Hip examination in the

child
J.L. CONROY, B.W. SCOTT

Introduction

The hip can be described as the joint of

childhood

In many cases, successful management of the

disease will prevent permanent damage to the
hip joint

avoiding the necessity for major hip surgery in

adult life

In this article we describe a basic hip

examination technique for the child

The childs hip examination

Preparation
Hip

examination in the child is less routine,

includes many pathology-specific tests and
must be child friendly

History

A detailed clinical history is mandatory in the clinical assessment of the hip

majority of information required to make a diagnosis is contained in the history

Pregnancy, labour and birth history are essential, particularly in infants and
toddlers.

Use Toys to watch their gait and general mobility of the hip

Pain has to be characterised by asking questions of the type, site, duration,

intensity, relieving or aggravating factors

Never forget referred pain from the hip to the thigh or knee

Determine the characteristics of any limp, stiffness or reduced range of movement

Past medical and surgical history should always be explored

General examination of the hip

Look

The examination begins as soon as the child enters the room

Look for obvious clues such as a limp, a child using crutches or being carried

Observe the child playing

ask them to stand barefoot so any scars, muscle wasting, leg length discrepancy,
contractures and deformities

Observe the standing patient from the front, side and back

Note any increased lumber lordosis suggestive of fixed flexion deformity of the
hips

If leg length discrepancy is evident, use blocks for the child to stand on

by looking at and palpating the iliac crests ensure the pelvis is level

Pelvic obliquity will be corrected if it is due to leg length inequality but not if
it is due to lumbosacral disease

Trendelenburg test1 to assess abductor function

the examiner standing behind the patient so that the dimples overlying the
posterior superior iliac spines could be observed to move with pelvic
inclination on single leg weight bearing

Hold the childs forearms with the elbows at 901 to allow them support if
necessary whilst allowing identification of a tilt to one side or another.

The patient is asked to stand on one leg with the opposite knee bent to 90 0

A positive test indicates abductor dysfunction on the standing leg side and
the pelvis on the unsupported side is seen to descend.

The examiner should now ask the child to walk to demonstrate any abnormal
gait patterns

Specific gait patterns should be looked for including antalgic, Trendelenburg

and short leg.

Gait can be stressed by asking a child to run and squat

If there is any doubt about general leg strength observe for Gowers sign2 by
asking the child to get up from a lying position on the floor

Feel

The patient should lie in a supine position on the examination couch

Bony landmarks are palpated including the anterior superior iliac spine and
greater trochanter

Square the pelvis on the examination couch by determining the position of

the anterior superior iliac spines

Inability to square the pelvis due to conditions such as structural scoliosis,

abnormal growth of the pelvis as a result of radiotherapy and fixed
abduction/adduction deformity must be accounted for in the examination.

Leg length can now be measured, starting with true leg length

The anterior superior iliac spine is used as the closest fixed point to the hip to
measure from proximally, whilst distally the medial malleolus is used.

Move

Active and passive movements can both be recorded using a linear angle
goniometer or by simple observation

Normal range of movement of a childs joint is greater than in the adult and
generally increases with age

a good range of movement in the child can still be pathologically limited, such
as abduction in flexion of less than 751 in an infants hip.

Flexion is tested in the supine position with the knee flexed to exclude
hamstring tightness. Ask the child to pull their knees up to their chest whilst
supine.

A fixed flexion deformity is identified by performing Thomass test

A patient with a fixed flexion deformity of the hip compensates when lying
supine by arching the spine and pelvis into an exaggerated lordosis.

As an alternative, fixed flexion deformity can be measured using the Prone

hip extension test

Adduction can only be accurately assessed if the opposite leg is in abduction

or held out of the way by an assistant.

Rotation should then be assessed both in flexion and extension to account for
capsular and ligamentous tightness in the differing positions.

In the extended hip with the patient supine, measure the range of rotation
internally and externally by observing an imaginary line through the patella
as the leg is rolled medially and laterally.

Muscle group power testing is seldom performed beyond assessment of gait,

squatting and Trendelenburg testing.

At the end of every hip examination it is important to examine the spine,

knee, vascular tree and neurological status of the lower limbs

Common pathology affecting the hip

in
children

Developmental hip dysplasia (DDH)

DDH is a term describing a spectrum of anatomical abnormalities of the hip that

may be congenital or develop during infancy or childhood.

occurs in 1:1000 infants

hip instability at birth can be present in 1:100 infants

The early diagnosis of DDH is critical to a successful outcome, as acetabular

development is abnormal if the hip is subluxed or dislocated

Delays in diagnosis, or problems in management, often lead to residual anatomical

defects and subsequent degenerative arthritis.

In children under 3 months of age Ortolanis and Barlows tests can be successfully
performed

Perthes disease

Perthes disease is a type of idiopathic juvenile avascular necrosis of the femoral

head

occurs in 1:10,000 children

males are four times more likely to be affected and it is bilateral in 1015% of
subjects.

It occurs between the ages 218 years but most commonly develops in boys
between the ages of 48 years.

An antalgic limp is usually the first sign and a Trendelenburg sign may be present.

The most prominent finding on examination is stiffness, first causing loss of

internal rotation, followed by limited abduction

Slipped upper femoral epiphysis (SUFE)

SUFE is the displacement of the metaphysis on theupper femoral epiphysis

most common adolescent hip disorder affecting 1:50,000 children, most

commonly in obese boys.

The peak age of onset is 13 years in boys and 11 years in girls

It is bilateral in approximately 25% of cases.

Significant slips cause (mal rotation), an out-toeing gait and Trendelenburg

gait.

There is also loss of internal hip rotation due to inflammation of the joint and
postero-inferior slippage of the femoral head in relation to the metaphysis.

Transient synovitis (irritable hip)

This is an idiopathic benign inflammatory condition of the hip joint.

most commonly occurs between2 and 8 years of age

often after a viral illness

It is thought to be a post infective reactive arthritis and can result in a small

amount of fluid in the joint.

It is important to rule out bacterial infection of the joint or osteomyelitis.

All movements of the hip are limited by pain, particularly internal rotation.

Septic arthritis

The early diagnosis and drainage of septic arthritis is critical due to the
tenuous vascularity of the hip.

The majority of children are less than 4 years of age.

present with acute onset of fever, pain, ill appearance and refuse to stand or
limp.

All movements of the hip are painful and reduced.

Spastic cerebral palsy

Hip adductor spasticity leads to fixed shortening of the adductors and often
causes hip instability in the longer term.

Hip dislocation hardly ever occurs in the walking patient but hip instability is
frequent in those with severe diplegia and whole body involvement.

Serial examination is important to monitor abduction range and the presence

of fixed flexion deformity.

Femoral anteversion

Femoral anteversion is highly variable in the child

It can be measured clinically using the trochanteric prominence angle test.

Psychological

Children in emotional conflict with themselves, their family or community

may present with symptoms which mimic organic disease. This diagnosis
should only be made once all other diagnoses have been explored.

Conclusion

A variety of conditions affect the hip in childhood.

majority of cases these can be identified by taking a concise history

and performing a structured hip examination, modified according to the
likely pathology.