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9.13. Shortening: examination (3):
Where there is significant true shortening the heels will not be level (the discrepancy is a guide to the amount of shortening) and the pelvis will not be tilted. The site and amount of shortening must now be further investigated.
9.14. Shortening: examination (4):
Begin by hooking the thumbs under the anterior spines. Feel for the greater trochanters with the fingers. If the distance between the thumb and fingers is shorter on one side, this suggests that the pathology lies above the trochanters.
9.15. Shortening: examination (5): II in the last test there was no evidence of shortening above the trochanter, look for causes below the trochanter. Slightly flex both knees and hips, and place a hand behind the heels to check that you now have them squarely together.
9.16. Shortening: examination (6): The position of the two knees should be compared. (A) This appearance suggests femoral shortening. (B) This appearance is suggestive of tibial shortening (in the diagram, the right side is as usual the site of the pathology).
9.17. Shortening: examination (7):
Further confirmation of tibial shortening may be made by direct measurement. Flex one knee, and with the thumb locate the prominences of the femur and tibia, with the joint line lying between. This is best performed on the medial side of the joint. Now mark the joint line, and repeat on the other side.
9.18. Shortening: examination (8): Now measure from the mark to the tip of the medial malleolus. Compare the two sides. Any difference indicates true tibial shortening. Note also any obvious tibial irregularity suggestive of old fracture.
9.19. Shortening: examination (9):
Measurement of femoral shaft shortening can only be attempted in the thin patient where the tip of the greater trochanter is easily palpable. Measure from the trochanter to the lateral joint line and compare the sides.
9.22. Shortening: examination (12):
When the patient is carefully positioned on the examination couch, and the pelvis is obviously tilted, try to correct this. If it cannot be levelled, then expect to find some apparent shortening of the limb; the discrepancy between the heels will give a measure of this. (Note, however, that as well as apparent shortening there may be some additional true shortening, which should be assessed by direct limb measurement as just described.)
9.20. Shortening: examination (10):
Measurement of total (true) leg shortening is the most valuable single assessment, although in itself it gives no indication of site. Begin by placing the metal end of the tape over the anterior spine; now press it backwards until it hooks under its inferior edge. In this way the end of the tape comes into firm contact with the iliac spine, and there is less chance of having difficulty in getting a reliable, fixed measuring point at this level.
9.23. Shortening: examination (13):
Apparent shortening may also be assessed by comparing the distances between the xiphisternum and each medial malleolus.
9.21. Shortening: examination (11):
Now measure to the middle or inferior border of the medial malleolus. Compare the sides, and always repeat the measurements until consistency is obtained. Deformity of the pelvis (which is rare) may sometimes lead to errors in assessment.
When there is an adduction deformity of the hip. and the leg lengths are being measured to assess any accompanying true shortening, the good leg should be adducted by the same amount before commencing measurement between the anterior spines and malleoli.
9.25. Shortening: examination (15):
True leg shortening may also be measured by blocking up the short leg until both anterior superior iliac spines and the iliac crests lie horizontally, and the natal cleft is vertical; a further check that the pelvis is level is to see that the posterior iliac spines remain horizontal when the patient flexes forw ards.
9.26. Shortening: examination (16): In the difficult case, sequential radiographs of the hips, knees and ankles, taken on a single plate without moving the patient, afford accurate comparison of the sides. For example. (A) indicates overall shortening, (B) indicates femoral shortening. (Note that in the older patient a discrepancy of 3-4 cm leads on walking to an increase in heart rate, ventilation and muscle activity which may seriously limit activity, especially if there is already some cardiac, pulmonary or neuromuscular impairment.)
9.27. Palpation (1): Place the fingers over the head of the femur below the inguinal ligament, lateral to the femoral artery. Note any tenderness. Now rotate the leg medially and laterally. Crepitus arising in the hip joint may be detected in this way.
9.30. Palpation (4): Palpate the region of the ischial tuberosity looking for tenderness. Strain of the hamstring origin occurs as a result of athletic activities, especially in children. Less commonly athletic injuries may affect the anterior superior and inferior spines.
9.28. Palpation (2): Palpate the origin of adductor longus. Tenderness occurs here in sports injuries (strain of adductor longus) and in patients developing adductor contractures in osteoarthritis of the hip.
9.31. Movements: extension (1): Place a hand behind the lumbar spine so that you can determine whether in the spine at rest there is any increase in lumbar lordosis, and later on in the course of the examination, whether this has been obliterated.
9.32. Movements: extension (2): Now flex the good hip fully, observing with the hand that the lumbar curvature is fully obliterated.
9.33. Movements: extension (3): If the hip being examined rises from the couch, this indicates loss of extension in that hip (also described as a fixed flexion deformity of the hip). Any loss should he measured and recorded. This test is usually referred to as Thomas's test.
9.34. Movements: extension (4): To check smaller losses of extension, especially when the other hip is normal, turn the patient over on to his face and steady the pelvis with one hand.
9.35. Movements: extension (5): Lift each leg in turn and compare the range of movements.
Normal range of extension = 5-20°.
A loss affecting extension only is often the first detectable sign of an effusion in the hip joint.
9.36. Movements: flexion (1): The good hip is first flexed to obliterate the lumbar curve and to steady the pelvis. The patient is asked to hold the leg in this position.
9.37. Movements: flexion (2): The hip is then flexed, using a hand to check that no further pelvic movement occurs. Note the range of movement. Normal range of flexion = 120°.
9.38. Movements: flexion (3): The range of flexion may be recorded in this example as •Flexion (R) hip: 30-90°', or 'Fixed flexion deformity of 30°. and hip flexes to 90°'. Flexion may also be tested with the patient lying on his side.
9.39. Movements: abduction (1): A false impression of hip movement may be gained if the pelvis tilts during the examination, so first grasp the opposite anterior superior iliac spine with the fingers and thumb, and anchor the other spine with the forearm.
9.40. Movements: abduction (2): An alternative way of fixing the pelvis is to flex the other leg over the edge of the couch and check that the pelvis does not move by holding the anterior superior iliac spine on the side being examined.
9.41. Movements: abduction (3): Now, having fixed the pelvis, move the leg laterally and note the range achieved. Normal range of abduction = 40°. Abduction may also be tested from a starting position of 90° hip flexion (see also below). This is of particular value in suspected osteoarthritis of the hip or congenital dislocation.
9.42. Patrick's test: Basically, this is a variation of abducting the hip from a position of 90° flexion. Pain during the manoeuvre is regarded as being the very first sign of osteoarthritis in a hip. To perform (on the right), tlex both hips and knees, place the right foot on the left knee and gently press down on the right knee. This is also known as the faber sign (flexion, abduction, external rotation).
9.43. Movements: adduction (1): Ideally an assistant should lift the good leg out of the way to allow the affected leg to be adducted while in full extension. Normal range of adduction = 25°.
9.44. Movements: adduction (2): If an assistant is not available, cross the leg being examined over the other. This brings the leg being examined into slight flexion, but is sufficiently accurate under most circumstances. If the hip is normal, the legs should cross about midthigh. Adduction may also be tested from a starting position of 90° hip flexion.
9.45. Movements: internal rotation at 90° flexion (1): Steady the flexed hip by holding the knee with one hand, and move the foot laterally to produce internal rotation of the hip. Note that this is a never-ending source of confusion; be sure that this is clear in your own mind. Although the foot moves laterally (or externally), the hip rotates internally (or medially).
9.46. Movements: internal rotation at 90° flexion (2): Measure the range of internal rotation by comparing the position of the leg and the midline. Normal range of internal rotation at 90° flexion = 45°.
Compare the sides. Loss of internal rotation is common in most hip pathologies.
9.47. Movements: internal rotation at 90° flexion (3): A sensitive comparison of the sides may be made by asking the patient to hold the knees together while you move both feet laterally.
9.48. Movements: external rotation at 90° flexion (1): The position of the hip is the same as for testing internal rotation, but in this case the foot is moved medially.
9.49. Movements: external rotation at 90° flexion (2): Measure external rotation in the same general way. Normal range of external rotation at 90° flexion = 45°.
External rotation becomes limited in most arthritic conditions of the hip.
9.50. Movements: external rotation at 90° flexion (3): Comparison between the sides may be made by crossing one leg over the other.
9.51. Movements: rotation in extension
(1): For a rough comparison of the sides, roll each leg medially and laterally, observing and allowing, however, for any play at the knee.
9.52. Movements: internal rotation in extension: For a more accurate assessment the patient should be prone, with the knees flexed. The two sides can easily be compared and measurements taken. Normal range of internal rotation in extension = 35°.
9.53. Anteversion of the femoral neck:
An assessment of anteversion may be made when the patient is in the same position. Hold the leg with one hand and rock it from side to side (A) while simultaneously feeling the prominence of the greater trochanter with the other (B). When the trochanter is facing truly laterally, anteversion is equal to the angle between the leg and the vertical. This is the most accurate clinical method of assessing anteversion.
9.54. Movements: external rotation in extension: Comparison and measurement may be made in the same way. Normal range of external rotation in extension = 45°.
9.55. Movements: testing for hip fusion
(1): When there is doubt regarding the solidity of a hip fusion, it is sometimes helpful to test for protective muscle contraction. Flex the good hip and knee. Feel for involuntary adductor contracture while suddenly attempting to abduct the leg.
9.56. Movements: testing for hip fusion
(2): Repeat the test, this time feeling for flexor (iliopsoas) contraction while making a sudden gentle attempt to extend the hip.
9.57. Trendelenburg's test (1): When standing on one leg (here the left), the centre of gravity (at S2) is brought over the stance foot by the hip abductors (gluteus medius and minimus). This tilts the pelvis and normally elevates the buttock of the non-stance side. The patient should be able to produce a greater pelvic tilt (by being asked to lift the side higher) and hold the position for 30 seconds.
9.58. Trendelenburg's test (2): Ask the patient to stand on the affected side: any support (stick or hand) must be on the same side. Now ask him to raise the non-stance leg further. Prevent excessive trunk movements (a vertical dropped from C7 should not fall beyond the foot). If the pelvis drops below the horizontal or cannot be held steady for 30 seconds, the test is positive. It is not valid below age 4: pain, poor cooperation or bad balance may give a false positive.
9.59. Trendelenburg's test (3): The test is positive as a result of (A) gluteal paralysis or weakness (e.g. from polio, muscle-wasting disease); (B) gluteal inhibition (e.g. from pain arising in the hip joint); (C) from gluteal inefficiency from coxa vara; or (D) developmental dislocation of the hip (DDH). Nevertheless, false positives have been recorded in about 10% of patients.
9.60. Duchenne sign: Note whether the patient, when walking, lurches to one side. If present, this is because the patient is trying to reduce pain by shifting his body weight over the hip. This is often also somewhat confusingly referred to as an abductor or Trendelenburg lurch. It is often associated with a positive Trendelenburg sign (ill), but not invariably.
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