Summary of Common Conditions Seen in OSCEs
Painful Hip
| Condition | History | Symptoms and signs |
| Osteoarthritis | Primary Secondary – infection, trauma, developmental dysplasia of the hip | Local Pain on weight-bearing Restricted ROM Referred pain – knee, buttocks Flexion contracture |
| Rheumatoid arthritis | Morning stiffness Age younger than for osteoarthritis | Muscle wasting Bilateral pain Trophic skin changes |
| Avascular necrosis of the hip | Trauma Alcohol intake Gout Diabetes | Groin pain upon walking Stiffness |
| Bursitis | Repetitive movement – ballet, rowing, dancing | Trochanteric – pain on adduction Ischiogluteal – pain upon sitting for long periods |
| Spondyloarthropathies | Ankylosing spondylitis Inflammatory bowel disease Psoriatic arthritis | Painful sacroiliac joint referred to the lower buttock and thigh Pain elicited by extension and compression of the hip |
| Piriformis syndrome | Compression of the sciatic nerve | Pain upon sitting |
| Septic arthritis | Immunocompromised | Fever Acute pain Erythema Swelling Hot Decreased motion |
Gait Abnormalities You May Encounter in a Hip Station
| Type of gait | Pathology | Condition |
| Waddling (Trendelenburg) | Weak proximal muscles | Muscular dystrophy Congenital hip dysplasia |
| Parkinsonian | Basal ganglion dysfunction | Parkinson’s disease Drugs – phenothiazines, haloperidol, thiothixene, metoclopramide Carbon monoxide poisoning |
| Scissoring | Spastic paraparesis | Multiple sclerosis Cord compression Cerebral palsy Syringomyelia Pernicious anaemia Liver failure |
| Cerebellar ataxia | Ipsilateral cerebellar lesion | Multiple sclerosis Alcohol Stroke/transient ischaemic attack |
| Foot drop | Common peroneal nerve palsy (unilateral) | Trauma to knee Fracture of fibula |
| Marche à petits pas | Diffuse cerebrovascular disease – lacunar state | |
| Sensory ataxia | Peripheral neuropathy | Diabetes Alcohol intake Multiple sclerosis |
| Antalgic gait | Trauma | See table above |
Hints and Tips for the Exam
Know Your Anatomy
The hip is a ball and socket joint in which the acetabulum is the ‘socket’ and the head of the femur is the ‘ball’. This musculoskeletal structure is used for weight-bearing and supporting bipedal movements. The following table exhibits the complexity of the muscular origins of the hip movements and will help in diagnosing a labral tear if one is apparent in the hip examination.
| Movement | Muscles |
| Flexion of hip | Iliacus Psoas major |
| Extension of hip | Hamstring muscles Gluteus maximus |
| Adduction of hip | Adductor brevis Adductor longus Adductor magnus |
| Abduction of hip | Gluteus medius Gluteus minimus |
| Lateral rotation of hip | Tensor fasciae latae Gluteus medius and minimus |
Special Tests
Apparent Limb Length and True Limb Length
- Apparent limb length = distance from the xiphisternum to the medial malleolus bilaterally.
- True limb length = distance between the anterior superior iliac spine and the medial malleolus bilaterally.
The clinical significance of this is that a fixed adduction deformity of the hip can be diagnosed if the apparent limb lengths are different but true limb lengths are equal. In hip dislocations, Perthes disease or slipped femoral epiphysis, there is a difference in true limb length.
Trendelenburg Test
Aim – To assess the abductor muscles of the hip (gluteus medius, gluteus minimus).
Technique – If you are assessing the left hip, the patient should stand upright, and then lift the right foot off the ground while flexing the right knee. The right hip should then move upwards as the left hip muscles contract to pull it up.
- If this happens, the test is negative as the left hip muscles are functioning normally.
- If the right hip sags down, the test is positive as the left hip muscles are unable to contract and pull the right hip upwards.
As easy way to remember this is that the ‘sound side sags’ – is if there is sagging of the hip (i.e. it does not move upwards when the foot is raised off the floor), the defect is in the contralateral hip abductors.
FABER Test
Aim – To assess hip joint pathology.
Technique –The patient lies supine with one leg flexed at the knee and externally rotated. The ankle rests upon the opposite knee joint. The patient extends the flexed knee while pressure is applied over the hip and knee joint by the examiner. This is repeated for the opposite hip joint (FABER = Flexion, Abduction, External Rotation).
Clinician’s position – The clinician stands by the flexed knee and applies pressure to the medial aspect of the knee and opposite hip joint.
Clinical Significance –
- Negative test: No pain upon movement, equal range of movement bilaterally, both knees are level at the end of the examination.
- Positive test: Hip pain upon movement and decreased ROM.
The pelvis articulates with the sacroiliac joint and the lumbar spine. The iliopsoas muscle functions as a hip flexor and external rotator of the femur. Thus, pressure exerted upon the hip joint exerts tension on these structures, causing pain if pathology is present. Articular hip pathology, for example synovitis or loose bodies, also presents with pain upon movement.
FAIR Test
Aim – To assess articular pathology.
Patient’s position – The patient lies in the lateral recumbent position, the upper hip and knee both flexed to 90 degrees.
Clinician’s position – The clinician stands placing a stabilising pressure on the hip while depressing the flexed knee, which internally rotates and adducts the hip (FAIR = Flexion, Adduction, Internal Rotation).
Clinical Significance –
- Negative test: No pain upon movement or compression of the hip.
- Positive test: Sciatic symptoms are recreated. There is hip pain upon movement.
The piriform muscle is attached to the superior medial aspect of the greater trochanter and inserts into the obturator internus. The piriform muscle has multiple functions, including acting as a flexor, abductor and internal rotator of the hip. The sciatic nerve pierces the piriformis muscle, so trauma or strenuous activity, for example long-distance running, leading to inflammation of the muscle, may compress the nerve, producing an intense shooting pain following the distribution of the sciatic nerve. Reproduction of the symptoms is achieved by the FAIR manoeuvre.
The psoas bursa is a fluid-filled sac that lies between the psoas tendon and the lesser trochanter of the femur. Strenuous repetitive exercise, such as ballet, rowing or gymnastics, can cause psoas bursitis. The FAIR manoeuvre can indicate towards a psoas bursitis or articular pathology if pain or an audible snap from the inguinal region is elicited.
Thomas Test
Aim – To assess for fixed flexion deformity.
Patient’s position – The patient lies supine, holding one knee flexed.
Clinician’s position – The clinician slides their hand under the spine and assesses the curvature of the lumbar spine. A normal patient will exhibit a flat plane.
Clinical significance –
- Negative test: No flexion of the pelvis.
- Positive test: Increased lumbar lordosis. The hip cannot remain extended and straight, and starts to flex.
The test is positive if a fixed flexion deformity is present. A variety of pathologies can cause this, osteoarthritis being a common one.
Management of Hip Fractures
There are some specific anatomical considerations to bear in mind when deciding how a hip fracture should be managed. The most important distinction is between intracapsular and extracapsular fractures (the numbers corresponding to the diagram below):
- Intracapsular fractures proximal to the capsular insertion:
- (1) Subcapital
- (2) Transcervical
- (1) Subcapital
- Extracapsular fractures (trochanteric and subtrochanteric – which can be further subdivided into undisplaced and displaced)
- (3) Basicervical
- (4) Intertrochanteric
- (5) Subtrochanteric
- (3) Basicervical
To understand the reasoning behind this, it is important to appreciate the blood supply of the hip. The femoral artery divides to form the medial and lateral circumflex arteries, which act as an arterial ring around the femoral neck. The posterior–superior retinacular arteries ascend from the arterial ring and ultimately form the lateral epiphyseal arteries. Thus, extracapsular fractures have a decreased risk of avascular necrosis due to the relatively extensive blood supply. In contrast, the more distal the fracture is, as with intracapsular fractures, the higher the risk of avascular necrosis – as the blood supply there is relatively limited.
Extracapsular Fractures
A dynamic hip screw is implanted into the femoral head, and a plate is fixed to the shaft of the femur with further screws. The dynamic hip screw allows controlled sliding of the femoral head component along the construct.
Undisplaced Intracapsular Fracture
The approach is internal fixation with the insertion of parallel screws that course through the neck and into the head of the femur to hold it in position.
Displaced Intracapsular Fracture
- <65 years and active patients undergo an open reduction and internal fixation.
- >65 years and those with pre-existing joint pathology have a hemiarthroplasty (replacing the femoral head): Austin Moore prosthesis, which has three components:
- Acetabular cup: cemented to the acetabulum.
- A femoral component: stem and femoral head cemented/non-cemented to the shaft of the femur.
- Articular interface: between the acetabular cup and the femoral component.
- Acetabular cup: cemented to the acetabulum.
Figure 19.1 Total hip replacement
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