4/5/2020 Examination of the Hip Joint – RP's Ortho Notes

RP's Ortho Notes

Passion for excellence and perfection…..

Examination of the Hip Joint

Introduction

Introduce yourself and get the consent of the patient or the parent of the child for examination.
Note down the name, age, sex, race and occupation of the patient.
The patient should be adequately exposed while making sure that external genitalia are covered
and the patient is comfortable and relaxed. Explaining why you need to expose and the steps of
examination will help in relaxing the patient and in establishing a good rapport.
When examining a female patient make sure that you have a female nurse or assistant.
Examine the child with the parents by the side. Very young children may be examined in the
parent’s lap.
First examine the normal or less symptomatic side first to establish the normal range of movement
for the particular patient and to make the patient understand what is going to be done on the
painful side.
Steps of all procedures should be explained to the patient to ensure patient comfort and
cooperation.

Patients with hip joint disease may present with pain, alteration of gait, instability, functional
limitation or limb length discrepancy as their presenting complaint. Hip symptoms may be due to
intra-articular, extra-articular or referred causes. Intra-articular conditions usually will cause
deformity, limitation of range of movement and worsening of symptoms on joint activity. Extra-
articular conditions usually will not cause restriction of range of movement, pain will be present
mainly in one particular movement or position of joint and tenderness will be localized to a specific
area. Always rule out referred pain from spine, pelvis, and sacroiliac joint or vascular causes. Rarely
hip disease may present as pain referred to the knee.

Examine the patient in standing, si ing, walking and lying down. When the patient is lying in the
supine position, always examine the patient from the right side. Make sure that the patient lies on a
hard surface to ensure that deformities are not concealed by a soft ma ress.

HISTORY

Presenting complaints – Give the presenting complaints in the chronological order.

History of presenting complaints

Pain

https://learningorthopaedics.com/examination-of-the-hip-joint/ 1/17
4/5/2020 Examination of the Hip Joint – RP's Ortho Notes

Duration – How long the pain is present?

Onset – How it started?
Progress – What has happened to the pain after it started? Has it increased, decreased or remain
in the same intensity. Is it constant or intermi ent?
Site- Ask the patient to pinpoint the site of pain with a single finger. Note down whether in the
groin, trochanteric area, bu ocks etc. and don’t use vague terms like pain in the hip. Remember that a
patient with hip disease may present with knee pain.
Severity- How disabling is the pain? What is its effect on routine activities, self care, locomotion,
occupation and recreational activities?
Character – What is the nature of pain? Throbbing pain is due to inflammatory causes, burning pain is
due to neuropathic causes.
Radiation- Pain of hip may radiate to knee or thigh. Pain radiating to the testes is suggestive of ureteric
calculi. Pain radiating below knee is due to sciatica.
Aggravating and relieving factors- Mechanical pain due to osteoarthritis or impingement is aggravated
by activity and relieved by rest. Pain due to inflammatory arthritis is aggravated by rest and partially
relieved by activity.
Diurnal variation- Pain of osteoarthritis is more towards the evening and less when patient gets up in the
morning. Pain of inflammatory arthritis like ankylosing spondylitis is more in the morning and less in the
evening. Nocturnal pain that interferes with sleep is an ominous sign of malignancy or infection.
Associated symptoms

Deformity

How long the deformity is present?

How did it start?
How is it progressing?
Any associated symptoms?
Is there any history of trauma or infection?

Limb length discrepancy

How long it is present?

Is it static or progressive?
Associated symptoms?
Any history of infection or trauma?

History to assess function

Walking ability
Normal or altered
Restricted or unrestricted
Aided or unaided
If aided; which aid is used
Ability to squat
Ability to sit cross legged
Ability to drive car
Ability to tie shoes

Fever – Whether associated with chills and rigor, severity, continued or intermi ent and the
treatment taken.

Past history

Hypertension
https://learningorthopaedics.com/examination-of-the-hip-joint/ 2/17
4/5/2020 Examination of the Hip Joint – RP's Ortho Notes

Diabetes mellitus
Inflammatory arthropathy
Septic arthritis
Tuberculosis
Umbilical sepsis
H/o prolonged IV infusion in childhood
Blood Dyscriasis
Frequent episodes of bleeding
Frequent episodes of infection
H/o Childhood limping
Previous hospital admission
Previous surgery
Previous trauma

Personal history

Prolonged drug intake

Alcohol abuse
Smoking
Diet
Menstrual history
Occupational history
Recreational activities

Treatment History

Family history

Any family history of dwarfism

Any family history of angular deformities
Metabolic disorders
Similar illness
Tuberculosis

GENERAL EXAMINATION

Head to foot examination

Eyes- Blue sclera, irirtis ,uveitis, squint, microophtalmos, cornea, pigmentation of sclera.

Pinna- Low set, blackish discoloration.

Cheeks- Malar rash.

Mouth – Normal dental hygiene, arch of palate.

Hair Line- Normal or low

Neck – Webbing , thyroid swelling.

Nipples- Normal level or not.

Shape of chest wall- Pectus carinatum/ excavatum.

Abdomen- Protuberant , undescended testis , hernias.

https://learningorthopaedics.com/examination-of-the-hip-joint/ 3/17
4/5/2020 Examination of the Hip Joint – RP's Ortho Notes

Nails- Pi ing.

Palms and soles- Hyperkeratosis.

Thickening of lower end radius, malleoli and costochondral junctions.

Ligamentous laxity (Wynne-Davis Criteria- 3 out of 5 needed for diagnosing generalized laxity)

Apposition of thumb to flexor aspect of forearm

Passive extension of fingers so that they lie parallel to the forearm.
Hyperextension of elbow at least 10 degrees
Hyperextension of knee at least 10 degrees
Excessive passive dorsiflexion of ankle (45 degree) with eversion of foot.

Neurocutaneous markers-

LOCAL EXAMINATION

The steps of local examination are inspection, palpation, movements, measurements, gait analysis,
special tests and examination of spine and other joints and other system.

Inspection

Inspection should be done with the patient standing, walking, si ing and lying down. Look from the
front, sides and back. Look for any asymmetry when compared to the normal side.

Look for the following.

A itude
Deformity
Bony contours
Soft tissue contours
Swelling
Wasting
Limb length discrepancy
Skin over the joint

A itude and Deformity

A itude is the position of joint which is most comfortable to the patient. Position of comfort for the
hip joint is flexion, abduction & external rotation; as it allows maximum distension of the capsule. If
the joint is moved it can be brought to neutral position. In deformity; there is a fixed contracture of
the joint which will prevent the joint from being placed in the neutral position. A flexed a itude of
the hip joint can be corrected but a fixed flexion deformity cannot be corrected.

Normally when a person lies supine on a firm surface the lumbar spine lies flat on the table and there
will not be any gap between the lumbar spine and the couch; if there is a gap then lumbar lordosis is
exaggerated. In the case of flexion deformity of the hip (FFD) it is usually masked by forward tilting
of the pelvis, which in turn is masked by increased lumbar lordosis. Hence exaggerated lumbar
lordosis is a sign of fixed flexion deformity of the hip. Unmasking of the fixed flexion deformity of
hip can be done by the Thomas well leg raising test.

A coronal plane deformity such as abduction or adduction is masked by compensatory coronal tilting
of the pelvis, which can be identified by looking at the level of both anterior superior iliac spines
(ASIS). In case of an adduction deformity; the ASIS of the deformed side will be at a higher level, the
https://learningorthopaedics.com/examination-of-the-hip-joint/ 4/17
4/5/2020 Examination of the Hip Joint – RP's Ortho Notes

affected limb will appear to be shortened and there will lumbar scoliosis with convexity to the
opposite side. In case of abduction deformity; the ASIS of the deformed side will be at a lower level,
the affected limb will appear to be lengthened and there will lumbar scoliosis with convexity to the
same side.

Anteriorly from proximal to distal;

Level of ASIS
Normal hollowing of iliac fossa
Inguinal orifices
Widened perineum
Femoral artery pulsations
Abnormal fullness in the Scarpa’s triangle
Contour and level of the greater trochanter
Contour and bulk of the thigh muscles looking for abnormal contour and wasting
Scars, discolorations, swellings and sinuses

Laterally:

Exaggerated lumbar lordosis

Position and bulk of the trochanter- Look for any superior migration and more posterior position when
compared to opposite side. Superior migration may be due to dislocation/subluxation, joint space
destruction, fracture of neck /trochanter and coxa vara. Excessive lateral prominence is seen in
subluxation/dislocation. Reduced prominence seen with protrusio acetabuli.
Scars sinuses or any abnormal prominences

Posteriorly:

Scoliosis
Level of posterior superior iliac spine and iliac crests
Symmetry of the gluteal folds
Wasting of gluteal muscles
Scars, sinus or abnormal masses

Palpation

Palpate for any local rise in temperature, tenderness, bony thickening or swelling, soft tissue mass or
defect.

Anteriorly:

Local rise of temperature

Anterior joint line tenderness- Anterior joint line is 2-3 cm below and lateral to mid-inguinal point. Mid-
inguinal point is the centre of a line connecting ASIS and the symphysis pubis.
Confirm level of ASIS.
Feel the resistance over the Scarpa’s triangle. It will be reduced if the hip is dislocated and it will be
more in case of cold abscess.
Femoral pulsations- The volume of pulse when compared to opposite side will be reduced if the head is
dislocated (Vascular sign of Narath).

Laterally:

Greater trochanter
https://learningorthopaedics.com/examination-of-the-hip-joint/ 5/17