REIDER PART 227

Chapter 5_Pclvi$, Hip, and Thigh 187

Figurę 5-41. Palpation of the hip joint.

Quadriceps. The large quadriceps muscle group is sub-ject to two distinct types of injury: (1) muscle contusions caused by a dircct blow to the muscle and (2) muscle strains or pulls caused by a violent eccentric contraction of the muscle itself.

In the case of a ąuadriceps contusion, careful gentle palpation allows Identification of the area of injury and often dclineation of an associated hematoma. When pal-pating these injuries, the examiner should be alert not only for tenderness but also for warmth. When a warm firm swelling develops following a quadriceps contusion, the patient is at risk of developing the syndrome of ectopic calcification known as myositis ossificans.

When palpating a ąuadriceps strain, the examiner should search carefully for a divot or defect in the muscle. Such deformities are usually subtle but can occasionally be dramatic. Quadriceps strains are not typically associated with myositis ossificans. The severity of both quadri-ceps contusions and strains can be graded by the restriction of prone knee flexion that results. To do so, the examiner asks the patient to lie prone and to flex the knee as far as possiblc (Fig. 5-42). In severe contusions or strains, the patient is unable to flex the knee even to 90°. Sartorius. Injuries of the sartorius most commonly involve the origin near the ASIS, as already described. Identification of the proximal sartorius may be facilitated by asking the patient to place the lower limb in a figure-four position. Further distally, the sartorius is difficult to distinguish from the quadriceps in most individuals, although isolated injury to this portion of the sartorius is unusual.

Lateral Aspect

Greater Trochanter. The most prominent landmark of the lateral hip and thigh is the greater trochanter. The greater trochanteric bursa, located between the bony trochanter and the overlying iliotibial tract, is a common site of painful inflammation. In obese patients, flexing

Figurę 5-42. Prone assessment of knee flexion to grade the $everity of ąuadriceps contusion or strain.

and extending the hip during palpation allows the exam-iner to feel the trochanter moving underneath the palpating fingers and thus identify it (Fig. 5-43).

Tenderness dircctly over the most prominent portion of the trochanter suggests trochanteric bursitis. In severe cases, the examiner actually fecls soft tissue crepitans as pas-sivc flexion and extension of the hip cause the trochanter to slide beneath the iliotibial tract. Trochanteric bursitis may be associated with tightncss of the iliotibial tract as judged by Obcrs test. Impingement of the iliotibial tract on the greater trochanter is another common cause of the snapping hip syndrome. In the presence of a snapping iliotibial tract, the examiner can palpate and often see the band snap back and forth across the trochanter as the hip is passively flexed and extended in the side-lying patient. Flexing the patients knee and adducting the hip may inerease the magnitude of the snapping sensation. In contrast to trochanteric bursitis, which produces tenderness directly over the greater trochanter, gluteus medius tendinitis is associated with tenderness just superior to this bony prominence. Tenderness

Figurę 5-43. Palpation of the greater trochanteric bursa.