Hip Examination

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Original Editor - Laura Ritchie Top Contributors - Samuel Adedigba, Kim Jackson, Vidya Acharya, Rachael Lowe, Laura Ritchie, Admin, Kai A. Sigel, 127.0.0.1, Naomi O'Reilly, Wanda van Niekerk and Tony Lowe

Introduction

The Hip joint is one of the most important joints in the body because of the vital role it plays in locomotion. It is the second largest weight-bearing joint in the body, after the knee joint. It is a ball-and-socket synovial joint formed between the os coxa (hip bone) and the femur. The rounded head of the femur forms the ball, which fits into the acetabulum (socket in the pelvic bone) and ligaments connect the ball to the socket, thereby providing tremendous stability to the joint. Functionally, the hip joint enjoys a very high range of motion.

All of the various components of the hip mechanism assist in the mobility of the joint. Damage to any single component can negatively affect range of motion and ability to bear weight on the joint. In hip injury, as with other traumatic presentations, age distribution is bimodal with high-energy trauma in the younger population and potentially trivial mechanisms of injury in the older population, e.g. a simple fall.

Subjective Examination

Patient Intake

The first step during the examination is the patient interview, during which the clinician gets a description of the presenting symptoms from the patient. Taking the history is a vital component of the subjective examination as it helps the clinician develop a hypothesis about the mechanism of injury, type of the injured structures and extent of the injury or damage. Details like the location of the pain, nature of the pain, 24-hour pattern of the pain, activities that trigger the pain, pain aggravating and relieving factors etc., are gotten from the patient during the interview.

The patient's past medical history, as well as their social/family history is also important as this helps the clinician rule out hereditary conditions. Any surgical histories that are specific to the hip region is also vital, for example, a patient who had a hip joint replacement surgery and is currently complaining of pain at the hip joint. The patient's drug history and current medications they are on should also be documented as well as any allergies they might have. The effects of the condition on the patient' functional status and Activities of Daily Living (ADLs) should be well assessed and documented.

In the elderly it is also worth considering whether a fall was the result of a simple trip, or secondary to another reason, e.g. seizure, cardiovascular trigger, stroke or loss of consciousness. Relevant assessment of the cardiovascular or neurological system may be required with additional tests, e.g. ECG, CT brain.

Special Questions

• Red Flags
• Yellow Flags
  

Investigations

The first investigation of choice in a patient with hip pain following trauma is a hip x-ray. This will be an AP radiograph of the pelvis and a lateral radiograph of the painful hip. Fractures are not always identified on initial x-ray imaging. If there is a clinical concern for a hip fracture, but the x-ray is normal, further imaging is required. Both CT and MRI can be used to look for a radiographically occult fracture - MRI is more sensitive, but CT is usually easier to organise and in many institutions is the second-line investigation of choice.

In complex fractures, CT can be helpful to get additional preoperative information that can be used to plan surgery and aid discussion about consent and prognosis. It is also worthwhile considering that interpretation of a hip x-ray will be complicated in the elderly by the present of other conditions, e.g. secondary osteoarthritis.

Objective Examination

Observation

Upon conclusion of the patient interview, the clinician proceeds to the objective examination by observing the patient's posture and gait. There are several types of abnormal gait patterns associated with hip pathologies which the clinician needs to look out for such as:

• Antalgic gait,
• Trendelenburg gait,
• Arthrogenic gait
• Lurching gait.

A Pain VAS is administered to determine the patient's baseline pain level.

Functional Tests

Apparent and Real leg length.

Neurologic Assessment

SLR, dermatome testing,

Movement Testing

• The available ranges of motion at the hip joint (Active and Passive) are measured using a goniometer and documented. These measurements serve as a baseline for the
• Muscle Strength: The strength of the muscle groups surrounding the hip joint are graded majorly the hip extensors, flexors, abductors, adductors, internal and external rotators.