(1)
Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
3.1 History
3.1.1 Localization and Kind of Complaint
Pain | Localization | Circumscribed/radiating |
Character | Numb/sharp/drilling/throbbing/burning/cramp-like | |
Situation | During certain movements, under load/at rest, at night | |
Swelling | Location/extent | |
Movement disorder | Location/kind/direction | Limitation of movement/locking/stiffness, walking distance |
Hypomobility (infants) | ||
Walking distance | Reduced/normal | –km |
Deformity | Location, kind | Altered posture, deformity |
Sensory function disorder | Location, kind | Paresthesia/numbness/tingling/pins and needles |
Motor function disorder | Gait uncertainty/muscular atrophy | |
Weakness/ paralysis/spasticity | ||
Hip/knee/ankle/foot | Flexion/extension/abduction/adduction |
3.1.2 Time Correlations
Beginning and course of disease | Congenital/acquired | (Age/point in time) |
Acute/chronic | ||
Slowly/stably progressive | ||
Occurs in flares with or without symptom-free intervals |
3.1.3 Concomitant Circumstances
Accident | Yes/no | |
Location | Leisure/workplace | |
Mechanism of injury | Triggering event | No triggering event/fall/bending/rising from a squatting position Height/weight/load/persons involved |
Motor vehicle accident | Type of vehicles involved/direction/speed, angle of impact, lateral, head-on or rear-end collision, head impact/headrest/safety belts | |
Preexisting conditions | Family medical history | |
Degenerative/bacteria/rheumatic inflammatory | No/if yes: local/systemic | |
Bacterial infection/viral infection | ||
Traumatic/tumor | ||
Malformations | ||
General symptoms | Fever, weight loss (time period of weight loss), fatigue, nocturnal sweating | Yes/no |
Pregnancy (infants) | Caesarean, breech birth | Course/birth |
3.1.4 Existing Treatment/Past Treatment
Medication | Medication/dose/duration of intake | Localized/systemic |
Relief | Yes/no | |
Physical therapy | Application | Forms/duration/frequency |
Relief | Yes/no | |
Orthopedic aids | Walking stick/crutches Basques/bandage Brace/cast | Yes/no |
Operations | Time/site/type/success |
3.2 Hip and Upper leg
3.2.1 Systematic Examination
Local findings (children and adults)
Gait | Inconspicuous/right-sided/left-sided limping | Painful limping, shortening limping, guarding limping, stiffened limping |
Pelvis stance | Pelvic stance level/asymmetric | Right/left (–cm) |
Axis | Physiological/pathological (right/left) | Femur varum Rotation (external/internal) |
Swelling/redness/hyperthermia | None, if yes then: | Location/extent/circumference/consistency (soft/firm/movable) |
Hematoma/abrasion/open wounds | None, if yes then: | Location/extent/circumference |
Scars | None, if yes then: | Location/extent/consistency (soft/firm/movable) |
Muscles | Buttocks/upper leg | Highly developed/wasted/shortened atrophy (significant?), muscle tone increase or decrease (right/left) |
Trendelenburg’s sign | Negative/positive (right/left) | |
Mobility of the hips | Extension/flexion abduction/adduction external/internal rotation | –/–/–Degrees (passive, right/left) |
Drehmann’s sign | Negative/positive (right/left) | |
Hip pain | Motion pain (active/passive, direction, continuous/at maximum ROM), groin pain, tenderness at the trochanter, piriformis flexion pain, traction pain/compression pain | None; if yes: positive (right/left) |
Impingement signs | Negative/positive (right/left) | |
Leg length | Absolute/relative | –cm (right/left) |
Amputation stump length | Ischium end of the stump | –cm (right/left) |
Local findings (infants)
Hypomobility | None; if yes: (right/left) | |
Symmetry of skin folds | None; if yes: (right/left) | Upper leg/buttocks |
Leg shortening | None; if yes: (right/left) | |
Inhibited abduction | None; if yes: (right/left) | |
Ortolani | Historic test | Should not be performed anymore as it can lead to dislocation |
Neurology
Deep tendon reflexes | Quadriceps tendon reflex (L4) Posterior tibial reflex (L5) Achilles tendon (S1) | Right/left Vigorous/decreased/absent/supernormal (hyperreflexic)/cloni (right/left) |
Babinski Gordon Oppenheimer | Negative/positive (right/left) | |
Sensory function examination | Dermatome (segment assignable/not exactly assignable) | Hypesthesia/paresthesia/ dysesthesia (right/left) |
Motor function | Knee flexion/hip adduction (L3) Knee extension/hip abduction (L4) Standing on the heels (foot and big toe dorsiflexors; L5, sciatic nerve, peroneal nerve). Standing on the toes (foot plantar flexors; S1) | Right/left intact/impaired function (M0–M1–M2–M3–M4–M5) |
Perfusion
Arteries | Femoral artery Popliteal artery Dorsalis pedis artery Posterior tibial artery | Fully/barely/not palpable (right/left) |
Veins | Varicosis cruris Venous stasis Hyperpigmentation | None/present (right/left) |
Capillary pulse | Toe tips | Visible/invisible |
Fig. 3.1
Examining the pelvis. If the spinal crests are not level, a board, with a thickness of 0.5–1 cm, is placed underneath the shortened leg until equal length is reached. This way, the shortening compensation or the difference in leg length can be determined
Fig. 3.2
(a, b) Testing the Trendelenburg’s sign. When the patient stands on the healthy leg, the pelvis can be kept horizontally level: the test is negative (a). If the pelvis drops down on one side, the test is positive for the leg the patient is standing on (b). This suggests muscular insufficiency of the pelvicotrochanteric muscles of the affected leg (simulated in this diagram)
Fig. 3.3
(a, b) Testing extension/flexion in the hip joint. To test mobility in the hip joint, the patient must lie on his/her back. Extension is normally not tested. The examiner grabs the lower leg and stabilizes the leg at the knee joint with the opposite hand. The range of motion values for extension and flexion, external rotation, internal rotation, abduction, and adduction is recorded. Normal values for extension/flexion: 0/0/130–140°
Fig. 3.4
(a, b) Testing for abduction/adduction in the hip joint. It is important to fixate the pelvis when performing the test to neutralize compensating movements from the opposite hip. Normal values for abduction/adduction: 30‐45/0/20–30°
Fig. 3.5
(a, b) Testing external/internal rotation in the hip joint. The examiner bends the hip and the knee into a 90° angle. External rotation is tested by moving the foot inward and external rotation by moving the foot outward. Normal values for external/internal rotation: 40–50/0/30–45°.
Fig. 3.6
(a, b) Drehmann’s sign: if flexion in the hip joint is limited, the leg spontaneously externally rotates. The Drehmann’s sign is positive if, during flexion of the hip joint, a spontaneous external rotation and abduction of the leg sets in. The sign is typically positive in slipped capital femoral epiphysis (Image courtesy of Dr. E. Schumann, University clinic Leipzig)
Fig. 3.7
Thomas test: serves to rule out flexion contracture in the hip joint. The patient is asked to hold onto the knee joint of the unaffected leg and to pull it toward the chest. The lumbar spine lordosis is flattened out and the flexion contracture in the hip joint becomes visible. During traction with forced flexion in the hip, the opposite, extended leg will lift off the table if contracture is present
Fig. 3.8
(a, b) Points of tenderness: to determine pathologies of the hip joint, especially coxarthrosis, groin tenderness, and tenderness to tapping at the trochanter need to be tested. Groin tenderness (a) suggests inflammation in the acetabulum, and trochanter tenderness to tapping (b) suggests inflammation of the trochanteric bursa. Both can be a consequence of wear in the hip joint. Be careful: many hip disorders initially manifest with knee pain!
Fig. 3.9
Piriformis flexibility test: this test serves to show irritation in the piriformis muscle, especially as a differential diagnosis in unclear hip pain. The patient lies on his stomach. The examiner flexes the knee into a 90° angle. The dorsal trochanter is palpated with two fingers, and the lower limb is simultaneously internally rotated (moving the foot outward). The test is positive if the patient reports pain in the buttocks at the height of the major trochanter (insertion site of the piriformis muscle)
Fig. 3.10
Impingement test: serves to test injury to the labrum of the hip joint or the acetabulum. The hip is flexed to 90° and adduction is performed in the direction of the opposite shoulder. The test is positive if the patient reports groin pain
Fig. 3.11
(a, b) Measuring the absolute leg length (major trochanter/medial malleolus) (a) and the relative leg length (anterior superior iliac spine/medial malleolus) (b). Shortening of the relative leg length is usually caused by a disorder between the femoral neck and the pelvis
Fig. 3.12
Asymmetry in the skin folds. Typical for hip dysplasia
Fig. 3.13
Testing leg length difference in an infant. This is typical for hip dysplasia
Fig. 3.14
Inhibited abduction in the left hip joint of the infant. This is typical for hip dysplasia
3.2.2 Leading Symptoms of the Hip and the Upper Leg
The leading symptoms of the hip and the upper leg are summarized in Table 3.1.
Table 3.1
Leading symptoms of the hip
History | Pain | Local findings, functional tests | Sensory function disorder | Motor function disorder | Points to |
|---|---|---|---|---|---|
Age 15–16, prepuberty, often overweight, pasty children (adiposogenital type), fatigue, increasing limping | Initially often knee pain, in some cases sudden pain in the hip and leg with immobility | Painful limping, increasing external rotation flexion of the leg, leg shortening, groin tenderness, Drehmann’s sign positive | None | None | Slipped capital femoral epiphysis |
Age 3–9 easily tired, increasing limping | Initially often presents with knee pain, in course hip pain | Painful limping, groin tenderness, limitation of abduction and internal rotation, leg shortening | None | None | Perthes disease |
Age 30–60, increasing limping | Initially often therapy-resistant knee pain, hip pain | Painful limping, groin tenderness, limitation of mobility (flexion often still possible) in course leg shortening, atrophy of the gluteal and upper leg muscles | None | None | Femoral head necrosis of the adult, differential diagnosis: pseudoradicular syndrome of the lumbar spine |
Age 50–60, increasing limitation of walking distance | Initially often knee pain, in course also hip pain (starting with pain upon strain, then also at rest) | Painful limping, in course shortening limping, groin tenderness, mobility limitation (at first adduction and internal rotation), leg shortening, atrophy of the buttocks and upper leg muscles | None | None | Coxarthrosis |
Total hip arthroplasty eventually exacerbating leg shortening (not obligatory) | Knee or hip pain (not obligatory) | Rotation pain, sometimes also traction pain and compression pain, eventually increased shortening compensation | None | None | Implant loosening, differential diagnosis Pseudoradicular syndrome of the lumbar spine |
Child, stumbling over its own feet, walking with increasingly inwardly rotated feet | In some cases after completed growth, strain-dependent, groin pain | Sitting in the inverted cross-legged position (sitting with the inner thighs toward the floor) is possible. Internal rotation when lying on the abdomen is possible up to 90°. External rotation is limited | None | None | Solitary coxa antetorta |
Infant, breech birth, preterm birth, sectio, hypomobility, delayed walking | None | Asymmetry of the folds at the upper leg and the buttocks, inhibited abduction, and leg shortening, in course positive Trendelenburg’s sign | None | None | Hip dysplasia |
Sudden snapping over the hips when walking | Often pain over the trochanter when snapping | Palpable snapping over the major trochanter when walking (with the flat palm of the hand) | None | None | Coxa saltans |
Child, mostly younger than 10 years, preceding trauma or flu, limping, no fever | Sudden hip and knee pain (at rest and during movement) | Painful limping, external rotation position of the leg, mobility—especially internal rotation and abduction—are decreased | None | None | Coxitis fugax |
Bacterial infection, punction, or surgery at the hip joint, patient cannot walk, fever, reduced general condition | At first diffuse and then severe groin and knee pain | Patient cannot walk, leg is fixed in adduction, flexion and external rotation, severe groin tenderness and tenderness to tapping at the trochanter, testing range of motion is not possible due to pain | None | None | Nonspecific bacterial coxitis |
Mostly older patients, following minor injury (a fall in a domestic context) | Groin pain | Patient cannot walk, the leg is shortened, externally rotated and adducted | None | None | Femoral neck fracture |
Younger patient, adequate trauma (traffic accident) | Severe groin pain and leg pain | Patient cannot walk, the leg is shortened, flexed in the hip, adducted, and internally rotated | Hypesthesia at the sole of the foot | Foot dorsiflexor paresis | Posterior hip dislocation (with injury to the sciatic nerve) |
3.2.3 Disorders of the Hip
Clinical pictures
Snapping Hip Syndrome (Coxa Saltans)
Sudden snapping of the iliotibial tract over the major trochanter during active movement of the hip joint.
Etiology: Constitutional loosening of the iliotibial tract. Congenital or acquired disorder involving the major trochanter or affecting leg length is rare.
History: Mostly young girls. Unintentionally or intentionally induced snapping over the major trochanter. Often painful.
Examination: Localized tenderness to pressure over the major trochanter. Palpable snapping over the major trochanter during walking or when standing up from a hunched position. Not inducible in a prone position. In some cases, a difference in leg length may be found (Figs. 3.1 and 3.11).
Diagnostics: Ultrasound (dynamic examination), eventually X-ray of the hip in two planes.
Piriformis Syndrome
Painful shortening of the piriformis muscle.
Etiology: Overuse injury.
History: Localized, sciatic pain in the buttocks. The pain occurs at rest and is exacerbated by movement.
Examination: Tenderness to pressure over the buttocks, medial to the top of the major trochanter. The piriformis flexion test is positive (Fig. 3.9, pain provocation by internal rotation of the hip when the patient lies on his/her stomach). Painful abduction and external rotation against resistance.
Diagnostics: If pain persists, X-ray of the hips in two planes, eventually including the lumbar spine in two planes (to rule out degenerative changes).
DD: Sciatica and coxarthrosis.
Slipped Capital Femoral Epiphysis
Dislocation of the femoral head epiphysis from the femoral neck. This dislocation is associated with slippage of the femoral head mostly in a posterior–caudal direction. Slippage is mostly slow (chronic) but can also, in rare cases, be acute. The acute form can also develop into the chronic form.
Etiology: Unknown for both the acute and chronic forms. Endocrine factors are being discussed. Atraumatic structural loosening.
History: Prepubertal children are commonly affected (boys 12–16 years, girls 10–14 years). Conspicuous bodily constitution, obesity, children with a pasty appearance and hypogonadism (adiposogenital type).
Chronic form: Initially little, uncharacteristic pain in the hip, back, and leg, often also knee pain. Patients soon feel fatigued when walking or standing, and in the course of disease, a limp may develop.
Acute form: Almost no complaints or complaints resembling the chronic form. Then a sudden inability of the hip to bear load. Pain and immobility.
Examination: Painful limp and leg shortening in advanced disease. External rotation of the leg. Groin pain and clear and painful reduction in leg abduction (Fig. 3.4) and internal rotation (Fig. 3.5). Positive Drehmann’s sign (Fig. 3.6): in passive hip flexion from the neutral position, external rotation must increase.
In the acute form, the risk of secondary femoral head necrosis exists. Acting quickly is essential!
Diagnostics: X-ray of the pelvis and the hips axially (Lauenstein, to visualize the slippage and to determine the slippage angle).
Legg–Calvé–Perthes Disease
Partial or complete necrosis of the femoral head commonly affecting the growth plate and the metaphysis in childhood. One distinguishes four typical stages: initial stage, fragmentation stage, re–ossification stage, and healed stage. This process takes 2–4 years, during which the epiphysis should not be exposed to too much load as the risk of deformation exists.
Etiology: Unknown. Ischemia, congenital vascular anomaly, and hormonal dysregulation.
History: More common in boys than girls. Commonly presents from the ages 3–9. Bilateral in about 20 % of cases, yet mostly begins with one hip. Early signs are especially knee pain. Mild pain in the hip. Patients report pain-free intervals in between, followed by sudden fatigue and limping.
Examination: Initially, mostly a limitation in abduction. Then a limitation of internal rotation (Figure 3.5, examined with the patient lying down) and pain during movement close to the maximum range of motion. In course, flexion contracture, atrophy of the buttocks and upper leg muscles, and compensation for the muscle shortening (Figs. 3.1 and 3.11, relative leg length decreased). Trendelenburg’s sign positive (Fig. 3.2).
Diagnostics: X-ray of the hips in two planes (the range of the bony changes according to Catteral). MRI (to show the necrosis in its early stages, differential diagnosis).
DD: Transient synovitis. Septic coxitis. Epiphyseal dysplasia.
Femoral Head Necrosis in Adults
Ischemic, atraumatic, and noninfectious femoral head necrosis of adults.
Etiology: Unknown. An arterial perfusion deficit is assumed. Also occurs following steroid treatment, alcohol abuse, kidney transplant, and chemotherapy. Furthermore, seen following radiation (often only presenting years post-exposure!), in metabolic disorders (hyperuricemia, dyslipidemia, Gaucher’s disease) or following pancreatitis. Hematological disorders (e.g., sickle cell anemia) and vascular disorders (e.g., peripheral artery disease, thrombosis, panarteritis nodosa, and connective tissue diseases).
History: Mostly men aged between 30 and 60. In about 50 % bilateral, commonly one side follows the other within 2 years. After this, the risk of the opposite side being affected decreases. Often presents as pain-resistant knee pain. Patients report increasing groin pain radiating into the thighs with an impaired range of motion. Leg shortening, pain at rest and during movement, and limitation of the walking distance.
Examination: Initially presents with nonspecific symptoms. Groin tenderness is common, eventually also painful limping. Atrophy of the buttocks and the upper leg muscles, including shortening of the leg in the advanced stage (this also involves limping). Leg shortening also leads to mobility impairment; flexion is commonly preserved for a longer time period.
Unclear knee complaints must always draw the examiner’s attention to the hip joint as well.
Diagnostics: X-ray of the hips in two planes. MRI is the gold standard to obtain a closer examination of the localization and extent of the necrosis. CT scans are recommended to rule out subchondral fracture. Scintigraphy (increased accumulation) only if contraindications exist for other diagnostic methods.
DD: Sciatica. Coxarthrosis. Rapidly Destructive Osteoarthritis. Coxitis. Tumors.
Protrusio Acetabuli
Pathological deepening and protrusion of the acetabulum into the pelvis. The femoral head is located deeper and is surrounded by the acetabulum. Is mostly associated with secondary coxarthrosis.
Etiology:
Primary form: Following disturbed ossification of the acetabulum.
Secondary form: Seen in rheumatoid arthritis, bacterial coxitis, and osteomalacia, following traumatic hip dislocation, hemiendoprosthesis, etc.
History:
Primary protrusio acetabuli: Always bilateral. Mostly in younger adults and in mid-adulthood. Pain only sets in once the disorder progresses into secondary coxarthrosis.
Secondary protrusio acetabuli: Determined largely by the underlying disorder. Pain, movement impairment, and limitation of the walking distance.
Examination:
Primary protrusio acetabuli: Hyperlordosis of the lumbar spine. Limitation of rotation and extension in the hip joint. In course, signs of secondary coxarthrosis.
Secondary protrusio acetabuli: Painful limping. Shortening compensation (the height of both spinal crests are palpated, and the two sides are equalized by placing a board under the shortened side; the height of the board is the alteration of length required to reach a level standing pelvis). Atrophy of the buttocks and the upper leg muscles. Groin tenderness, tenderness to tapping at the trochanter, and painful limitation of movement.
Diagnostics: X-ray of the pelvis. Functional imaging (to visualize damage and its influence on mobility).
DD: All etiologically relevant differential diagnoses.
Femoroacetabular Impingement
Mechanical conflict between the anterior acetabular margin at the pelvis or its circular cartilage ridge and the anterior femoral neck. Impingement leads to pain in the hip. One distinguishes between pincer femoroacetabular impingement (retrotorsion of the acetabulum or the coverage of the femoral head appears too great, e. g., in protrusio acetabuli or coxa profunda) and cam femoroacetabular impingement (bony protrusions at the femoral neck close to the hip joint). A combination of both forms is mostly present.
Etiology: Cam impingement probably occurs due to a slippage of the femoral head during the growth phase, causing the normal junction between the head and the femoral neck to change (also called an offset disorder). In pincer impingement, the femoral head is surrounded by the acetabulum like a pincer. This disorder already presents in toddlers or in childhood. In both cases, the femoral neck comes into contact with the acetabulum ridge and damages the acetabular labrum as well as the cartilage.
History: Pain especially during hip flexion, partly radiating into the lower limb. During flexion of the hip or internal rotation of the leg, sharp groin pain can be felt. Often presents during periods of long driving or during strain. In the late stage, the hip joint suffers wear and subsequent movement impairment sets in.
Examination: Pain during adduction and simultaneous internal rotation (positive impingement test; Fig. 3.10). Internal rotation pain disappears when the patient performs a slight abduction (in contrast to coxarthrosis).
Diagnostics:
X-ray anterior–posterior in the Lauenstein position: The normal slimming in the middle is lacking and there is bone accumulation at the junction between the femoral head and the femoral neck (cam impingement); crossover sign of the acetabulum as a sign of retroversion in the anterior–posterior imaging and cranial covering of the acetabulum (pincer impingement).
DD: Initial coxarthrosis and dysplasia
Total Hip Endoprosthesis Loosening
Loosening of a total hip endoprosthesis. Can present as an early or late loosening of the implant. Currently cemented implants remain stable for 12–20 years. Loosening can also present earlier and in rare cases later. In cementless implants, longer stability should be expected.
Etiology: Aseptic loosening under the influence of polyethylene particles set free from the cup implant due to wear. The etiology is not always clear. Septic loosening occurs during early infections following implantation of a prosthesis and as a late infection following hematogenous spreading from a different focus of infection (tonsillitis, pyelonephritis, infected pseudoexostosis in a context of severe bunion—hallux abducto valgus).
History: Often nonspecific. Pain in the joint on rising. Hip, knee, or upper limb pain. Shortening of the operated leg. In some cases, palpable movement of the implant. Reduction of the walking distance.
Examination: Limping gait, eventually positive Trendelenburg’s sign (Fig. 3.2). Increase in the shortening compensation in comparison to earlier examinations. Pain induced by traction or compression is not always present, and it represents an uncertain sign of loosening. Pain during rotation at the maximum range of motion. In septic loosening, fistula can occur around the scar.
The clinical findings are often nonspecific. The extent of the bone defects occurring in the context of loosening does not always correlate with reported pain and physical findings. A loosened prosthesis without large bone defects can elicit more pain than a loosening involving extensive bone loss.
Diagnostics: X-ray of the hips in two planes (to visualize a loosening—radiolucent lines, altered position). Scintigraphy (increased accumulation). Swab/puncture of the infection sight.
DD: All etiologically relevant differential diagnoses. Pseudoradicular syndrome of the lumbar spine.
Congenital deformity and metabolic defects
Hip Dysplasia and Hip Dislocation
Hip dysplasia is a dysplasia of the acetabulum without a dislocation of the femoral head. It is associated with coxa valga and coxa antetorta (pathologically increased antetorsion of the femur neck). In hip dislocation (luxatio coxae congenita), a subluxation or dislocation of the femoral head sets in from the dysplastic acetabulum. It is also known as congenital hip dislocation and secondarily leads to coxarthrosis.
It is important to distinguish teratologic hip dislocation, in which the femoral head is primarily located next to the acetabulum (also known as prenatal dislocation).
Etiology: Multifactorial genetic illness (regional increases in incidence are found in Germany in the federal states of eastern Thuringia, Franconia, and Saxony as well as in the Czech Republic, Slovakia, Hungary, Finland, Jamaica, and the state of Pennsylvania). More common in babies born by breech birth.
History: In about 2–4 % of all births in Germany. Six times more common in girls compared to boys. Familial predisposition. Breech birth, preterm birth, or caesarean section. Other malformations (pes calcaneus, pigeon toe, clubfoot, muscular torticollis). Decreased mobility, guarding of the leg when crawling, and slowed walking. In remaining dysplasia, pain often only sets in during middle age.
Examination: Asymmetry of the skin folds (Fig. 3.12). Inhibited abduction (Fig. 3.14) and leg shortening (Fig. 3.13) in side comparison (be cautious of bilateral disease!). Positive Ortholani sign (should not be tested due to risk of dislocation!). Trendelenburg’s sign (Fig. 3.2), unilateral or bilateral Trendelenburg’s limping. If dysplasia remains in middle age, internal rotation increases when the patient lies on his stomach.
For the course of this disorder, the early examination is essential. Clinical signs and findings are nonspecific and need to be supplemented by further diagnostic tests.
Diagnostics: Ultrasound. X-ray of the pelvis (after the third month, following therapy). If there is insufficient cover for the femoral head in the X-ray, the remaining dysplasia should be suspected (center edge angle). MRI should be performed to rule out arthrosis signs (damage to the labrum, cysts).
DD: Dislocation in infantile cerebral palsy and in myelomeningocele. Teratogenic hip dislocation.
Solitary Coxa Antetorta
Pathological enlargement of the antetorsion angle of the femur neck. Mostly bilateral. Also known as idiopathic coxa antetorta.
Etiology: Congenital deformity or delayed involution of the increased antetorsion which is physiological in childhood. Also associated with other congenital deformities of the hip joint, especially congenital hip dislocation.
History: Pain is absent. Affected children walk with their feet increasingly rotated inward and stumble over their own feet. In some cases, following the end of growth, strain-dependent pain can occur.
Examination: When testing rotation with the patient lying on their stomach, internal rotation up to 90° is possible (Fig. 3.5), and external rotation is limited. Sitting in the inverted cross-legged position (sitting with the inner thighs toward the floor) is possible.
Diagnostics: X-ray of the pelvis. Rippstein imaging (determining the exact angle).
DD: Solitary coxa valga. Hip dysplasia. Hip dislocation.
Solitary Coxa Valga
Pathological increase the collodiaphyseal angle.
Etiology: Congenital (constitutional coxa valga).
Acquired coxa valga: Spastic or flaccid paresis. Injury to the epiphyseal growth plate (inflammation, trauma, tumor). Femoral neck or subtrochanteric fractures healed in a malposition. Common after successful conservative dysplasia treatment.
History and Examination: Constitutional coxa valga is mostly inconspicuous. Acquired coxa valga is determined by whether or not secondary coxarthrosis occurs.
Diagnostics: X-ray of the pelvis. Rippstein imaging (exact determination of the angle).
DD: Solitary coxa antetorta. Hip dysplasia. Hip dislocation.
Coxa Vara Congenita
Varus deformity with a shortening of and thickening of the femur neck. The physiological collodiaphyseal angle is decreased.
Etiology:
Primary form: Malformation that set in prior to birth.
Secondary form: Hypoplasia in the growth plates of the epiphysis of the femoral neck leading to a varus deformity.
History: Mostly unilateral. Limping sets in when the toddler begins to walk.
Examination: Limping, Trendelenburg’s limping, and positive Trendelenburg’s sign (Fig. 3.2). Decreased abduction. In the course of disease, concentric movement impairment.
Diagnostics: X-ray of the pelvis (to visualize changes to the joint).
DD: Coxa vara symptomatica (following systematic disorders, local development disorders, trauma, inflammation, and tumors).
Degenerative disorders
Coxarthrosis
Degenerative changes to the hip joint
Etiology:
Primary coxarthrosis (about 25 %): Unknown etiology.
Secondary coxarthrosis (75 %): Congenital hip dislocation (30 %), slipped capital femoral epiphysis (20 %), and inflammatory disorders (10 %). Less commonly Legg–Calvé–Perthes disease, trauma, chronic polyarthritis, and psoriatic arthritis, among others.
History: Mostly begins between 50 and 60. Secondary coxarthrosis can present earlier depending on the structural damage. Often begins with knee pain. Pain at rest and under strain usually sets in later. In some cases, no pain is felt (e.g., depending on the activity of the coxarthrosis). Limitation of the walking distance.
Examination: Painful limping, in the course of the disorder also a shortening limping and differing leg length. Groin pain, tenderness to tapping over the trochanter (Fig. 3.8) and tenderness to pressure over the sacroiliac joint (Fig. 1.34). Mennel’s sign is positive (Fig. 1.35) and a positive Patrick’s test (Fig. 1.36) is often positive. Adduction and internal rotation are commonly the first movements that are impaired, followed by other movements (Figs. 3.3, 3.4, and 3.5). Flexion contracture (Fig. 3.7, Thomas test), hyperlordosis of the lumbar spine. Also atrophy of the gluteal and the upper limb muscles.
Diagnostics: X-ray of the hips in two planes (to visualize wear).
DD: Femoral head necrosis. Inflammation (rheumatic, nonspecific). Tumor.
Inflammatory disorders
Nonspecific Inflammation
Transient synovitis of the hip
Transitory inflammation of the hip joint in children.
Etiology: Unknown. Eventually allergic, toxic, or infectious.
History: Mostly children younger than 10. Often following flu or smaller trauma. Sudden hip and knee pain, pain at rest and during movement. Guarding, limping, absent fever, and no subjective impairment of the general condition. Usually clears within 1–2 weeks.
Examination: Painful limping, groin pain, and the leg is externally rotated. Mobility (especially internal rotation, Fig. 3.5 as well as abduction during flexion, Fig. 3.4) is painfully limited.
Diagnostics: X-ray of the hips in two planes (to rule out pathological changes to bone, differential diagnosis). Ultrasound (effusion). Blood tests (inflammation markers inconspicuous). Eventually puncture/swab.
DD: Legg–Calvé–Perthes disease, nonspecific bacterial coxitis.
Nonspecific bacterial coxitis
Purulent infection of the hip joint. Prototype for infectious arthritis.
Etiology: Almost always staphylococcal. Often the focus is at a different location involving hematogenous spreading. Also as phlegmon from the surrounding tissue. Coxitis can also be caused by direct infection (puncture, operation, open wounds).
History: At first, diffuse groin pain and then upper leg and knee pain. Debilitated general condition and fever. Patients cannot walk anymore. Examination is only possible when lying down. Severe pain in the hip during the slightest movement.
Examination: The leg is adducted, flexed, and externally rotated. Pain upon palpation, severe groin tenderness to pressure, and tenderness to tapping at the trochanter. Testing range of motion is not possible due to the severity of the pain!
Diagnostics: X-ray of the hips in two planes (to rule out pathological changes to bone, differential diagnosis). Ultrasound (effusion). Blood tests (erythrocyte sedimentation rate, leukocytes, CRP). Puncture/swab.
DD: Specific coxitis. Postinfectious reactive coxitis. In children younger than 10, transient synovitis of the hip or an early stage of Legg–Calvé–Perthes disease.
Traumatic disorders
Traumatic Hip Dislocation
This is a serious injury that is easily overlooked in the context of polytrauma. Anterior and posterior dislocations are surgical emergencies due to the risk of femoral head necrosis, requiring immediate relocation.
Posterior hip dislocation.
By far the most common type of traumatic hip dislocation. Often in combination with other injuries of the lower extremities. In 10 % of cases, associated with injury to the sciatic nerve.
Etiology: Severe force translated via the femur shaft and the major trochanter, involving adduction and flexion of the hip.
History: Severe pain!
Examination: The leg is shortened, adducted, flexed, and internally rotated. Injury to the sciatic nerve can be tested via paresis of the dorsiflexors of the foot (Fig. 1.47) and hypesthesia at the sole of the foot (Fig. 1.46).
Diagnostics: X-ray of the pelvis and hips with the upper legs in two planes (to rule out fracture, to visualize dislocation).
DD: Femur neck fracture. Femur shaft fracture.
Anterior hip dislocation
Less common type of traumatic hip dislocation. Neurovascular injury is possible.
Etiology: Severe force translated via the femoral shaft and the major trochanter involving abduction and flexion in the hip.
History: Severe pain!
Examination: The leg is shortened, abducted, and externally rotated. Neurological deficits are possible (weakened knee flexion, hypesthesia at the anterior thigh—Fig. 3.49).
Diagnostics: X-ray of the pelvis, the hips, the upper legs, and the knee joint in two planes (to rule out fracture, to visualize the dislocation).
DD: Femur fracture. Femur shaft fracture.
Central hip dislocation.
Severe injury also affecting the organs of the pelvis.
Etiology: Severe force that is translated via the major trochanter toward the femoral head.
History: Severe pain!
Examination: The leg is mostly shortened and fixed in the neutral position.
Diagnostics: X-ray of the pelvis, the hip with the upper legs, and the knee in two planes (to rule out fracture or dislocation).
DD: Femur neck fracture. Femur shaft fracture.
Proximal Femur Fractures/Femur Shaft Fracture
Femur shaft fracture/femur neck fracture/intertrochanteric fracture.
Medial (most common), intermediate, or lateral femur neck fracture.
Depending on the angle of the fracture (between the horizontal plane and the fracture line), three grades are distinguished according to Pauwels: Pauwels I, <30°, abduction fracture; Pauwels II, 30–70°, adduction fracture; and Pauwels III, >70°, avulsion fracture. Depending on the dislocation of fragments, a further classification according to Garden 1–4 is used.
Etiology: Fall—often at home (minor trauma). Weak bones (osteoporosis, osteomalacia).
History: After the fall, the patient reports groin pain.
Examination: The leg is shortened, mostly adducted, and externally rotated. Groin tenderness. Due to pain, testing mobility is not possible.
Diagnostics: X-ray of the hips in two planes (to visualize the fracture).
DD: Femur shaft fracture. Subtrochanteric femur fracture.
Subtrochanteric femur fracture
Femur fracture below the trochanter. Relatively rare.
Etiology: Almost always a pathological fracture.
History and Examination: Are similar to the other proximal femur fractures. If a pathological fracture is suspected, the examiner should look for a focus.
Diagnostics: X-ray of the hip in two planes (to visualize the fracture).
DD: Femoral neck fracture. Intertrochanteric fracture. Femur shaft fracture.
Femur neck fracture in children
Divided into subcapital, transcervical, cervicobasal, and intertrochanteric fracture. Due to the common perfusion disturbance of the femur head, this fracture mostly leads to femur head necrosis and secondary coxarthrosis within 2 years.
Etiology: Mostly adequate trauma is involved (e.g., motorcycle accident) or an underlying disease (osteogenesis imperfecta, juvenile bone cyst, tumors).
History: Severe pain in the hip and the leg.
Examination: The leg is shortened, adducted, and externally rotated. Groin tenderness. Testing range of motion is not possible due to pain.
Diagnostics: X-ray of the hip in two planes (to visualize the fracture).
DD: Femur shaft fracture.
Femur shaft fracture in adults
As spiral and horizontal fracture of the femur shaft. Often associated with severe blood loss, especially in young adults, and can lead to shock.
Etiology: Severe force in adults (in children also lesser force). Spiral fracture via torsion. Horizontal fracture via snapping force. Horizontal fractures are also morphologically typical for pathological fractures.
History: Severe pain. Malpositioning of the leg.
Examination: In some cases, swelling of the upper leg. The leg may be shortened. External rotation, abduction, and flexion of the leg proximal to the fracture. Medial displacement of the leg distal to the fracture. Pain prevents the examiner from testing range of motion in the hip and the knee.
Diagnostics: X-ray of the hips with the upper leg and the knee in two planes (to visualize the fracture).
DD: Femur neck fracture. Intertrochanteric fracture. Pathological fracture.
Tumor disorders
Primary Tumors
Chondrosarcoma
Primary and secondary chondrosarcoma. After osteosarcoma, it is the second most common malignant bone tumor. Mostly affects the long bones and the bones of the skeletal trunk, the pelvis, and the shoulder. Grows slowly with lymphatic metastasis. Classified according to malignancy in grades I–IV. The closer the tumor is to the skeletal trunk, the higher its malignancy.
Etiology: Main representative of malignant cartilage tumors.
History: Mostly presents in adults. Symptoms include nonspecific pain, e.g., at the knee joint, often lasting years. In some cases only noticed due to swelling.
Examination: Palpable swelling at the upper leg. Localized tenderness.
Diagnostics: X-ray of the upper leg with the hips in two planes (to visualize the tumor). Scintigraphy (increased accumulation). CT/MRI (localization and extent of the tumor). Biopsy.
DD: Enchondroma.
Neurological disorders
Meralgia Paresthetica
Injury to the sensory lateral femoral cutaneous nerve (L2–L3) at its passage from the external to the middle third of the inguinal ligament.
Etiology: Pressure or excessive flexion, e. g., in the context of hip surgery with an anterior approach or in osteotomy. Stretching of abdominal tissue due to obesity or pregnancy.
History: Burning pain and paresthesia at the outer, anterior thigh. Symptoms are exacerbated by walking, standing, and lying down. Sitting, by taking the tension out of the inguinal ligament, relieves the pain.
Examination: Paresthesia and hypesthesia at the anterolateral thigh. Relief comes from sitting. The diagnosis is secured by injecting local anesthetic at the entry point of the nerve (this offers immediate pain relief).
Sciatic Nerve Paresis (L4–S3)
Injury to the sciatic nerve, mostly at the buttocks. The peroneal nerve injury often dominates or is the only nerve that is damaged.
Etiology: Mostly via faulty i.m. injection in the buttocks. Also in a context of trauma, e. g., in pelvic fracture, dislocation of the hip joint, and gunshot wounds. Iatrogenic following total hip arthroplasty.
History: Insecure gait, e. g., directly following the injection or postoperatively, but also hours or days later. Sensory disorder at the foot.
Examination: If the peroneal nerve is affected, foot and toe dorsiflexion is disturbed (power grade 4-0). Hypesthesia (Fig. 1.47). Hypesthesia between the first and the second toe, at the back of the foot and at the lateral distal lower leg (Fig. 3.49). Achilles tendon reflex can be elicited! In case of complete lesion of the nerve, foot plantar flexion is additionally disturbed, and hypesthesia is present at the calves and the sole of the foot. Active hip mobility and some knee flexion are still possible. Achilles tendon reflex is absent (Fig. 1.42).
Diagnostics: Neurological consultation (electromyography, electroneurography, new or old damage, denervation, repair).
DD: Peroneal paresis. Root lesion L5/S1.
Femoral Nerve Paresis (L1–L4)
Injury to the femoral nerve, mostly at the inguinal ligament or in the context of intrapelvic injury.
Etiology: Retroperitoneal hematoma (e. g., under anticoagulation therapy). Surgical interventions (total hip arthroplasty). Trauma. Aneurysm of the abdominal aorta. Inflammatory processes at the hip joints.
History: Noticed fairly quickly due to the inability to extend the knee.
Examination: Weakness in knee extension and hip flexion (M4–M0; in intrapelvic injury). Solitary knee flexion weakness (M4–M0, in injury at the inguinal ligament). Hypesthesia at the anterior, at the internal thigh, at the internal-anterior lower leg, and at the medial foot (Fig. 3.49). Patellar tendon reflex is absent (Fig. 1.41).
Diagnostics: Eventually neurological consultation (electromyography, electroneurography, new or old damage, denervation, repair).
DD: Root lesion L3/L4.
3.3 Knee Joint and the Lower Leg
3.3.1 Systematic Examination
Local findings
Gait | Inconspicuous/limping(right/left) | Painful limping, shortening limping, guarding limping, stiffening limping |
Pelvic | Pelvic stance level/asymmetric/compensated | Right/left (–cm) |
Axes | Physiological/pathological: –degree (right/left) | Genu valgum/varum Genu recurvatum Crus varum Rotation (external/internal) |
Intercondylar distance Malleolar distance | –cm (right/left) | |
Swelling/redness/hyperthermia | None, if yes then: | Localization/extent/consistency/ Circumference (soft/firm/movable) |
Hematoma/abrasion/open wounds/scars | None, if yes then: | Localization/extent/circumference |
None, if yes then: | Location/extent/consistency (soft/firm/movable) | |
Capsular swelling | None, if yes then (right/left): | Minimal/severe |
Effusion | None, if yes then (right/left): | Minimal/firm/dancing patella |
Muscles | Quadriceps femoris muscle/medial vastus muscle, knee flexors | Highly developed/wasted/shortened Atrophy (significant?), muscle tone increase or decrease (right/left) |
Circumference | 20 cm above the medial joint space 10 cm above the medial joint space middle of the knee 15 cm above the medial joint space Lower leg’s smallest circumference Malleoli Forefoot ball | –cm (right/left) |
Mobility knee | Extension/flexion | –/–/–Degree (passive, right/left) |
Mobility patella | Mobility | Hypermobile/normal/firm (right/left) |
Mobility during flexion | Central/lateralized (right/left) | |
Crepitation | None; if yes: fine/rough (right/left) | Retropatellar/medial compartment/lateral compartment |
Knee joint pain | Movement pain (direction, continuous/at maximal ROM). Pain upon moving patella. Zohlen’s sign Tenderness to pressure: joint space (anterior/dorsal, medial/lateral), collateral ligament insertion site (femoral/tibial), femoral condyle, patellar facet, Apley distraction pain | None; if yes: positive (right/left) |
Meniscus sign | Tenderness to pressure at the joint space (medial/lateral) Medial external rotation pain (Steinmann I)/internal rotation pain, lateral tenderness in medial the joint space during flexion further posterior (Steinmann II) Adduction pain medial/abduction pain lateral (Böhler) Payr test Apley compression test Hyperflexion pain/hyperextension pain | Negative/positive (right/left) |
Collateral ligaments | In the neutral position and at 30° flexion | Stable/increased lateral instability (medial/lateral; right/left) |
Cruciate ligaments | In 90° flexion (in a neutral position, at 15° external rotation, at 30° internal rotation) | Stable/positive anterior translation of the drawer phenomenon (+/++/+++) (right/left) |
In 90° flexion | Stable/positive posterior translation in the drawer phenomenon (+/++/+++) (right/left) | |
Firm resistance when testing the drawer sign | Soft/hard | |
Lachman’s test Pivot-shift test | Negative/positive (right/left) | |
Amputation stump length | Internal knee joint space–end of the amputation stump | –cm (right/left) |
Neurology
Deep tendon reflexes | Quadriceps tendon reflex (L4) Posterior tibial reflex (L5) Achilles tendon (S1) | Right/left Vigorous/decreased/absent/supernormal (hyperreflexic)/cloni (right/left) |
Sensory function | Dermatome (segment assignable/not exactly assignable) | Hypesthesia/paresthesia/dysesthesia (right/left) |
Motor function | Knee flexion/hip adduction (L3) Knee extension/hip abduction (L4) Standing on the heels (foot and big toe dorsiflexors; L5, sciatic nerve, peroneal nerve). Standing on the toes (foot plantar flexors; S1) | Right/left intact/impaired function (M0–M1–M2–M3–M4–M5) |
Perfusion
Arteries | Popliteal artery Dorsalis pedis artery Posterior tibial artery | Fully/barely/not palpable (right/left) |
Veins | Varicosis cruris Venous stasis Hyperpigmentation | None/present (right/left) |
Capillary pulse | Tips of the toes | Visible/invisible |
Fig. 3.15
(a, b, c) Genu valgum (a), genu varum (b), genu recurvatum (c)
Fig. 3.16
(a, b) Measuring the intercondylar distance (a) and the malleolar distance (b). Both values are indirect indicators for deformity in the knee joint
Fig. 3.17
Testing for knee joint effusion: the examiner uses a flat hand to squeeze the superior recesses in a distal direction (to concentrate the effusion on the small space). The examiner holds the patella, but does not fixate it. With the index finger of the opposite hand, in case of effusion, the patella can be squeezed down and jumps back (“dancing patella”)
Fig. 3.18
(a, b) Testing extension/flexion in the knee joint. The knee is extended (a) and flexed (b). The normal range of motion is 5–10/0/120–150°
Fig. 3.19
Testing the tenderness to movement in the patella. The patella is fixed at the inferior and superior pole by the examiner’s thumb and index finger. If retropatellar chondropathy is present, pain is reported upon shifting the patella in a medial or lateral position
Fig. 3.20
Testing the Zohlen’s sign: the examiner grips the patella from the front and fixates it with slight distal pressure. The sign characterizes retropatellar cartilage injury. It is positive if the patient reports retropatellar pain upon activation of the knee extensor muscles. The Zohlen’s sign is often positive in healthy patients. A negative test suggests an absence of retropatellar cartilage injury
Fig. 3.21
Testing for tenderness at the knee joint: medial and lateral joint space (anterior/dorsal), medial and lateral collateral ligament (tibial and femoral), and medial and lateral facet of the patella. By applying pressure to the medial and lateral joint space, the meniscus can be tested. In case of meniscal tearing, pain can be elicited. Tenderness over the joint space can also be present in cases of collateral ligament injury. To differentiate this diagnosis, the examiner can pay attention to the patient reporting pain while testing the collateral ligaments. A ruptured collateral is painful when stretched, while a meniscus is painful under compression of the affected joint space. Further points of tenderness include the patellar facet and indicate injury in this region (chondropathy, plica mediopatellaris)
Fig. 3.22
Apley distraction test: the patient lies on his/her stomach; the examiner rotates the leg (that is bent into a 90° angle) externally and internally. If pain persists, a joint capsule lesion is likely. If a meniscal lesion is present, pain will not be elicited
Fig. 3.23
(a, b) To test the internal meniscus, the lower leg is externally rotated while the knee is flexed. In case of internal meniscus tear, pain can be elicited (a). If the external meniscus is affected, pain is elicited by internal rotation (b) (Steinmann I)
Fig. 3.24
(a, b) If tenderness at the medial joint space radiates (a) dorsally when flexing the knee (b), a lesion to the posterior horn of the internal meniscus is present (Steinmann II). This occurs because the menisci and the femur condyles move backward when the knee is flexed
Fig. 3.25
Testing abduction pain: a medial adduction pain (a) indicates an internal meniscal lesion; lateral abduction pain (b) indicates a lesion to the external meniscus (Böhler’s sign)
Fig. 3.26
Payr test: the patient sits with crossed legs. The examiner presses down on the affected knee joint. This leads to impingement of the internal meniscus. The test is positive if pain is reported at the medial joint space. This indicates a lesion to the internal meniscus
Fig. 3.27
(a, b) Apley compression test (Apley grinding test): the patient lies on his stomach, and the examiner presses the lower legs down and rotates the leg simultaneously inward and outward. If pain presents during external rotation, it indicates a lesion to the internal meniscus (a); if pain presents during internal rotation, it indicates lesion to the external meniscus (b)
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