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

Articular Inflammatory joint diseases Rheumatoid arthritis Spondyloarthropathies Polymyalgia rheumatica Degenerative joint diseases Primary osteoarthritis Secondary osteoarthritis Metabolic joint diseases Gout Pseudogout Ochronosis Hemochromatosis Wilson disease Acromegaly Infections Tumors Benign Pigmented villonodular synovitis Osteochondromatosis Malignant Synovial sarcoma Synovial metastasis Hemarthrosis Juvenile Transient toxic synovitis Juvenile chronic arthritis Periarticular Bursitis Trochanteric Iliopsoas Ischiogluteal Tendinitis Trochanteric Adductor Acute calcific periarthritis Heterotropic calcifications Osseous Bone lesions 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) Juvenile Congenital dislocation of the hip Acetabular dysplasia Coxa vara Slipped capital femoral epiphysis Legg-Calvé-Perthes disease Rickets Neurologic Entrapment neuropathies Lateral femoral cutaneous nerve (meralgia paresthetica) Lumbar nerve root compression L2, L3, and L4 Vascular 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.

ORTHOPEDIC GAMUT 10-5 HIP RANGE OF MOTION

In testing range of motion of the hips, the patient performs the following:

WHILE SUPINE

1. Raises the leg above the body with the knee extended

2. Brings the knee to the chest while keeping the other leg straight

3. Swings the leg laterally and medially while keeping the knee straight

4. Places the side of the foot on the opposite knee and moves the flexed knee down toward the examination table (external rotation)

5. Flexes the knee and rotates the leg so that the flexed knee moves inward toward the opposite leg (internal rotation)

WHILE EITHER PRONE OR STANDING

Swings the straightened leg behind the body

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

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