Hip Examination

DR. (PROF.) ANIL ARORA

MS (Ortho) DNB (Ortho) Dip SIROT (USA)
FAPOA (Korea), FIGOF (Germany), FJOA (Japan)
Commonwealth Fellow Joint Replacement
(Royal National Orthopaedic Hospital, London, UK)
Senior Knee and Hip Replacement Surgeon
Associate Director
Department of Orthopaedics and Joint Replacement
Max Superspeciality Hospital, Patparganj, Delhi (India)
Email: anilarora@delhiorthojournal.com
Background – Skeletal Anatomy
 Background – Hip Flexors
Hip flexors
• Ilio-psoas
• Accessory M.
 Background – Hip
Extensors:
• Gluteus Max
• Hamstrings
Abductors:
• Medius, Minimus
Adductors:
• Brevis, longus and
magnus
 Hip Examination

• Introduce yourself

• Take Consent for Examination

• Expose the patient

 Introduction
Always remember
• Inspection
• Palpation
• Movements
• Measurements
• Special tests
 Inspection

Scan patient from head to toe

 Inspection
Pre - requisites

• Flat bed / couch

• Adequate exposure
• Comfortable painless position
Standing- from front

• Level of shoulders
• Trunk
• ASIS level, Pelvic Tilt
• Iliac fossae
• Groin fold, Scarpa’s
• Attitude of limb as a
whole
• Knee, ankles, feet.
 Standing- from front
• Scars
• Sinuses
• Fullness / swelling
• Muscle wasting
• Abnormal position / pulsations
 Standing- from sides
• Iliac crest- level
• Supra-trochanteric depression
• Infra-trochanteric depression
• Lateral thigh mass
• Level of GT in relation to ASIS
• Knee, ankle, feet
Standing- from back
• Imaginary plumb line
• Shoulders, trunk, spine
• PSIS
• Gluteal folds- level
• Back of thigh
• Knee, ankle, feet
 Standing- from back
• Posterior thigh muscle wasting
• Swelling
• Sinuses
• Scars
• Contractures
Note the scar
 Gait
• Use of support
• Walk without support
• Swing phase
• Stance phase
• Time spent in each phase
• Level of shoulders, trunk.
• Hip, knee, ankle, feet
 Gait
• Antalgic
• Short Limb
• Trendelenburg
• Waddling
• Stiff hip
• In-toeing
• Out-toeing
 Trendelenberg Test
• Patient’s back to the examiner
• Patient stands on the normal leg
• Opposite hip extended
• Opposite knee flexed
• Shall stand for 30 seconds.
• The pelvis should remain level or tilt
slightly upwards on the unsupported side.
Standing on normal side
 Trendelenberg Test
• Patient then stands on affected leg
• Opposite Hip extendedd, Knee flexed
• If the pelvis tilts downwards on the
unsupported side, then this confirms a
positive sign.
Trendelenberg Test
 Indirect
Trendelenberg
 Trendelenberg Test
Assess the ability of the hip abductors to
stabilise the pelvis on the femur.

Causes of positive test-

Disturbance in pivotal mechanism –

Dislocation or subluxation of hip
Shortening of femoral neck
 Trendelenberg Test
Disturbance in effort
Myopathy, neuropathy- abductors

Disturbance in effort (lever) arm

Fracture neck femur, I/T #
 Trendelenberg Test
Fallacies
• Bear wt on affected extremity for at least
30 seconds
• Bilateral cases- difficult to interpret
• Grotesque deformity (Mainly fixed
abduction deformity)
 Sitting

• Squatting
• Sitting cross-legged
( For functional assessment)
 Inspection-lying down-supine
• Exaggerated lumbar lordosis
• ASIS level
• Swelling/ scar/ sinuses in Iliac fossae
• Attitude of limb
Attitude
 Inspection-lying down-supine
• Swelling/scars/sinuses/abnormal
pulsations in Scarpa’s triangle
• Wasting of Quads.
• Level of patella
• Tibial Tuberosities
• Level of medial malleolus
Level of patellae, tibial tuberosities
Patella : assess rotation of the limb
Foot Size
 Inspection-lying down-SIDE

• Iliac crest
• Lumbar lordosis
• Trochanteric region
Increased lumbar lordosis
Inspection-Sides
Inspection from Side
 Inspection-lying down-PRONE
• Level of PSIS
• Gluteal folds
• Wasting of glutei
• Swelling, scar, sinuses, MASS??
• Wasting of hams
• Popliteal fossa
• Calf wasting
Popliteal Fossae
Gluteal Wasting
Palpation
Lumbar Lordosis
Iliac Fossae
Iliac crest
ASIS
Temperature
Tenderness
Narath’s sign
Greater Trochanter
GT Palpation
GT Palpation
Gluteal palpation
Femur
Knee
Tibial Tubercle
Tibia
Medial Malleolus
Palpatory Bryant’s
Palpatory Bryant’s
Deformities
Performing Thomas test
FFD- Alternative method

Alternative Method
 Fallacies of Thomas’ test

• Hurts an already painful hip

• Difficult in obese patient
• Inaccurate in Bilateral FFD
• Falters with Ankylosed Knee
Squaring the pelvis- Revealing the deformity
Kothari’s Angle
Kothari’s Angle
Movements
Hip Flexion
Flexion
Hip Abduction and Adduction
Extension
Movements- Rotations
ROTATIONS- in extension
ROTATIONS- in flexion
ROTATIONS- in prone
ROTATIONS- in sitting
Measurements
Apparent Length
Apparent Measurements
Compare with opposite side
TRUE LENGTH
True Length
True Length
True Length
True Length- Alternative method
True Length- normal limb
True Length-normal limb
Where is the shortening
Bryant’s Triangle
Bryant’s Triangle
Supratrochanteric shortening
Pelvis should be square
Supratrochanteric Shortening..

? Has the Trochanter gone up

Schoemaker’s line
Schoemaker’s line
Chiene’s test
Nelaton’s Line- Lateral position
ALLEN’S TEST
Special Tests
Guavain’s Test
FABER Test
 Others….
• Opposite Hip
• SI joints
• Spine
• Both Knees
• Distal Neurovascular status
• Per Rectal Examination
Chest Expansion
Thank You