Hip Examination (OSCE)

Introduction

 Greet the patient and introduce yourself 👋

 Confirm patient details ✍

 Briefly explain the examination in a patient friendly manner 

 Check if the patient has had a hip replacement 

 Get patient consent ✅

 Expose the patient’s legs and ask them to stand

 Wash hands ✋

 Check the patient is not in any pain

Look

Inspect the patient for any clinically relevant signs:

 Scars: indicate prior surgery

 Obesity: joint pathology risk factor

 Muscle wastage: associated with lower motor neuron injury or disuse atrophy 💪

Inspect for objects/equipment which may be clinically relevant:

 Prescriptions: indicate recent medications 💊

 Walking aids: indicate hip/ankle/ knee pathology ♿

Inspect the anterior aspect of the hips:

 Swelling: identify asymmetry indicate of unilateral swelling

 Scars: indicate prior surgery/trauma 🏨

 Bruising: indicate prior surgery/trauma

 Lateral pelvic tilt: indicates scoliosis/hip abductor ribbon/difference in leg length

 Quadricep wastage: identify asymmetry caused by lower motor neuron lesion/ disuse atrophy 

 Different length legs: congenital or acquired by pathology/surgery 🏨

Inspect the lateral aspect of the hips:

 Fixed flexion deformity: may indicate contracture due to inflammatory conditions, prior trauma or neurological disease

Inspect the posterior aspect of the hips:

 Muscle wastage: identify asymmetry caused by lower motor neuron lesion or disuse atrophy 

 Scars: indicate prior surgery/trauma 🏨

Observe the patient as they walk to the end of the room and back:

 Gait cycle: identify abnormalities 🚶

 Waddling gait: indicates weakness of the hip abductor muscles on both sides, associated with myopathies 

 Trendelenburg’s gait: indicates weakness of the hip abductor muscles on one side, due to L5 radiculopathy or superior gluteal nerve lesion 

 Leg length: differences can indicate joint pathology 📏

 Limp: can indicate joint pain/weakness

 Slow turning: can indicate joint restrictions

 Footwear: unequal wearing of the sole can indicate an abnormal gait 👟

 Movement: reduced range of movement indicates chronic joint pathology

Normal gait cycle:

1. Heel makes contact with floor
2. Foot becomes flat and weight is transferred onto it
3. Weight balanced on flat foot’s leg
4. Heel lifted off floor
5. Toes lifted off floor
6. Foot swings forward and cycle begins again

Trendelenburg’s gait:

 Caused by hip abductor muscle unilateral weakness 

 Causes difficulty supporting the body’s weight during the swing phase on the side which is affected. Results in the pelvis falling on the opposite side to the swinging leg 🚶

Waddling gait:

 Caused by hip abductor muscle bilateral weakness 

 Causes myopathies

Inspect the patient in the supine position:

 Bruising

 Scars 

 Swelling

 Fixed flexion deformity

 Quadricep wastage 

 Asymmetry of hip joints

Feel

Assess the temperature of the hip joints, using back of your hands:

 High temperature indicates inflammatory or septic arthritis when in conjunction with swelling and tenderness 😪

Palpate the hip joints:

 Palpate the greater trochanter of both legs 

 If tenderness is observed, it is indicative of trochanteric bursitis

Assess the length of the legs:

 Assess the apparent leg length: compare the distance between the tip of the medial malleolus of each leg and the umbilicus 

 Assess the true leg length: using a tape measure, measure the distance between the tip of the medial malleolus of each leg and the anterior superior iliac spine 📏

Move

Assess active movement (performed independently):

 Hip flexion: ask the patient to move their knee as close to their chest as possible (normal = 120°) to flex their hip 📐

 Hip extension: ask the patient to straighten their leg as much as possible (normal = 180°) 📐

Assess passive movement (performed by the clinician):

 Hip flexion: flex the hip as far as possible (normal = 120°) 📐

 Hip internal rotation: flex hip and knee joint 90° and rotate foot outwards (normal = 40°) 📐

 Hip external rotation: flex hip and knee joint 90° and rotate foot inwards (normal = 45°) 📐

 Lateral hip abduction: with the patient lying in the supine position, hold the ankle and stabilise the pelvis by placing your hand over the contralateral iliac crest, then move the ankle outwards to abduct the hip (normal = 45°) 📐

 Medial hip abduction: repeat, moving the ankle medially instead of laterally (normal = 30°) 📐

 Hip extension: with patient lying face down, hold the ankle with one hand, and put your other hand on the ipsilateral pelvis, lift the leg and assess the range of hip joint extension

Special tests

Thomas’s test for fixed flexion deformity:

1. With patient lying in supine position, position your palm beneath their lumbar spine ✋
2. Passively flex the hip of the leg which is unaffected whilst simultaneously observing the affected leg
3. Repeat on the affected leg 🔄

 If the affected thigh lifts off the bed, it is indicative of fixed flexion deformity, suggesting the patient has lost some hip joint extension

Trendelenburg’s test for hip abductor weakness:

1. Ask the patient to stand and position their hands on your shoulders
2. Place your fingers either side of the iliac crest 
3. Ask patient to lift one leg off the floor
4. Observe your fingers, assessing for lateral pelvic tilt 
5. Repeat for the opposite leg 🔄

 Normal: pelvis remains stable/rise slightly on raised side

 Weakness: indicate by pelvis dropping on the raised side

Completion 

 Tell the patient the examination is finished ✅

 Thank patient 

 Wash hands ✋

 Summarise what the examination revealed 

Summary:

1. Greet the patient and briefly explain the examination
2. Inspect the patient to identify anything clinically relevant
3. Inspect the anterior, lateral and posterior aspects of the hips
4. Observe the patient walking to the end of the room and back to identify: normal gait, waddling gait or Trendelenburg's gait
5. Inspect the patient in supine position to identify anything clinically relevant
6. Assess the temperature and palpate the hip joints
7. Assess the length of the legs
8. Assess the active and passive hip movements
9. Perform special tests such as Thomas's test and Trendelenburg's test