying off the affected side due to pain (antalgic gait)
- Leg length discrepancy (appear to “rise and drop”, can be subtle)
2. Pain when walking
3. Use of walking aids
4. Pace
“Look”
Once the patient has been observed in a standing position, what is the next step?
Test for trendelenburg sign at this point!
Patient is already standing so makes sense to get it out the way (only special test for the hip)
Explain the process of testing for Trendelenburg sign
(On both legs)
1. Examiner stands behind patient
2. Ask the patient to stand on one leg and hold for 30 seconds
3. To remain stable the non-weight bearing side of the pelvis will be held slightly higher
4. This is achieved by hip abductor action in the weight bearing leg
5. Positive Trendelenburg sign - If the pelvis on the non-weight bearing side falls below the the weight bearing side
What is a positive Trendelenburg sign an indicator of?
A problem affecting the hip abductor muscles, which may be due to:
1. Presence of hip pain (OA, and others)
2. Weakness in the abductors due to nerve paralysis, muscle wasting, reduced activity levels
In order to complete a hip examination, what should be done?
- Conduct a peripheral vascular examination (palpate the femoral, popliteal and dorsalis pedis pulses)
- Examine the joints above and below the hip (lumbar spine and the knee)
Measure
What two things are measured in a hip examination?
Leg length discrepancy (BOTH legs compared)
- True leg length disrepancy
Will determine the presence of a different in length - Apparent leg length discrepancy
Will determine a lateral pelvic tilt
What do the measurements conducted in a hip examination tell us if they are deemed abnormal (positive findings)
True leg length discrepancy:
- If present, indicates a hip problem on the shorter side
(Measure from ASIS to medial malleolus)
Apparent leg length disrepancy
- Due to lateral pelvic tilt (may be hip adduction problem due to hip deformity on one side)
Measure from medial malleolus to umbilicus
After special test of the hip, what step is performed next?
Special test for the hip is done whilst the patient is standing, therefore the supine examination is conducted next (Feel, Move measure)
What should be looked for in a supine examination of the hip?
- Observe patients resting position
- External rotation is a position of comfort in hip pain
- Check position of knee or foot as a guide (turned out - good indicator for ext rotation)
- Deformity of hip
- Muscle wasting (quadriceps and gluteals)
- Scars and skin changes
Also, Check the posterolateral hip for surgery scars
What is important to remember when looking at a patient to find clues for pathology?
To check the skin on all surfaces to be sure no previous scars are present (anterior, lateral, posterior)
Feel
Outline the order of what is felt in a hip examination?
Presence of joint tenderness and tendon attachment:
In this order:
Step 1: ASIS - sartorius attachment
Step 2: Below the midpoint of the inguinal ligament (@ the location of the femoral head - hip joint)
Step 3: Greater trochanter on the lateral hip - tenderness suggests trochanteric bursitis
List the movements that are tested at the hip joint in order:
Hip flexion
Hip Internal rotation (leg out towards examiner) - bent 90 degrees
Hip external rotation - (leg inward over the top of patient) bent 90 degrees
Adduction - straight leg, neutral hip
Abduction - straight leg, neutral hip
Extension - patient lying prone
List the normal ranges of movement at the hip joint for the following:
a) Hip flexion
Range 110-120 degrees
List the normal ranges of movement at the hip joint for the following:
Hip extension
Range 20-30 degrees
List the normal ranges of movement at the hip joint for the following:
Hip abduction
Range: 50 degrees
List the normal ranges of movement at the hip joint for the following:
Hip adduction
Range: 25 - 30 degrees (more than this; implies flexion is complicating the appearance)
List the normal ranges of movement at the hip joint for the following:
External rotation
Range 50 degrees
List the normal ranges of movement at the hip joint for the following:
Internal rotation
Range 40 degrees
