Student guide to examination of the hip
Ball and socket joint of synovial joint.
Connects the pelvic girdle to the lower limb
Made up of femoral head and acetabulum
Designed for stability and wide range of movement
Covered with a thin layer of hyaline cartilage
The articular surface of is horse-shoe shaped and is deficient inferiorlyacetabular notch
Has a labrum
- is a circular layer of cartilage which surrounds the outer part of the
acetabulum making the socket deeper and so helping provide more
stability
-
Acetabular labral tears are a common injury from major or repeated
minor trauma
Iliofemoral ligament
This is a strong ligament which connects the pelvis to the femur
at the front of the joint. It resembles a Y in shape
Stabilises the hip by limiting hyperextension
Pubofemoral ligament
 The pubofemoral ligament attaches the part of the pelvis known
as the pubis (most forward part, either side of the pubic
symphysis) to the femur.
Ischiofemoral ligament:
 This is a ligament which reinforces the posterior aspect of the
capsule
 attaches the ischium to the two trochanters of the femur.
Transverse acetabular Ligament:
 Bridges acetabular notch.
Ligament of head of femur: flat and triangular in shape
Lies within joint, ensheathed by synovium
• Synovium –covers non-articular surfaces of joint and can bulge out
anteriorly to form a bursa under psoas tendon, where this crosses the
joint.
Note:
•
Capsule of the hip.
•
Retinacula
•
Blood supply to femoral neck.
Osteo myelitis of the upper femoral metaphysis will involve the neck (intracapsular) and rapidly
produce a secondary pyogenic arthritis of the hip joint
MOVEMENTS
• Flexors:
Iliopsoas, sartorius, tensor fascia lata, rectus femorus, pectineus,
adductor longus, brevis, and magnus, gracilis
• Extensors:
- hamstrings, addcutor magnus, gluteus maximus
• Adductors:
- adductor longus, brevis, and magnus, gracilis, pectineus
• Abductors:
- gluteus medius, minimus, tensor fascia lata
• External rotators:
- obturator externus, internus, piriformis, quadratus femoris,
gluteus maximus
• Internal Rotators:
- gluteus medius, minimus, tensor fascia lata.
Muscles
Gluteals:
Gluteus Maximus, Gluteus Minimus and Gluteus Medius
Attach to the Ilium and travel laterally to insert into the greater trochanter of
the femur
Medius and Minimus abduct and medially rotate the hip joint, as well as
stabilising the pelvis
Gluteus maximus extends and laterally rotates the hip joint
Quadriceps
The four Quadricep muscles are Vastus lateralis, medialis, intermedius and
Rectus femoris
All attach inferiorly to the tibial tuberosity
Rectus femoris originates at the Anterior Inferior Iliac Spine and acts to flex the
hip
The 3 other Quad muscles do not cross the hip joint, and attach around the
greater trochanter and just below it.
Iliopsoas:
The is the primary hip flexor muscle which consists of 2 parts
Attaches superiorly to the lower part of the spine and the inside of the ilium
Cross the hip joint and insert to the lesser trochanter of the femur
Hamstrings:
The hamstrings are three muscles which form the back of the thigh
Attach superiorly to the ischial tuberosity
Cause hip extension
Nerves
Femoral (L2,3,4)
Obturator (L2, 3, 4)
Sciatic (L4,5, S1, 2,)
WHY ARE THESE IMPORTANT???
-
Referred pain to the knee can hide hip pathology and vis versa
Relations around the hip:
• Anterior –iliacus, psoas, pectineus. Femoral artery/vein
• Lateral – tensor fasciae latae, gluteus medius and minimus.
• Posterior – tendon of obturator internus with gemelli,
quadratus femoris. Sciatic N. And superficially gluteus max.
• Superior – reflected head of rectus femoris lying in contact with
joint capsule.
• Inferior – obturator externus, passing back to its insertion in
trochanteric fossa.
Blood supply
Common hip pathologies
Osteoathritis:
A degenerative joint disease that causes stiffness, pain, and
reduction in movement
What are the two types?
Primary OA: middle aged/ elderly, aetiology unknown
Secondary OA: anyone with predisposing factors such as SUFEslipped upper femoral epiphysis, CDH-, DDH-dev. Dysplasia of the
hip, Perthes, or early onset trauma/ fracture to hip joint etc
Pathogenesis : Affects weight bearing joint.
Prevalence increases with age
- Disease accelerated by mechanical instability/ stress on
jt/increased stress on jt surface
-
initial changes in articular cartilage  fibrillation of cartilage
vertical clefts  exposure of subchondral bone
-
with continuous pressure this leads to sclerosis of subchondral
bone (eburnation)
-
bone degeneration under stress creates cysts
At joint margins new bone forms resulting in spurs/ osteophy
Presentation : Pain: relieved by rest
 Stiffness: typically lasting 15-20min then disappears
 Joints show reduced movement and is associated with crepitus
 Joint swelling/ deformity
 Usually affects weight bearing joint
 Hip: pain in buttock/upper thigh, limited movement
resulting in antalgic gait, hesitant gait to avoid pain
 Knee: pain/crepitus at joint surface, deformity results in
bow legs/ knock knees
 Spine: usually C/L spine, stiffness, radicular pain from
compression of spinal nerves
 Hands: Heberden’s node, Bouchard’s nodes
 Feet: deformity of 1st MT bunion
X- ray findings???
Management
Conservative
 Weight loss
 Modify daily activities, walking aids
 Physiotherapy
 Analgesia: aspirin, paracetamol , NSAIDS + other opioid.
Surgical
 Arthroplasty
 When patients have severe pain, nocturnal pain,
pain at rest, and severely restricted mobility &
functional in-capacity.
 Arthrodesis
 Rarely used in OA, sometimes used in pt too young
for hip replacement
 Osteotomy
 Utilised to realign deformities and spread the
transmitted loads more evenly in younger pts
.
Hip dislocation
• Usually dislocated backwards. Force applies along femoral shaft
with hip in flexed position (e.g. Knee strikes against seat in
front when a head-on car collision occurs)
• If hip is also in adducted position, head of femur is not
supported posteriorly by acetabulum and dislocation occurs
with an associated acetabular fracture.
• In abduction, dislocation may also have fracture of posterior
acetabular lip.
• Damage to SCIATIC NERVE, posterior and close to hip, may
occur in these injuries.
• Management: This is quite simple provided a deep anaesthetic
is used to relax surrounding muscles; the hip is flexed, rotated
into neutral position and lifted back into acetabulum.
Occasionally, forcible abduction of hip will dislocate the hip forward.
Violent force along shaft (i.e. fall from a height) may thrust femoral
head through floor of acetabulum, producing a central dislocation of
the hip
Other pathologies include nerve damage rheumatoid arthritis
.......read
Trendelenburg’s test
• Stability of hip in standing position, depends on 2 factors;
1. strength of surrounding muscles,
2. integrity of lever system of femoral neck and head within the
intact hip joint.
• When standing on one leg, abductors of hip on this side ( glut
med. & min, tensor fasciae latae) provide powerful action to
maintain fixation at hip joint. Pelvis rises on opposite side.
• If any defect in these muscles or lever mechanism of joint, the
body weight forces the pelvis to tilt downwards on the opposite
side.
A positive Trendelenburg test seen if;
1. hip abductors are paralysed (e.g. Poliomyelitis).
2. old unreduced or congenital dislocation.
3. head of femur has been destroyed by disease
4. head of femur removed operatively (pseudarthrosis)
5. un-united fracture of femoral neck.
6. severe degree of coxa vara
History and examination
History :
• Age
– infancy: congenital hip dysplasia
– 3-12 year old boys: Legg-Calve-Perthes Dz
– middle age & elderly: osteoarthritis
• Mechanism of injury
– land on outside hip
– land on knee
– repetitive loading
• Pain details
– location
– snapping
– progression of symptoms
– exacerbating factors
– alleviating factors
• Weakness
• Occupation, Sport
OSCE –Examine the HIP
Before starting
• Introduce yourself to the patient.
• Explain the examination and ask for his/her consent to carry it out.
• Ask him/her to undress to his/her undergarments.
• Ensure that he/she is comfortable.
Examination : The patient is standing
• LOOK.
1. General inspection: posture, symmetry of legs and spine.
2. Gait. Observe from front and back, and accompany.
3. Trendelenburg test: Ask the patient to stand on each leg in turn,
lifting the other one off the ground and bending it at the knee. The test
is positive if the pelvis drops on the unsupported side.
Ask patient to lie supine :check
1. Skin: colour, sinuses, scars.
2. Position: limb shortening, limb rotation, abduction or
adduction deformity, flexion deformity.
3. Limb length:
– To measure true leg length, position the pelvis so that the iliac
crests lie in the same horizontal plane, at right angles to the trunk
(if this is not possible there is a fixed abduction or adduction
deformity) and then measure the distance from the anterior
superior iliac spine to the medial malleolus. True limb shortening
suggests pathology of the hip joint.
– To measure apparent leg length, measure the distance from the
xiphisternum to the medial malleolus.
4. Circumference of quadriceps muscles at a fixed point.
Feel or palpate
SKIN: temperature, effusions.
Bones and joints: bony landmarks of the hip joint, inguinal ligament.
Move
• FLEXION:
• Flex both hips. Active Range of Motion 110 to 120 degrees
• Hold one hip flexed and straighten the other leg, keeping one hand in
the small of the back. If the leg cannot be straightened, there is a fixed
flexion deformity (Thomas’ test).
• Repeat for the other leg.
Abduction and adduction:
• Drop one leg over the edge of the couch to fix the pelvis.
• Place one hand on the anterior superior iliac spine to fix the pelvis.
• Carry the other leg through abduction and adduction.
Repeat for the other leg.
Abdtn: 30 to 50 degrees
Adduction: 30 degrees
Rotation : Flex the hip and knee.
• Hold the knee in the left hand and the ankle in the right hand.
• Using your right hand , rotate the hip internally and externally.
• Repeat for the other leg.
External rotation:
40 to 60 degrees
• Internal rotation: 30 to 40 degrees
Ask patient to lie prone and inspect the posterion aspect of the hip and
thigh.
Extension :
Other specific tests:
• Patrick’sTest
– supine
– foot on opposite knee
– hip involvement
iliopsoas spasm
SI joint involvement
• Galeazzi Test
– knees & hips flexed to 90 degrees
– positive test: one knee higher
• Telescoping Sign
– knee & hip flexed to 90 degrees, axial load and distraction applied
– positive test: increased relative movement
•
Conclusion: After examining both hips:
• - Offer to help the patient put his/her clothes back on.
- Offer a differential diagnosis.
• Eg. Osteoarthritis: hip in flexion, external rotation, and adduction,
apparent limb shortening, pain, limp, limited range of movement,
Heberden’s nodes on distal interphalangeal joints.
• Hip replacement
• Hip arthrodesis
• Slipped upper femoral epiphysis.
Note : common exam cases
Dr Y. Bugri
Dr F. Akkermans
Dr P. Turner