HIP

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CHAPTER TEN HIP

AXIOMS IN ASSESSING THE HIP

• The hip joint is a ball-and-socket synovial joint.

• The hip is an exceptionally strong and stable joint, with a wide range of multiaxial movements.

INTRODUCTION

Hip pain is a common symptom with diverse etiologies. Typically, hip disease is characterized by pain in the groin. The pain may radiate to the anterior, lateral, or medial thigh and occasionally to the knee. Causes of pain in the groin and anterior thigh area include iliopsoas bursitis, adduction tendinitis, hernias, and pain from retroperitoneal structures, as well as femoroacetabular impingement.

Pain in the trochanteric area aggravated by lateral decubitus position is highly suggestive of trochanteric bursitis. Pain in the ischiogluteal area aggravated by the sitting position should suggest an ischiogluteal bursitis. Groin pain aggravated by walking and relieved by rest is suggestive of a degenerative hip arthropathy. Pain in the same location, when associated with morning stiffness lasting more than 30 minutes and relieved by activity, is typical of an inflammatory arthropathy. Vascular insufficiency tends to produce buttock pain aggravated by walking and relieved within minutes by rest (Table 10-3).

TABLE 10-3 HIP DIAGNOSTIC CONSIDERATIONS

Inflammatory joint diseases

Rheumatoid arthritis

Spondyloarthropathies

Polymyalgia rheumatica

Degenerative joint diseases

Primary osteoarthritis

Secondary osteoarthritis

Metabolic joint diseases

Hemochromatosis

Pigmented villonodular synovitis

Osteochondromatosis

Synovial sarcoma

Synovial metastasis

Transient toxic synovitis

Juvenile chronic arthritis

Periarticular

Acute calcific periarthritis

Heterotropic calcifications

Fractures, neoplasms, infection, osteonecrosis of the femoral head, metabolic bone disease (Paget disease of bone, stress fractures, osteomalacia, hyperparathyroidism, renal osteodystrophy), reflex sympathetic dystrophy (transient migratory osteoporosis)

Congenital dislocation of the hip

Acetabular dysplasia

Slipped capital femoral epiphysis

Legg-Calvé-Perthes disease

Entrapment neuropathies

Lateral femoral cutaneous nerve (meralgia paresthetica)

Lumbar nerve root compression L2, L3, and L4

Atherosclerosis of aorta iliac vessels

Modified from Klippel JH, Dieppe PA: Rheumatology, vol 1-2, ed 2, London, 1998, Mosby.

TABLE 10-1 HIP JOINT CROSS-REFERENCE TABLE BY ASSESSMENT PROCEDURE

TABLE 10-2 HIP JOINT CROSS-REFERENCE TABLE FOR SYNDROME OR TISSUE

Calcaneal fractures	Anvil test
Coxa abnormality	Anvil test Gauvain sign Jansen test Patrick test Phelps test Thomas test
Coxa vara	Trendelenburg test
Fracture	Anvil test Chiene test Ludloff sign Trendelenburg test
Gracilis contracture	Phelps test
Hip dislocation	Allis sign Hip telescoping test Trendelenburg test
Hip flexion contracture	Thomas test
Iliotibial band	Ober test
Leg length	Actual leg-length test Apparent leg-length test
Legg-Calvé-Perthes disease	Trendelenburg test
Meningeal irritation	Guilland sign
Osteoarthritis	Jansen sign Trendelenburg test
Pelvic obliquity	Actual leg-length test Apparent leg-length test
Poliomyelitis	Trendelenburg test
Subluxation	Trendelenburg test
Tibial dysplasia	Allis sign
Tibial/fibular fracture	Anvil test

Hip disease may result in adduction or abduction deformities. An adduction deformity is an upward tilt of the pelvis on the side of the adducted thigh. An abduction deformity is an elevation of the uninvolved side.

ORTHOPEDIC GAMUT 10-1 HIP

Loading forces acting on the hip:

1. Standing transfers one third of the body weight to the hip joint mechanism.

2. Standing on one limb transfers 2.4 to 2.6 times the body weight to the hip joint mechanism.

3. Walking transfers 1.3 to 5.8 times the body weight on the hip joint mechanism.

Pain in the posterior aspect of the hip is most often referred from the lumbar spine. Sacroiliac disorders can also cause buttock pain. Mechanical disorders of the thoracolumbar junction (T12 and L1) may refer pain to the greater trochanter area and thus may mimic trochanteric bursitis. Thrombosis or aneurysm formation of branches of the aorta or iliac vessels may give rise to buttock, thigh, or leg pain that may be confused with hip pain. The presence of pain at the extremes of abduction and internal rotation suggests early hip disease caused by arthritis or osteonecrosis. Limitation of hip movements in all directions in a diabetic patient suggests an adhesive capsulitis of the hip joint. The presence of systemic symptoms such as fatigue, fever, weight loss, or worsening of pain at night requires baseline laboratory tests and a radionuclide bone scan in search of a tumor or an indolent infectious process.

ESSENTIAL ANATOMY

The femur is the longest and strongest bone in the body. The femoral neck forms an angle of inclination with the femoral shaft on the frontal plane. In children, this angle may be up to 150 degrees; in adults, however, it is approximately 125 degrees. Variations in this angle commonly occur. An increase in the angle of inclination is known as coxa valga, and a reduction in this angle is coxa vara. The femoral neck is typically aligned anterior to the femoral shaft on the transverse plane. This angle of anteversion is approximately 15 degrees in adults. An increase in this angle is known as excessive femoral anteversion; a decrease is often called femoral retroversion.

ORTHOPEDIC GAMUT 10-2 PROXIMAL FEMUR

The four major components of the proximal femur are:

1. Greater trochanter

2. Lesser trochanter

3. Femoral neck

4. Femoral head

ORTHOPEDIC GAMUT 10-3 GENDER PREVALENCE FACTORS IN OSTEOPOROSIS

The prevalence of osteoporosis is lower in men than in women for several physiologic reasons:

• A greater accumulation of skeletal mass during growth

• Greater bone size

• Absence of midlife menopause

• A slower rate of bone loss

• A shorter male life expectancy

ORTHOPEDIC GAMUT 10-4 HIP BURSAE

The three most clinically important hip bursae are as follows:

1. Trochanteric bursa

2. Iliopsoas bursa

3. Ischiogluteal bursa

ESSENTIAL MOTION ASSESSMENT

When measuring the range of hip movement, the examiner must ensure that the patient’s pelvis remains stationary. To accomplish this task, the examiner keeps a hand on the patient’s anterosuperior iliac spine to detect any movement.

Among all of the movements of the hip, abduction and internal rotation are usually the first ones to be painful or limited in the presence of a hip abnormality (Figs. 10-1 to 10-6).

FIG. 10-1 Range of motion of the hip. A, Hip flexion with the leg extended. B, Hip hyperextension, knee extended. C, Hip flexion, knee flexed. D, Abduction E, Internal rotation. F, External rotation.

FIG. 10-2 Extension of the hip is defined as the upward (or backward) motion of the hip from the zero starting position. Motion beyond the neutral position (0 degrees) is sometimes alternatively called hyperextension.

With the available methods of eliminating exaggerated lumbar lordosis and accomplishing fixation of the pelvis, 15 degrees of extension or hyperextension of the hip may be obtained.

FIG. 10-3 The thigh can be flexed to 120 degrees from the neutral or extended position (0 degrees) if the knee has first been flexed to 90 degrees.

FIG. 10-4 Abduction and adduction are measured while both thighs and legs are in the extended position and are parallel to each other. Normally, when the leg and thigh are extended, the hip abducts to approximately 40 to 45 degrees from the neutral position.

FIG. 10-5 Adduction with the leg straight out is limited by the legs and thighs, which come into contact with each other. Adduction is usually possible to approximate 20 to 30 degrees from the neutral (starting) position.

FIG. 10-6 A, External and internal rotation of the hip can be tested with the patient’s hip and knee fully extended while the patient is supine. B, Rolling the thigh, leg, and foot inward. C, Rolling the thigh, leg, and foot outward. The hip normally rotates inward approximately 40 degrees and outward approximately 45 degrees.

ESSENTIAL MUSCLE FUNCTION ASSESSMENT

The innervation of the hip joint follows Hilton’s law, which states that a joint is innervated by the same nerves that innervate the muscles acting on it. Thus, branches from the femoral, sciatic, obturator, and superior and inferior gluteal nerves innervate the hip joint. The sclerotome reference for the hip joint is generally considered to be L3. The cutaneous innervation of the hip, buttock, and thigh can be referenced to peripheral nerves or dermatomes (Figs. 10-7 to 10-12).

FIG. 10-7 The iliopsoas is the primary flexor of the hip, and it is innervated by the femoral nerve, which contains the L1, L2, and L3 nerve roots. The examiner asks the patient to flex the hip against manual resistance.

FIG. 10-8 Prime movers in extension of the hip are the gluteus maximus (inferior gluteal nerve, L5, S1, and S2), semitendinosus (tibial branch of sciatic nerve, L4, L5, S1, and S2), and semimembranosus (tibial branch of sciatic nerve, L5, S1, and S2) muscles, as well as the long head of the biceps femoris (tibial branch of the sciatic nerve, S1, S2, and S3) muscle. To measure the strength of the gluteus maximus, the patient is directed to extend the hip against the examiner’s hand.

FIG. 10-9 The gluteus medius muscle (superior gluteal nerve, L4, L5, and S1) is the prime mover in abduction of the hip. An additional test can be performed by placing the patient in a side-lying position on the examination table and having the patient abduct the hip against resistance provided by the examiner.

FIG. 10-10 Prime movers in adduction of the hip are the adductor magnus (obturator and sciatic nerves, L3, L4, L5, and S1), adductor brevis (obturator nerve, L3, and L4), adductor longus (obturator nerve, L3, and L4), pectineus (femoral nerve, L2, L3, L4, and occasionally obturator nerve, L3, and L4), and gracilis (obturator nerve, L3, and L4) muscles. The patient then adducts the lower leg off the table, toward the elevated leg. The examiner’s free hand provides graded resistance proximal to the knee joint.

FIG. 10-11 Prime movers in external rotation of the hip are the obturator externus (obturator nerve, L3, and L4), obturator internus (sacral plexus, L4, L5, and S1), piriformis (sacral plexus, S1, and S2), gemellus superior (sacral plexus, L5, S1, and S2), gemellus inferior (sacral plexus, L4, L5, and S1), and the gluteus maximus (inferior gluteal nerve, L5, S1, and S2) muscles. The patient then rotates the hip and thigh laterally, and the lower leg rotates medially while the examiner’s other hand applies graded resistance above the ankle against the motion being tested.

FIG. 10-12 Prime movers in internal rotation of the hip are the gluteus minimus (superior gluteal nerve, L4, L5, and S1) and the tensor fasciae latae (superior gluteal nerve, L4, L5, and S1) muscles. The patient then rotates the thigh medially and rotates the lower leg laterally while the examiner’s other hand provides graded resistance above the ankle joint.

ESSENTIAL IMAGING

The major part of the pelvis is typically visualized with a single anteroposterior (AP) view. Both lower extremities are internally rotated approximately 20 degrees to elongate the femoral necks and take the trochanteric processes out of superimposition with the femoral necks.

ORTHOPEDIC GAMUT 10-6 BASIC HIP IMAGING STUDY

The basic hip plain-film imaging study:

1. AP pelvic view

2. AP spot hip view

3. Lateral (frog leg) spot view of the side of complaint

ORTHOPEDIC GAMUT 10-7 OSSEOUS DEFORMITIES OF THE PROXIMAL FEMUR

Four common osseous deformities of the proximal femur are:

3. Femoral anteversion

4. Femoral retroversion

ORTHOPEDIC GAMUT 10-8 COXA VARA

The developmental and acquired conditions that can resulting in coxa vara are:

1. Intertrochanteric fracture

2. Slipped capital femoral epiphysis

3. Legg-Calvé-Perthes disease

4. Congenital hip dislocation

6. Paget disease

ACTUAL LEG-LENGTH TEST

Assessment for True Leg-Length Discrepancy

Comment

Methods of measuring the lower limbs are often confusing. Accuracy in measurement is of more than academic significance. Accurate measurement is of practical importance when corrective operations or adjustments to the shoes are contemplated. Limb length can be measured clinically within an error of 1 cm. If greater accurancy is needed, radiograpic measurement (scanography) is recommended. The first required step is to measure the real, or true, length of each limb. Second, the examiner must determine the existence of any apparent, or false, discrepancy in the length of the limbs as a result of fixed pelvic tilt. Measuring the true leg length is always necessary. Also necessary is to measure apparent discrepancy only when a correctable pelvic tilt is observed.

ORTHOPEDIC GAMUT 10-9 LEG-LENGTH DEFICIENCY

Tests to determine leg-length deficiency occurring above the trochanteric level include:

1. Measurement of Bryant triangle

2. Construction of Nélaton line

3. Construction of Shoemaker line

PROCEDURE

• The patient is lying supine with the feet together, the knees and hips straight, and the anterosuperior iliac spines and the iliac crests exposed.

• The examiner, by way of palpation, marks the apex of the anterior iliac spines and the crests of the ilia.

• The examiner then measures the distance between these features and the medial malleolus (Fig. 10-13).

• The distance is recorded and compared with the opposite side.

• These distances represent the actual leg length.

• Actual leg-length discrepancies are caused by an abnormality above or below the trochanter level.

FIG. 10-13

Causes of true shortening above the trochanter include (1) coxa vara, resulting from neck fractures, slipped epiphysis, Perthes disease, and congenital coxa vara; (2) loss of articular cartilage from infection or arthritis; and (3) dislocation of the hip. Rarely does lengthening of the other limb give relative, true shortening. This relative, true shortening may be caused by (1) stimulation of bone growth from increased vascularity, which may occur after long bone fracture in children or bone tumor, and (2) coxa valga, which follows polio.

ALLIS SIGN

ALSO KNOWN AS GALEAZZI SIGN

Assessment for Femoral Portion Structural Deficiency or Tibial Portion Structural Deficiency

ORTHOPEDIC GAMUT 10-10 FORMS OF CONGENITAL HIP DISLOCATION

1. Congenital hip dysplasia

2. Acetabular dysplasia

3. Congenital subluxation

ORTHOPEDIC GAMUT 10-11 DIAGNOSING CONGENITAL HIP DYSPLASIA

1. Neonatal (birth to 1 month): Barlow test, Ortolani test

2. Infancy (1 month to 2 years): limited hip abduction with the hips flexed to 45 degrees, shortening on the affected side with hips and knees flexed (Galeazzi sign), Trendelenburg sign

3. Age 2 to 6 years: obvious limp, Trendelenburg sign, limb shortening if unilateral

4. Older than 6 years: limp, limited hip abduction

ORTHOPEDIC GAMUT 10-12 CATEGORIES OF PEDIATRIC LIMPING

I. An antalgic limp is one that is painful, and a child with an antalgic limp spends a greater portion of the gait cycle on the asymptomatic leg than the symptomatic leg.

II. A Trendelenburg limp is not painful but is caused by muscle weakness or instability of the hip joint such as in unilateral developmental dysplasia of the hip. A child with a Trendelenburg gait tilts the pelvis away from the involved side. In a single-limb stance on the affected side, the patient shifts the trunk over the involved side to stabilize the hip.

III. A child with bilateral developmental dysplasia of the hip has a waddling gait.

PROCEDURE

• The patient is lying supine with the knees flexed and the soles of the feet flat on the table, the great toes and malleoli being approximated bilaterally.

• The examiner observes the heights of the knees from a viewpoint at the foot of table.

• If one knee is lower than the other, ipsilateral hip dislocation or severe coxa disorder is indicated (Fig. 10-14).

• Tibial length discrepancies are also discerned in this position.

• From viewing the position from the side, the examiner can assess femoral length discrepancies (Fig. 10-15).

FIG. 10-14

FIG. 10-15

Congenital dislocation of the hip is a condition in which one or both hips are dislocated at birth or are dislocated in the first few weeks of life. The disorder has a familial tendency and a well-established geographic distribution. It may also occur with other congenital defects.

APPARENT LEG-LENGTH TEST

Assessment for Apparent Leg-Length Discrepancy

ORTHOPEDIC GAMUT 10-14 ANATOMIC LEG-LENGTH DIFFERENCE

Causes of an anatomic leg-length difference include:

1. Poliomyelitis of the lower limb

2. Fracture of the femur or tibia

3. Bone growth problems of the lower extremity (epiphyseal plate damage)

ORTHOPEDIC GAMUT 10-15 LEG-LENGTH MEASUREMENTS

Leg-length measurement landmarks include:

1. Iliac crest to greater trochanter to determine whether coxa vara is present

2. Greater trochanter to knee for femur length

3. Knee joint line to medial malleolus for tibial length

ORTHOPEDIC GAMUT 10-16 FUNCTIONAL LEG-LENGTH DIFFERENCE

Causes of a functional leg-length difference include:

1. One pronated foot or one supinated foot

2. Muscle spasms in one hip

3. Hip capsule tightness

4. Adductor muscle spasm on one side

5. More genu valgus on one side

6. Femoral anteversion on one side

PROCEDURE

• Measurement is made bilaterally from the umbilicus or xiphisternum to the apex of the medial malleolus (Fig. 10-17).

• This measurement is an index of the functional length of the lower extremities.

FIG. 10-17

Pelvic tilting accompanied by a heel discrepancy indicates apparent shortening of the limb. This apparent shortening may be accompanied by some true shortening. The discrepancy at the heels provides a measure of its degree.

CHIENE TEST

Assessment for Fracture of the Neck of the Femur; Hip Dislocation

ORTHOPEDIC GAMUT 10-17 HIP FRACTURES

Typical locations of fractures of the hip include:

1. Extracapsular or trochanteric

2. Femoral neck or subcapital areas (These areas are intracapsular.)

3. Proximal femoral shaft or subtrochanteric areas

ORTHOPEDIC GAMUT 10-18 SUBTROCHANTERIC FRACTURE COMPLICATIONS

2. Delayed union

ORTHOPEDIC GAMUT 10-19 HIP FRACTURE MALUNION AND NON-UNION

Two factors associated with hip fracture malunion and non-union:

1. The subtrochanteric area of the proximal femur is cortical bone, with decreased blood supply.

2. The subtrochanteric area is prone to large biomechanical stresses that can lead to loosening of various fixation devices.

ORTHOPEDIC GAMUT 10-20 FEMORAL NECK FRACTURE NON-UNION

Non-union of femoral neck fractures occurs in approximately 15% of the cases. Reasons for non-union are:

1. Meager blood supply

2. Inaccurate approximation and rigid fixation of the fragments

ORTHOPEDIC GAMUT 10-21 FACTORS INFLUENCING THE OCCURRENCE OF AVASCULAR NECROSIS IN PEDIATRIC PROXIMAL FEMUR FRACTURE

• Ligamentum teres contributes very little blood supply to the head until the age of 8; as an adult, it serves only 20%.

• Medial and lateral circumflex metaphyseal vessels that traverse the femoral neck predominately supply the head at birth. These later become virtually nonexistent by the age of 4, owing to the development of the cartilaginous physis that forms a barrier to these penetrating vessels.

• As the metaphyseal vessels diminish, their supply to the femoral head, the lateral epiphyseal vessels, become the main blood supply as they bypass the physeal barrier. These vessels can be identified as the posteroinferior and posterosuperior branches of the medial circumflex artery that supply the femoral head throughout the rest of its life.

ORTHOPEDIC GAMUT 10-22 CLINICAL FEATURES OF NON-UNION OF FEMORAL NECK FRACTURES

1. Pain in the hip when bearing weight

2. Shortening and external rotation of the limb

3. Grating or crepitus in the hip during motion

PROCEDURE

• The examiner determines whether a fracture of the neck of the femur has occurred by using a tape measure.

• The patient is supine with the legs extended on the examination table.

• Using a tape measure, the examiner measures the circumference of the thigh, passing the tape over the level of the greater trochanter (Fig. 10-18).

• The distance is recorded and compared with that of the opposite leg.

• An increased diameter indicates that the trochanter has rolled laterally.

• This increased measurement correlates with fracture of the neck of the femur.

FIG. 10-18

A fracture of the neck of the femur occurs mainly among elderly women whose bones are osteoporotic. The patient may fall, but the patient more often catches a foot on something and ends up twisting the hip. The femoral neck is broken by rotational force. In most cases, the fracture is markedly displaced and completely unstable. In some cases, the fragments are impacted, and the patient may even walk about, albeit with some pain.

GAUVAIN SIGN

Assessment for Tuberculous Arthritis of the Hip Joint or Adult-Onset Osteonecrosis of the Femoral Head

ORTHOPEDIC GAMUT 10-23 OSTEONECROSIS

Common causes of osteonecrosis include:

5. Metabolic problems

6. Genetic problems

ORTHOPEDIC GAMUT 10-24 HIP PAIN

Other causes of hip pain producing symptoms similar to osteonecrosis include:

2. Femoral or inguinal hernia

3. Pigmented villonodular synovitis

4. Stress fracture of femoral neck

5. Rheumatoid arthritis

ORTHOPEDIC GAMUT 10-25 RADIOGRAPHIC STAGES OF OSTEONECROSIS AIDING PROGNOSIS

Osteonecrosis is classified into several radiographic stages that aid with prognosis:

Stage 0: No change on plain-film radiographs but a positive magnetic resonance imaging scan

Stage I. Mottled densities or osteopenia

Stage II. Areas of increased density in the femoral head crescent sign with subchondral fracture

Stage III. Depression of femoral head

Stage IV. Flattening and collapse of femoral head

Stage V. Degenerative arthrosis

PROCEDURE

• The patient is lying supine or in a side-lying position with the affected thigh extended.

• The examiner carefully rotates the thigh (Fig. 10-19).

• The sign is positive if contraction of the abdominal muscles is noted on the same side that is being maneuvered.

• The sign is significant for reflex muscle spasm, which is commonly elicited in tuberculosis of the coxa, or adult-onset osteonecrosis.

FIG. 10-19

A resurgence in tuberculosis (TB) has occurred worldwide. Approximately 2 billion people have latent infection, 8 million develop active TB annually, and 2 to 3 million die as a result of TB. With this resurgence, cases with extrapulmonary TB have also shown an increase. Approximately 10% to 11% of extrapulmonary TB involves joints and bones, which is approximately 1% to 3% of all TB cases. The global prevalence of latent joint and bone TB is approximately 19 to 38 million. TB arthritis is most commonly associated with monoarthritis of weightbearing joints in the hip or the knee. A child infected with this disease walks with a limp and often complains of pain in the groin or knee. Night pain is another feature. In early cases, complete resolution may be hoped for with antituberculous therapy, bed rest, and traction. In the advanced case, joint debridement is carried out with efforts to obtain a bony fusion of the joint.

GUILLAND SIGN

Assessment for Meningeal Irritation

Comment

The signs and symptoms of meningitis may develop explosively de novo or may appear in the waning stages of an infection that is localized elsewhere. Headache, backache, nausea, and vomiting are common symptoms, and nuchal rigidity occurs in more than 80% of patients. Kernig/Brudzinski sign is often present. Only in the neonate and very young infant is meningitis often unattended by evidence of increased pressure and meningeal irriation. At this stage, even fever may be absent. Photophobia may be a prominent, early symptom and is related in some way to the meningeal inflammation.

PROCEDURE

• While the patient is in a supine position, a brisk flexion of the hip and the knee occurs when the quadriceps muscle on the opposite limb is irritated, such as by a firm pinch (Fig. 10-20).

• The sign is present in cases of meningeal irritation.

FIG. 10-20

Acute meningitis (associated with cortical encephalitis and often with ventriculitis) is an emergency and should be suspected in any patient with the acute onset of nonlocalizing central nervous system signs. Fever, nuchal rigidity, headache, altered mental status, vomiting, and photophobia are typically present. The absence of fever is not uncommon. Meningeal signs are not usually present in infants younger than 6 months. Acute signs may also be less apparent in elderly, alcoholic, immunocompromised, or comatose patients.

PROCEDURE

• The patient is in a supine position.

• The hip and knee are both flexed to 90 degrees.

• The femur is pushed down toward the examination table (Fig. 10-21).

• The leg is lifted from the examination table.

• Movement in hip dislocation will be considerable.

• This is hip telescoping.

FIG. 10-21

When treatment in childhood for congenital dislocation of the hip has been unsuccessful, or even where the condition has not been diagnosed, a patient may seek help during the third and fourth decades of life. Symptoms may arise from the hips or the spine. In the hips, secondary arthritic changes occur in the false joint that may form between the dislocated femoral head and the ilium. In the spine, osteoarthritic changes are the result of longstanding scoliosis. The telescoping test may remain positive for as long as the cause of the dislocation goes untreated.

JANSEN TEST

Assessment for Osteoarthritis of the Hip Joint

ORTHOPEDIC GAMUT 10-27 PIRIFORMIS SYNDROME AXIOMS

1. Symptoms of piriformis syndrome are not usually substantiated by clinical or electrophysiologic findings.

2. Denervation in the sciatic nerve distribution is usually caused by aberrant fascial bands, rather than piriformis muscle.

PROCEDURE

• In osteoarthritis deformans of the hip, the patient is asked to cross the legs, with a point just above the ankle resting on the opposite knee (Fig. 10-22).

• If significant disease exists, this test and motion are impossible.

FIG. 10-22

Primary osteoarthritis of the hip occurs in middle-age and elderly patients and is often associated with obesity and overuse. However, in many instances, no obvious cause can be found. The symptoms of secondary osteoarthritis of the hip are identical to those of primary osteoarthritis. The condition most commonly occurs as a sequel to congenital hip dislocation.

PROCEDURE

• In traumatic separation of the epiphysis of the lesser trochanter, swelling and ecchymosis are present at the base of Scarpa triangle, and the patient cannot raise the thigh when in the seated position (Fig. 10-23).

FIG. 10-23

As with femoral neck fractures, this fracture is common in elderly, osteoporotic women. However, in sharp contrast to the intracapsular neck fractures, the extracapsular trochanteric fractures unite very easily and seldom cause avascular necrosis.

OBER TEST

Assessment for Iliotibial Band Contracture

PROCEDURE

• The patient is in a side-lying position on the unaffected hip and thigh.

• The examiner places one hand on the patient’s pelvis to steady it and grasps the patient’s ankle lightly with the other hand, holding the knee flexed at a right angle.

• The thigh is abducted and extended in the coronal plane of the body.

• In the presence of iliotibial band contracture, the leg will remain abducted; the degree of abduction depends on the amount of contracture present (Fig. 10-24).

• The sign is present both in the conscious and in the anesthetized patient.

• Ober calls attention to the frequency of a negative roentgenogram in the presence of clinical signs and symptoms of irritation of the sacroiliac or lumbosacral joints.

• He refers to the importance of the iliotibial band as a factor to consider in the occurrence of lumbosacral spinal disorders with or without associated sciatica.

FIG. 10-24

Transient synovitis of the hip is the most common cause of an irritable hip and can produce a limp and a positive Ober test. The patient sometimes has a history of preceding minor trauma, which in some cases is at least coincidental. Radiographs of the hip sometimes give confirmatory evidence of synovitis, but no other pathologic condition is demonstrable.

PROCEDURE

• Patrick test is of particular value in geriatric cases because it indicates hip joint disease.

• The patient lies supine, and the examiner grasps the patient’s ankle and flexes the knee.

• The thigh is flexed, abducted, externally rotated, and extended (Fig. 10-25).

• The first letters of these words form the acronym FABERE.

• Pain in the hip during the maneuver, particularly on abduction and external rotation, is a positive sign of a coxa pathologic condition.

FIG. 10-25

An intracapsular fracture, which can cause a positive Patrick test, can cut off the blood supply to the femoral head completely, which can lead to aseptic necrosis, non-union, or both. Because the fracture line is inside the capsule, blood is contained within it. This trapped blood raises the intracapsular pressure, damaging the femoral head still further, and prevents visible bruising because the blood cannot reach the subcutaneous tissues.

PHELPS TEST

Assessment for Contracture of the Gracilis Muscle, Associated with a Pathologic Condition of the Hip Joint

PROCEDURE

• The patient is lying prone, the knees are extended, and the thighs are maximally abducted.

• Pain and resistance should be used as criteria for maximal abduction.

• The patient’s knees are flexed bilaterally to a right angle (Fig. 10-26).

• The examiner notes if the maneuver allows more hip abduction.

• The test is positive if knee flexion increases or knee extension decreases hip abduction.

• The test indicates contracture of the gracilis muscle.

FIG. 10-26

Two nonspecific gait abnormalities commonly result from hip disease. The antalgic gait usually indicates a painful hip. The patient shortens the stance phase on the affected hip, leaning over the affected side, to prevent painful contraction of the hip abductors. Trendelenburg gait, or abductor limp, indicates weakness of the abductors on the affected side. During the stance phase, on the affected side, the contralateral pelvis dips down, and the body leans to the unaffected side. If the condition is bilateral, a waddling gait is produced.

THOMAS TEST

Assessment for Flexion Contracture Involving the Iliopsoas

PROCEDURE

• The patient lies supine, and the thigh is flexed with the knee bent toward the abdomen.

• The patient’s lumbar spine should normally flatten, or flex.

• If the spine maintains a lordosis, the test is positive and indicates hip flexion contracture, as from a shortened iliopsoas muscle (Fig. 10-27).

FIG. 10-27

Restricted hip flexion may be compensated by an increase in lumbar lordosis. This increase masks the fixed flexion deformity. Fixed flexion, external rotation, and abduction accumulate sequentially as the hip disease progresses.

PROCEDURE

• The patient with a suspected hip involvement stands on one foot, on the side of the involvement, and raises the other foot and leg for thigh flexion and knee flexion.

• If the hip and its muscles are normal, the iliac crest will be low on the standing side and high on the side of the elevated leg.

• If hip joint involvement and muscle weakness are involved, the iliac crest will be high on the standing side and low on the side of the elevated leg (Fig. 10-28).

• The test is commonly positive in a developing Legg-Calvé-Perthes disease, poliomyelitis, muscular dystrophy, coxa vara, Otto pelvis, epiphyseal separation, coxa ankylosis, dislocation, fracture, or subluxation.

FIG. 10-28

Trendelenburg test is positive as a result of (1) gluteal paralysis or weakness (from polio), (2) gluteal inhibition (from pain arising in the hip joint), (3) gluteal insufficiency from coxa vara, or (4) congenital dislocation of the hip. Nevertheless, false-positive results have been recorded in approximately 10% of the patients with hip pain.

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