Deformities of the Hip: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

• General physical examination – including blood pressure, pulse, body weight, height; furthermore:
  • Inspection (viewing).
    • Skin and mucous membranes
    • Gait [limping]
    • Body or joint posture
    • Malpositions [deformity, shortening, rotational malposition].
    • Wrinkle asymmetries on the posterior thighs?
    • Muscle atrophies
  • Palpation (palpation) of prominent bone points, tendons, ligaments; musculature; joint (joint effusion); soft tissue swelling; tenderness (localization! ); findings:
    • Pressure pain: trochanter (thigh ring), groin (coxogenic; differential diagnosis: inguinal hernia (groin hernia), hip joint infection; deep vein thrombosis (DVT), lymphoma), anterior pelvic ring.
    • Leg crush pain, if necessary, crepitations (audible and palpable crackling sound when fragments of a fractured bone rub against each other), snapping phenomena
  • Measurement of joint range of motion (according to the neutral zero method: range of motion is expressed as the maximum deflection of the joint from the neutral position in angular degrees, where the neutral position is designated as 0°. The starting position is the “neutral position”: the person stands upright with the arms hanging down and relaxed, the thumbs pointing forward and the feet parallel. The adjacent angles are defined as the zero position. Standard is that the value away from the body is given first. )Range of motion of the hip:
    • Extension (stretch)/flexion (bend): 0°-0°-130°.
    • Abduction (lateral displacement of a body part from the center of the body)/Adduction (bringing a body part to the body or limb axis): 45°-0°-30°.
  • Specific tests
    • Ortolani sign (screening in the neonatal period or when congenital hip dysplasia is suspected):
      • Detection: congenital hip dysplasia.
      • Procedure: the thigh is pressed vertically toward the spine and then moved outward.
      • Ortolani positive: in the presence of hip dysplasia, the initially subluxated femoral heads slide back into the acetabulum with a clicking sound – the Ortolani sign (snap phenomenon).
      • Caveat. In the positive case, the test must be performed only once in the newborn, otherwise the cartilaginous rim of the acetabulum (the labrum acetabuli) can be damaged by the femoral head repeatedly sliding over it. In the most unfavorable case, this can result in femoral head necrosis.
    • Barlow sign
      • Evidence: congenital hip dysplasia.
      • Procedure: place thumb in groin and grasp thigh with hand. Through abduction and adduction attempted inward and outward levering of the femoral head.
      • Caveat. This maneuver can overstretch the joint capsule and damage the joint. In the worst case, this can result in femoral head necrosis.
    • Thomas handle
      • Evidence: flexion contracture in the hip joint.
      • Starting position: examiner’s hand is under the lumbar spine (note: hyperlordosis (hyperextension with hollow back) in the lumbar spine may compensate for and thus mask shortening of the hip flexor muscles in a supine patient)
      • Execution: the unaffected leg is flexed to the maximum (with the knee bent), so that the hollow back is cancelled. With hip flexion contracture of the other leg, the leg under examination does not remain flat on the support, but follows the progressive hip flexion).
    • Trendelenburg sign
      • Evidence (clinical picture) of paralysis of the glutei medius and minimus muscles, which may be due to damage to the superior gluteal nerve.
      • Trendelenburg positive: when standing on one leg, the pelvis sinks to the healthy sideby insufficiency of the Mm. glutaei.
  • Assessment of blood flow, motor function and sensitivity.
    • Circulation (palpation of pulses).
    • Motor function: testing of gross strength in lateral comparison.
    • If necessary, sensitivity (neurological examination).
• Health check

Square brackets [ ] indicate possible pathological (pathological) physical findings.

The main diagnostic criteria

The European Pediatric Orthopaedic Society (EPOS) has compiled 23 criteria that are associated with an increased risk of congenital hip dysplasia in children younger than 9 weeks. These were evaluated for significance in a study. In this study, 4 parameters were found to be statistically significant:

• Ortolani or Barlow sign.
• Asymmetry in abduction of ≥ 20° and abduction in one or both hips ≤ 45°.
• Hip dysplasia in a first-degree relative.
• Leg length discrepancy