Clinical Evaluation

PHYSICAL EXAMINATION The examination of the hip begins with a detailed history and complete examination of the patient. The pelvis and hip are then carefully evaluated. The unclothed, erect patient is inspected for a list, injuries, scars, or asymmetry of the muscles. Gait should be tested, if possible.

If the patient is a trauma victim, after primary survey and initial stabilization observe the position of the extremities, looking for deformities, shortening, rotation, lacerations, or bruises, and test for stability and range of motion. On palpation, feel for irregularities in movement at the iliac crest, pubic rami, and ischial rami. Compress the pelvis lateral to medial through the iliac crest; anterior to posterior through the symphysis pubis; and anterior to posterior through the iliac crest, seeking pain and tenderness. Also, compress the greater trochanters of the hips.

If no significant abnormalities are found, range of motion of the hips should then be studied. If rotation of the hip with the leg in extension is painful all other maneuvers should be done cautiously. If a hip or pelvic fracture or dislocation is identified in a trauma victim, assume that intra-abdominal, retroperitoneal, and urologic injuries have occurred as well, until it has been proved otherwise. Always perform a detailed neurovascular examination and a rectal examination, looking for displacement of the prostate in male patients. Associated femoral shaft fractures should be ruled out.

RADIOLOGIC EVALUATION Roentgenographic evaluation of the pelvis and hips is a must in all unconscious patients who have sustained multiple injuries. The threshold for obtaining radiographs in demented elderly patients who have sustained minor falls should also be relatively low because those patients may be particularly difficult to evaluate.23 Lower extremity long bone fractures, as well as pelvic symptoms or signs, are also indications for these x-ray examinations. The x-ray evaluation should include a standard AP and a lateral view of the pelvis. If further studies are needed, AP views of either hemipelvis, internal and external oblique views of the hemipelvis as described by Judet and colleagues, or "inlet" and "tilt" views may be done. In certain instances, such views allow better identification and detail of the acetabulum and femoral head and neck. Always inspect not only the hip joint but also the femur and knee when evaluating hip disorders on x-ray films. Disorders to the knee and the femoral shaft often occur with hip injuries. Significant hip pain with weight-bearing following trauma and normal radiographs suggest the possibility of occult fracture, especially at the femoral neck or acetabulum. 24 The patient should be prescribed protected weight-bearing and the emergency physician should communicate with the patient's primary care provider or orthopedist regarding close follow-up for possible CT or MR hip imaging to rule out occult fracture.2 2 MR is reliable in detecting occult fractures within 24 h of injury.

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