Ask Patient’s name, DOB and what they like to be called
Explain examination and obtain consent
Expose to underwear
Patient: e.g. age, pain/discomfort, signs of trauma
Around bed: e.g. mobility aids
Gait: speed, walking phases, stride length, arm swing, abnormal gaits (e.g. Trendelenburg’s waddling gait(abductor dysfunction) or antalgic gait)
Front (straight stance, pelvic tilt, any deformities of hip/knee/ankle/foot)
Side (stoop, lumbar lordosis)
Behind (scoliosis, gluteal atrophy)
Trendelenburg test: crouch down and hold the patient’s ASIS’s from the front, then ask them to stand on one leg by bending the contralateral knee. Then repeat on the other side. Normally their gluteal abducting muscles will tilt the pelvis so the contralateral (unsupported) side rises to balance. If the contralateral side dips, there is abductor muscle weakness on the side they are standing on.
Lying inspection: observe legs and compare sides – look for symmetry and rotation (one leg shortened and externally rotated = fractured neck of femur), hip scars, sinuses, dressings or skin changes
Measure true/apparent leg lengths: square hips then measure apparent leg length, i.e. xiphisternum/umbilicus to each medial malleolus (unequal = spinal or pelvic deformity, e.g. scoliosis). Next measure true leg length, i.e. ASIS to ipsilateral medial malleolus (unequal = true limb shortening, e.g. in fracture or developmental problems).
Ask about any pain and then start by examining the normal side.
Bony landmark tenderness: run hand up leg to greater trochanter (tenderness may indicatetrochanteric bursitis),thento ASIS, then pubic rami
Skin: palpate general area for temperature and soft tissue swelling/tenderness
First test all active movements (except internal and external rotation), then test passive movements.
Start by rolling each leg from side to side (assesses for hip fracture)
Flexion (120˚): flex the patient’s hip and knee and press their knee against their chest
Internal (30˚) and external (40˚) rotation: with the knee and hip flexed to 90˚, turn shin inwards (external rotation) and outwards (internal rotation). Internal rotation is lost early in osteoarthritis.
Abduction (45˚) and adduction (30˚): place your left hand on the patient’s contralateral iliac crest to detect pelvic movement. Hold their calf in your right hand and abduct until pelvis tilts. Test adduction by crossing their leg over the other.
Extension (20˚): ask patient to lie prone. Inspect for scars and muscle wasting. Extend hip actively then passively. Place your left hand on their pelvis/lumbar spine to detect movement while lifting each thigh.
Fully flex the patient’s hip on one side (with their knee also in flexion) and place a hand under their lumbar spine. The lumbar lordosis should be reduced. If the contralateral thigh is forced off the couch, there is a fixed flexion deformity of that hip. Now repeat on the other side.
(Gait: already observed)
Thank patient and restore clothing
‘To complete my examination, I would examine the spine and the knees, and perform a distal neurovascular examination.’
Summarise and suggest further investigations you would consider after a full history
Common hip pathology
Now try some questions
What is trochanteric bursitis and who does it normally affect?
List some causes of hip pain in children
How would you classify hip/neck of femur fractures and how would each type be managed?
What are the possible complications of hip fractures?