Inspection - standing
□ Ohserve ihe patient when standing and walking and note any abnormality of gait.
n Observe the patient from behind and look for scoliosis and pelvic tilling which may conceal a hip deformity or true shortening of one leg (Figs 8.22, 8.23, and 8.24). If pelvic Lilt is present, examination of leg lengths is essential.
Test for stability of the hip - Trendelenburg's test
□ Ask the patient to stand first on one leg and then the other.
□ Observe any change in pelvic tilt on the non-weight-bearing side (Fig. 8.25).
Inspection - supine
□ Inspect the patient supine, positioned so that the pelvic brim is at right angles to the spine.
□ Inspect the posture of each leg and note any deformity, swelling or other signs of inflammation, muscle wasting, sinus formation or obvious asymmetry.
□ Palpate for local tenderness over the from of the hip and over the greater trochanter.
□ Measure leg lengths as follows:
• To measure 'apparent' shortening, place the legs parallel with Ihe patient lying supine. Measure from a
Fig, 8.22 0 Abduction deformity of the right hip. E] A left shoe raise straightens the right leg but does not correct the pelvic tilt or the scoliosis.
Fig, 8.23 0 Adduction deformity of the left hip. [U A left shoe raise straightens the right leg without correcting the pelvic tilt or the scoliosis.
fixed point such as the xiphistemum or umbilicus to the lip of the medial malleolus on cacli side (Fig. 8.26).
• To measure 'true' shortening with the patient lying supine, place the normal limb in a comparable position of adduction or abduction to the abnormal limb. Measure from the anterior superior iliac spine to the medial malleolus (Fig. 8.27).
Fig. 8,24 Effect of true shortening of right leg on posture. H Causes pelvic tilt and scoliosis. ® The pelvic tilt and scoliosis are fully corrected by providing a shoe raise.
□ Position the pelvis so that the pelvic brim is at right angles to the spine. (Any fixed adduction or abduction will usually be revealed immediately.)
□ With one hand stabilising the iliac crest, use the other hand to flex each hip and note the range of flexion (0-120 degrees) (Fig. 8.28).
Fig. 8.27 Measurement for true shortening of the leg. The patient has an adduction deformity of the right limb. On placing Ihe normal limb in the same position of adduction, the leg lengths are the same, excluding true shortening. El Incorrect because legs are not In a comparable position S Correct because the legs are in a comparable position of adduction.
□ Perform Thomas's test first on one side and then the other in order to unmask a flexion deformity of the hip concealcd by the presence of a compensatory lumbar lordosis.
□ Place one hand between Ihe palient's lumbar spine and the examination couch.
□ Flex the unaffected hip to its limit and continue to push to straighten the lumbar spine; as the lumbar lordosis is
obliterated, the examining hand is squashed between the patient's spine and the examination couch.
□ The opposite leg, if abnormal, will rise off the table revealing the amount of flexion deformity present (Fig. 8.29B).
I. I Immobilise the pelvis by grasping the opposite iliac crest, then abduct (variable, minimum 45 degrees) (Fig. 8.30) and adduct (25 degrees) each hip, noting the range of movement. At each extreme the pelvis will be felt to tilt with the limb.
□ To measure rotation with the hip flexed, flex the hip and knee to 90 degrees and use the tibia lo assess the arc of rotation - internal rotation (30 degrees) and external rotation (45 degrees),
□ To measure with the hip extended, roll each leg on the couch and measure the range of rotation using the feet as indicators (90 degrees are of movement).
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