May 30, 2024

Hip examination is very important in orthopedics surgery to diagnose hip pathology and locate the lesion in complex hip structures.

PRE-REQUISITES

  • Suitably Undressed (Only in underwear)
  • Should be kept in Hard Bed

Look for the Gait of the patient

An attitude of the patient/ If any visible deformity

Inspection

Inspection during hip examination is done in Standing, Supine and Prone positions

Standing

Front

Inspecting from front comment on the following topics:

  • Level of shoulder
  • ASIS + Iliac fossa + Groin fold
  • Pubic symphysis
  • Pubic tubercle
  • Wasting of muscles( Quadriceps)
  • Scarpa’s Triangle
  • Hernia side

Sides

  • Lordosis of spine
  • Pelvic tilt
  • Trochanteric prominences
  • Flexion at hip, Knee, and equinus at ankle

Behind

  • PSIS Level (dimple of venous)
  • Natal cleft (mid-line shift)
  • Curvature of spine
  • Lumber triangle for fullness
  • Gluteal fold and symmetry

Patella

  • Compare the level of both patella, Same level or not
  • Facing patella towards roof (in supine)

Prone position

Back

  • Look for Bedsores in elderly patients or patients with bedridden

Palpation

Explain the procedures before doing any procedures

TEMPERATURES AND TENDERNESS

Palpate on the ipsilateral side and compare with contralateral sides

Bony Points

To identify different points palpate in the following sequences

Semi-flex the hip and knee and slightly abduct the hip

Place one hand over the medial side of the knee and request the patient to try and adduct against resistance

The proximal attachment of the adductor tendon will become PROMINENT

Palpate prominence tendinous attachment (adductors) to the ischiopubic rami

Superiorly: Pubic crest (after it soft tissue abdomen begins)

Then small bony prominence of the pubic tubercle

Confirm pubic tubercle by palpating inguinal lymph nodes

Then, Palpate medially until you find a groove ( symphysis pubis)

Continue with inguinal ligaments

1st Bony Point is ASIS

Continue bony palpation from ASIS (laterally and superiorly)=> Iliac crest

From highest point (bone) => Starting palpating downward

Soft tissue ( Gluteus medius)

Bony Point => Greater trochanter (GT)

To COnfirm GT

  • Grasp thigh and gently adduct, abduct, and rotate
  • GT shoulder move in the same direction as the thigh being moved

Finally palpate the most superior part of the GT, which is the tip of the GT

Greater Trochanter (GT)

Examination of Greater Trochanter (GT) involves:

Look for Size, Shape, and Surface,(use thickened, broadened, irregular) Level

Palpate for any Tenderness(Pertrochanteric, Anterior-posterior, bitrochanteric tenderness), transmitted movements

Anterior and Posterior Superior Iliac Spine (ASIS, PSIS)

Identify the level and compare it with the contralateral side

Look for the tenderness and irregularities

Ischial tuberosity

Lateral position (side to examine facing upward)

Hip and knee fixed to 90° (Gluteal muscle moves up uncovering the tuberosity)

Palpate bony prominence midway between the posterior border of the trochanter and the lower sacrum and coccyx (at the level of the gluteal fold)

Confirm: Patient to flex the knee against resistance, make hamstring tout, and palpating its attachment to the tuberosity

Adductor Muscle (Roll test)

Standing on the affected side and gently roll the thigh with both your hand (medially and laterally)

Note comparative resistance to movement of both lower limb

We fill resistance: Patient complaints of pain

Other examination

Vascular sign of Narath (Femoral Pulsation)

Inguinal lymph nodes

Sciatic Point ( between the ischial tuberosity and GT)

Coccygeal tenderness

Ludloff Sign: Tenderness over the anteromedial aspect of thigh at base of Scarpa’s triangle

Scarpa’s Triangle

Tenderness

Anterior Hip Joint tenderness

1.5 cm below and lateral to mid inguinal point behind femoral artery pulsation

Bitrochanteric Compression test (Indirect method)

Percussion

Anvil test

Percussion at the heel after raising 30° at supine position

Pain in inflammatory condition

Movement

PRIME MOVERSASSISTED BY
Flexion (0-110°/130°) L2-L3Psoas MajorRectus femoris, Pectineus, Sartorius, Tensor fascia lata, Adductor (longus, brevis, magnus)
Extension (0-20°) L4,L5,S1,S2,S3Gluteus Maximus, Semitendinosus, Semimembranous, Bicep femoris 
Abduction (0-45°/55°)
L4,L5,S1
Gluteus mediusGluteal minimus,

Gluteal Maximus, Tensor fascia lata
Adduction (0-35°/45°) L2,L3,L4Adductor (magnus, longus, brevis), Pectinous, Gracialis 
External Rotation(0-40°/50°)Obturator externus/internus, Quardatus femoris, Piriformis, Gemelli superior/ inferiorSartorius, Long head of biceps
Internal Rotation (0-30°/40°) L4,L5,S1Gluteus minimus, Tensor fascia lataGluteus medius, Semi membranous, Semitendinous
Muscles and their functions

All movements should be done by Holding the pelvis firmly with the left hand with thump and ASIS and finger embracing trochanter

Thomas Test

Pre-requisites for doing the Thomas test: Knee should be Normal

Fallacies

  1. Fused spine
  2. Fixed flexion deformity of the knee
  3. Bilateral fixed flexion deformity

Methods of examination

Examiner stands on the affected side

Insulate the palm towards the head of the patient between bed and lumbar lordosis

Grasp (Non-pathological lower limb just beneath the knee)

With hand facing towards the foot of patients

Gradually flex the hip ( Knee anatomically flex)

Until the lower back of the patient touches the finger and palm of hand

Then remove hand

Maximally flex just enough to obliterate the lumbar lordosis

Further flexion will cause anterior tilting of the pelvis

Ask the patient to hold this position

Apply downward pressure over the anterior aspect of the thigh ( Pathological/ affected side)

Extra Hip flexion due to muscle spasm/ pain will be obliterated

Measure angle between the longitudinal axis of thigh and bed

In the case of B/L FFD, Ipsilateral Fixed Knee Deformity

Bring the patient to the edge of the table

Pelvis and body remain supported ( Lower limb dangled down free)

Gently start to extend both hips until resistance is felt (reappearance of lumbar lordosis)

Angle made between horizontal (forearm) and hanging pathological sides: FFD

One by one we can identify each pathology

Modified thomas test for B/L FFD

Test for Fixed Abduction/Adduction

In Fixed Abduction Deformity: There will be no adduction but can be some abduction

In Fixed Adduction Deformity: There will be no abduction but can be some adduction

Fixed Abduction and Adduction deformity

ASIS is not in the same level

Square the pelvis

Fixed Abduction deformity / Fixed Adduction deformity

In Fixed adduction deformity

With a certain amount of adduction, there will not be pelvic movement (as some free adduction is possible)

Then, further, adduct till pelvic becomes square (But this is not fixed adduction deformity as free adduction is added here)

So, now abduct the limb till the pelvic starts moving

That angle is FIXED ADDUCTION DEFORMITY

Rotational deformity

No compensatory / canceling mechanism for fixed rotational deformities

If the Hip is fixed in Internal rotation, No external rotation is seen or vice versa

Methods to do rotation:

  1. Rotation will hip extended (raise leg 4′-6′ from bed for this maneuver)
  2. Rotation with hip flexed (Both hips simultaneously; Hip and knee at 90 degrees)
  3. Rotation in the prone position ( Hip extended and knee flexed to 90 degrees)

Measurements

Shortening in one lower limb is usually compensated

  1. Tilting of pelvis
  2. Gradual acquiring of equinus position
  3. Flexion of the opposite lower limb (hip and knee)
    • When shortening is beyond compensatory capacity

Apparent Measurement

Gives an idea about the amount of compensation the body has to be canceled, the hip deformity or scoliosis

True Measurement

Distance between ASIS to the tip of medial malleolus changes with abduction/ adduction of Hip

So, SQUARING OF PELVIS is necessary

Measure affected leg after squaring pelvis (adduction/abduction)

Then, measure the non-affected lower limb exactly in the same position (Abduction/Adduction) as the affected side

Measurement of LLD in a standing position

More accurate as it is done in a weight-bearing position.

Adduction deformity: True length more than apparent length (10° for 10 cm)

[Keep the measurement block beneath the foot until ASIS are at the same level]

Circumferential measurement

Only Hip examination where an affected side is measured first

15 cms from the medial joint line.

Visually note area of marked wasting

Segmental measurement of the hip examination

Galeazzi test or Allen’s test

To identify whether shortening is in the thigh or leg

Semi-flex both hip and knee and should be bilateral

Such a way that both feet are placed side by side

Confirmed by placing the ulnar border of the hand

Bring low to bring your eye line horizontal to the level of the knees

  1. In femoral Shortening: The knee is found to be more prominent
  2. In Tibial Shortening: The knee is found to be more distal

Supratrochanteric Shortening

Bryants TriangleS

Digital Bryants Triangle:

Tip of thumb= ASIS

Tip of middle finger = GT

Tip of index finger = Imaginary line of intersection of perpendicular drop ASIS over the bed and trochanteric tip over the first line

Geometrical Bryants Triangle:

Drawing line Between GT and ASIS, ASIS to perpendicular drop over the bed and another line from GT to drop a line.

Compare with the opposite side

Fallacies of Bryants Triangle:

  1. Bilateral affection of hip
  2. Excision of ASIS

Quantitative measurement of Bryant’s triangle is confirmed by qualitative measurement of

  1. Nelaton’s line
  2. Shoe maker’s line
  3. Chiene’s line
  4. Morris bitrochanteric test

Nelaton’s Line

Turn the patient to the normal or opposite side

Hip bend at 90° and knee bends at 90°

The line from ischial tuberosity to ASIS

Normally: Line just passes the tip of the GT

In Supratrochanteric shortening, the trochanter will be above this line (measure only on the affected side)

(But in fixed flexion deformity of hip we can do Nelaton’s line without 90° of flexion)

Shoemaker’s Line

Supine position

ASIS to GT line

This should meet at the central line above the umbilicus on the opposite side

In unilateral shortening:- crossing always misses the midline and lies on the opposite side of the midline

Shoemaker line

Chiene’s test

2 line is drawn from

ASIS to ASIS
GT to GT

Normally should be parallel

If GT is up ridden: The line will get converse to the affected side

Morris Bitrochanteric test

Distance between the tip of the trochanter to the pubic symphysis

Should be equal normally

Special Tests

Test for the stability of Hip

  1. Active SLRT
  2. Trendelenburg test
  3. Telescopic test
  4. DDH
    1. Ortolani tests
    2. Barlows test

Active SLRT

Unable to do this will indicates the pathology

Trendelenberg test

SSS: Sound Side Sags

Patient is standing

To access the integrity of the Abductor mechanism of the Hip to ensure stability

Sit behind the patient

Ask the patient to stand on the unaffected side first

Lifting the affected side foot and flexing the hip between neutral and 30°

In some patients to maintain balance either a supporting stick can be used on the hand of a weight-bearing Hip/an examiner can support both shoulders

Note the position of the pelvis

Repeat the same on the affected side

Normally: (-) test

One is able to lift the other side (watch iliac crest) without losing balance for at least 30 sec and the lift is equal to the abduction possible at that hip

Gluteal fold: Standard reference for judging pelvis lift

In muscle wasting: PSIS as a reference

Alternately, one can stand in front of the patient and support the patient palm

Perform the test in a similar way

Note the pressure transmitted by the patient’s palm when they try to balance

Increase pressure on the opposite side in an attempt to gain support from you and suggest a positive test (+).

Fulcrum: Dislocation of Hip Joint

Lever: Fracture NOF

Abduction: Paralysis of Abduction (Polio), Decrease effectiveness ( Coxa-vara)

Positive test:

  1. maximum elevation not achieved
  2. Sustained elevation not achieved for 30 sec
  3. Iliac crest not elevated
  4. Pelvic dropdown

Trendelenberg test is not done in:

  • In fixed coronal plane deformities (abduction/ Adduction)
  • Ankylosing Hip
  • Cannot stand for >30 sec (Painful Hip)
  • Gross Shortening
  • Child < 5 years of age

In such scenarios modified Trendelenburg test

Telescopic test

Intactness and adaptation of the Head and acetabulum are accessed

Supine Position: Flex the hip and knee 90 degree

To access the patient’s right hip, Put your opened up left hand closely adapted to the trochanter and outer part of the buttock

Then, the Right hand holding the lower end of the femur pushes down and pulled up away from and towards the bed.

Impingement test

Impingement test of hip examination
Impingement tests

Other tests:

Gauvain Sign

Spasms of abdominal muscles on initiating rotatory movement of hip

(In active tuberculosis / Stage of synovitis)

Narath Sign (Vascular Sign)

Craig Test

The patient lies prone with the knee flexed to 90°

Examiner palpates the posterior aspect of GT ( One hand over GT)

The hip is passively rotated medially and laterally until GT is parallel with the examining table or reaches its most lateral position. (Another hand rotates)

The degree of anteversion can then be eliminated, based on the angle of the lower leg with verticle

Ely’s Test

Prone position

Examiner passively flex the patient the knee

On flexion of the knee, the patient’s hip on the same side will spontaneously flex

Indicates tightness of rectus femoris muscle

Noble compression test

To identify iliotibial band friction syndrome

In the Supine position, the knee flexed to 90°

Accompanied by hip flexion

Examiner then applies pressure with the thumb to lateral epicondyle / 1-2 cm proximal to it

Maintaining pressure: The patient slowly extends the knee

At approximately 90° of flexion (0-straight leg)

Patient complaints of severe pain over the pressure side

Ober’s Test

Contraction of TFL ( Tight IT Band)

Sideline position at lower leg flex at hip and knee

Examiner abducts leg and slightly extend

If the leg stays in the air and does not fall on releasing the hand

Test is positive

Sectoral Sign

The range of internal rotation is less in hip flexion compared to when the hip is in extension

Other not to be missed:

Examine Spine and SI joint

Look for Ipsilateral Knee

Look for chest movements for Ankylosing Spondylitis

Per rectal examination

Distal Neurovascular structure (DNVS)

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