coxa vara pdf3

Upload: lucila-lugo

Post on 03-Apr-2018

254 views

Category:

Documents


0 download

TRANSCRIPT

  • 7/28/2019 Coxa Vara Pdf3

    1/6

    Pos i t ive Negat iveTrendelenburgs Siga

    F ig . ITh ese d raw ing s d em ons tra te w h at T ren delenb urg d esc rib ed as a p osi-t ive an d negat ive s ign . N ote th at b o th hand s are h eld by an a ssis tan tan d th e alignm en t of th e p elv is w ith re sp ect to th e grou nd is observ ed .

    ( From M ercer R angs A ni/z olo gt n /o rth op ae di cs , w it h p er mi ss io n) .

    P. 1-1 . 1 -Ia rdc astle , FRAC S. S en ior Lectu rer in O r tho paed ic S urg eryS . M . L . N ade. M D . FRAC S. P rofe sso r ofO rth op aed ic Su rge ryQ ueen E liz abe th I I M edic al C entre , N edlands . W estern A u stra lia 60 09 .R equ ests fo r re prin ts sh ould he sen t to P rofesso r S . M . L .N ade .I 1 985 B rit ish Ed ito r ia l So ciety of B one an d Jo in t S urgery0 30 1 6 20 X 85 51 50 S2 .0 0. VOL . 67 B . No. 5 . NOVEM B ER 1985 74 1

    THE SIGN IFICANCE O F THE TRENDELENBURG TESTPH IL IP H ARDCA STLE , SYDNEY NADE

    From tile U n ive rsity o f W este rn A ustra lia

    T rende lenburg s te st o f fun c tio n of th e h ip jo in t w as first repo rted b efore rad io log y w as a va ila b le. A tlea st fo u r m ethod s of p erform ing it h av e sin ce b een d escr ib ed in th e litera tu re.

    W e exam in ed 50 norm al sub jec ts and 103 peop le w ith d isord ers a ffect in g eith er th e sp in e or th e h ip , inord er to d e term in e th e d ifferen t respon ses th at occurred w hen th ey w ere ask ed to stand on one leg . T h is hasenab led u s to d e fin e a standard m ethod of p er form ing th e T rende lenburg test , and to in terp re t th e te st as am ethod o f asse ss in g h ip abducto r fun c tion .

    T he m ajor p itfa lls th at resu lt in m isin terp re ta tio n , or fa lse -po sitive respon ses , are pa in , lack o f co -op era tion from the p a tien t, an d im pin gem en t be tw een the rib cage and the ilia c c rest. False-negativeresponses resu lt from th e patien t u sin g m uscle s above and below th e p e lv is , and from lean ing b eyond th e h ipon th e s tand ing sid e .

    In 1897 F ried rich T rende lenb urg desc r ibed a te st w h ichhe foun d use fu l in de term in ing the in teg rity o fh ip ab duc -to r m usc le fu nc tion , w ith spec ific re ference to con gen ita ld is locatio n o f the h ip and p ro gress ive m uscu la r a tro phy(R ang 1966 ). T rende lenbu rg s repo rt (F ig . I) app ea redo n ly tw o y ea rs af te r the d iscove ry o fx -ray s b y R oen tgen ,a t a tim e w hen the p hy sician had few a id s to d iagn osiso the r th an h is ears , ey es , and fin ge rs . T he tes t is m en-tion ed in m ost m a jo r o rthop aed ic an d physio the rapytex tbo oks as a d iag nos tic m ano eu vre to b e carr ied ou t inthe asse ssm en t o f fun ctio n and dysfunc tio n of th e h ip .

    In the standa rd tex tbo ok s w e found a t lea st fou r d if-feren t m e thod s o f pe rfo rm ing the T rend elenb urg tes t,u su ally desc rib ed vague ly , and it w as se ldom c lea r h owthe te st sh ou ld be in te rp re ted . F urthe rm ore, the re w aslittle ag reem en t am ong our co lleagues abo u t the p e r-fo rm an ce o r in terp re tatio n of th e tes t, a lthou gh m ost o fth em had rou tin ely carried o u t th eir ow n ve rs ion ofit o nm any of th eir pa tien ts . B ecau se o f th is confusio n as toth e # ti c t/ io d , i ne at ti ng an d va lue of the te st, w e decid ed toin ve stig ate it .

    T he a im s of th is s tudy w ere , f irs t, to reco rd th erespon ses o f no rm a l peo p le to the requ est to stan d o none leg , and hence to de fine a s tan da rd T ren de len burgte st; an d secon d , to s tudy peop le w ith va rious ab norm a li-tie s o f the h ip an d its m usc le s in o rde r to assess the va luean d th e p itfa lls o f th e te st a s used in cu rren t o rtho paed icp ract ice.

    SUB JECTSN orm al v o lun teers. A grou p o f 50 norm a l p eop le agedbe tw een 3 an d 50 y ea rs w ere exam ined to de te rm ine w ha thapp en ed to th eir p ostu re w hen th ey stood on one leg .Tw o position s o f the non -stance leg w ere stud ied : f irs tthe te st w as pe rfo rm ed w ith the h ip flexed to 30 , an dthen it w as repeated w ith the h ip flexed to 90 . E ach pe r-so n w as asked to m a in ta in the o ne -leg stance p ostu re fo r --- 30seconds.

  • 7/28/2019 Coxa Vara Pdf3

    2/6

    2 . M ech anical d isord ers(a ) O f the sp ine

    (b) O fthe h ip(i) I n c hi ld re n

    ScoliosisA nkylosing sp ondyli tisIl iac cre st defect afte r

    an terior sp inal fus ion

    II3.5.59

    Ii3

    20

    .5

    .554

    15I5

    S4

    74 2 P . H . H ARDCASTLE , S . M . L . N ADE

    TH E JOURNA L OF BON E AND JO INT SURGERY

    V olun teers w ith n eu rom uscu losk e leta l d isord ers. O f th e103 peop le stud ied , 12 h ad b ilate ral h ip d iso rd ers . Th eage ran ge o f the 10 3 pa tien ts w as from 6 to 82 y ea rs .Th ey w ere d iv id ed in to tw o m ajo r g ro ups (T ab le I) : tho sew ith neuro log ical d iso rd e rs and th ose w ith m echan ica ld iso rd ers o fth e h ip o r sp in e.

    DATA ANALY SISC lin ica l photog raphy and v id eotap e . In itia lly , co lo u rv ideo tap es w ere used in o rd er to stu dy th e m ov em en tpa tterns b y s in g le -fram e ana lysis . A s w e b ecam e m oreexpe rien ced , th e re sp onses w ere reco rded on 35 m mcolou r p ro jec tion slide s.E lec t romyog raphy . Th is w as pe rfo rm ed on th ree n orm a lvo lu n tee rs . G lu teus m ax im us , g lu teus m ed ius, g lu teusm in im us, ten so r fa sc ia la ta and ad duc to r m agnus m usc leactiv ities w ere reco rded w ith the su b ject a t re st and su b-sequ en tly w ith th e p elv is in th e d iffe ren t po sitions fou ndto occu r regu la rly w h en th e test w as pe rfo rm ed . T hreew alk ing su b jects w ith incom ple te pa rap leg ia du e to trau -m a tic fractu re -d isloca tion w ere also stud ied .A sses sm en t o f abductor m usc le pow er . W ith th e sub jec tly ing on one s id e , the streng th o fabdu c tio n o fthe h ip w asasse ssed , usin g the M ed ica l R esea rch C ounc il g rad ing ofm uscle pow er.

    R E SULTSNorm al respon sesWi th th e non -s tan ce h ip flex ed at 3 0 . T hree d iffe ren t pa t-te rns o f pe lv ic and sp ina l m ovem en t occu rred w ith thenon -stan ce h ip flexed to 3 0R esponse 1 . T he pe lv is rose on the n on-stance side , thetyp ica l d esc r ip tion o f a nega tive T rend elenb urg te st ;

    T ab le I. C las sificat ion of the neurom u scu loske leta l d isorders ofthe 10 3

    volun teers

    I . N euro lo g ic al co ndition s In com plete p arap leg iaM uscu lar dy stro ph yN erv e roo t en trapm en tC e reb ral palsyPoliomyeli t isHem ip l eg i a

    C onge nita l d islo cationSubluxat ionCoxa v araP erth es d is eas eS lip ped cap ita l fem o ral ep iph ysis

    ( ii) In adu lts F ractured neck of fem u rA ft er a rt hr op la st yOsteoar th r i t isA va scu lar n ecro sis

    C In clu d in g o ne w ith con gen ita l d is loc atio n ofth e h ip (F ig . 1 3)

    th ere w as a com pensa to ry sco lio sis co nvex to th e stan ceside (F ig . 2 ) .R esponse 2 . The pe lv is rem a ined p ara llel to the g rou ndw ith m in im a l sp ina l com pensa tion (F ig . 3 ) .R esponse 3 . T he pe lv is d ropp ed o n the non -sta nce sic/c an dth e bu tto ck c rease m oved dow nw ard s. Th is w as assoc i-ated w ith ad duc tion of the w e igh t-bea rin g h ip and acom pen sa to ry sco lio sis conv ex to the non -stan ce s ide , a sseen in the c la ssical pos itive T rende lenbu rg te st .B a lance w as ach ieved by m oving the to rso an d cen tre o fg rav ity d irec tly ove r the w e igh t-bea rin g h ip (F ig . 4 ).Wi th th e non -stan ce h ip flexed 90 . Response 1 . In th ispositio n the pe lv is rose o n the non -s tan ce s ide b u t no t a s

    Fig . 2 F ig . 3 F ig . 4Th ree d if fere n t respo nse s w ere se en in norma/ vo lun teers w h en they w ere asked to sta nd o n on eleg w ith th e h ip on the no n-s tan ce side flexed at ab ou t 3 0 . F igure 2-Th e pelv is o n the n on -s tan ce s ide ro se ab ov e the stanc e side w ith the tru nk cen tred o ver th e s tan ce h ip (a negat ivere spo nse ). F igu re 3-The p elv is rem ained pa ral le l to the ground . F ig ure 4 -Th e p elv is on the

    no n-s tan ce s ide dropp ed be low the lev el o fth e sta nce s ide (a p os itiv e T rend elen bu rg sign ).

  • 7/28/2019 Coxa Vara Pdf3

    3/6

    F igure 5 -A fa lse-neg ative test c an o ccu r if th e tru nk sh ifts ex ces siv elyto red uce the ab duc tor m usc le forc e n ece ssa ry to o b ta in eq uil ib rium :n ote the w as ting of the r igh t th ig h due to po liom yelit is . F igure 6 -W hen the trunk is re-aligned o ver the stanc e h ip th e pelv is dro psrap id ly o n th e non -stanc e s ide bec au se there is no t enough m usc le

    pow er av aila b le to m ain tain th e eleva ted p os itio n .

    W id e lateral tran slo cat ion of tru nkto al low b alance ove r th e h ip asa f ul cr um

    TH E SIGN IF ICANCE O F TH E TRENDELENBURG TEST 74 3

    VOL . 67- B . N o . S . NOVEM BER 1985

    h igh as w hen th e n on -stance h ip w as flexed on ly 3 0 . Th isw as b ecause pe lv ic ro tatio n bro ugh t the ilia c c re st c lo serto the rib cage and m ade sp ina l com pen satio n un com fort-ab le.Resp onse 2 . The pe lv is rem ain ed p a ra lle l to the g rou nd .

    T he re w as no th ird respon se w ith the h ip flex ed90 -in no sub jec t d id the pe lv is d ro p on the n on-stanceside.E lec trom yograph ic f ind in g s. E lec trom yogram s w ereob ta ined from th ree vo lu n tee rs . It w as fou nd th a t w ithth e th ird re sp onse (fals e-po sitive test) no activ ity w aspresen t in g lu teus m ax im us, g lu teus m ed ius, g lu teu sm in im u s or addu cto r m agnu s; ac tiv ity w as p resen t intenso r fa sc ia la ta . If the sub jec t, o n comm and , vo lun -ta rily ra ised the pe lv is on the n on-stance sid e , th e re w as ag radu a l inc rea se o f th e h ip ab duc to r m usc le ac tiv ity ,reach in g a m ax im um w hen the firs t re spon se w asach ieved ; no activ ity w as reco rded in add uc to r m agnu so r g lu teus m ax im u s. W ith the no n-stan ce h ip a t 9#{216}cab duc to r ac tiv ity w as the sam e as during R espo nses Ian d 2 w ith the n on-stance h ip a t 30 .

    R espon ses in abnorm al sub jec tsR eco rd in g an d c la ssify ing th e find ings .in a g roup o fch ild ren an d adu lts w ith a w id e sp ec trum o f d iffe ren tco nd itio ns p ro ved d iff icu lt a t firs t. B ecause w e exam in edab norm a l sub jec ts be fo re w e had cla r ified th e va riab lere spon se pa tterns in norm a l peop le , w e h ad no t de fin ed as tan da rd w ay o f p erfo rm ing the te st. W hat becam e clea rw as th at som e peop le w ith pa tho lo g ica l d iso rd ers had aIa/se n eg a tive T ren de lenbu rg te st (T ab le II).Table II . F alse r esp on ses to T rend elenburg tes t

    Cau se s o f f a lse n ega tiv es C ause s of f a lse posi t ivesU se o fsu prapelv ic m usc les Pa inU se o fpsoas and re ctu s fem oris P oo r ba lanc e

    L ack o fco -op era tio n orunderstand ing

    Costo -pe lv ic imp in g emen t

    This fals e nega tive w as pa rticu lar ly ev iden t inp a tien ts w ith neuro lo g ical d iso rd ers , m any of w homcou ld raise th e pe lv is on the no n-s tan ce side . Th ey d idth is , f irs t, by m ov ing the to rso w ell ove r the w e igh t-b earing h ip , the reby redu c in g th e am oun t o f ab duc to rac tiv ity n ecessa ry to m a in ta in th is postu re (F ig . 5 ).S econ d ly . by supporting th e hand on a tab le o r w all onth e non -stance side , they w ere th en ab le , by a com b ina -tion o f m usc le co n trac tion of th e sh ou ld er ad duc to rs ,especia lly la tiss im u s do rsi, and (p ossib ly ) p soas m a jo r onth e n on-stance sid e, w ith q uadratu s lum bo rum on thew e igh t-bea rin g sid e, to ra ise the n on-stance sid e o f th epe lv is abov e th at o f the w eig h t-bearing h ip (F ig . 6 ) . W ea lso fo und tha t p eop le w ith p ain in the h ip ten ded to sh iftthe cen tre o f g rav ity ove r the h ip to d ec rease the pu ll o fthe abd uc to rs . O the r p atien ts w ith a p ain fu l h ip o r sp in e

    w ere ab le to stan d o n th e pa in fu l h ip fo r on ly a ve ry sh ortpe r iod . In the ab sen ce of sig n if ican t pa in , sub jec ts w ithw eak h ip abdu c to r m usc le s cou ld ach ieve ba lance by lif t-ing the pe lv is o n th e n on-stance sid e, us ing fu nc tion in gm u sc les , k ine tic ene rgy and g rav ity .

    E lec trom yograp hy w as p erfo rm ed on th ree pa tien tsw ho cou ld e leva te the non -stance sid e o f the pe lv is bye ithe r lean in g w e ll ov er the h ip jo in t o r us ing m u scleg ro ups ab ove the p e lv is ; m in im a l e lectr ical ac tiv ity w asreco rded in the abdu cto r m usc le g ro ups . Thu s, s im p lyloo k ing a t the fina l pos itio n o f the trans- ilia c line o f thep elv is g ives n o as se ssm en t o fabdu cto r m uscle fun ctio n .

    It w as our exp erience th at ch ild ren u nde r th e ageo f fou r y ea rs co u ld no t be re liab ly asse ssed , h ow ev e rthe te st w as p erfo rm ed . In ch ild ren ove r fou r , theT ren de len burg te st cou ld be asse ssed on ly if the ch ild renco u ld u nde rstand and co-o pe ra te fu lly ; un le ss th is w asp ossib le, a sse ssm en t w as inva lid , an d d iffe ren t re spon sesw ere seen a t sepa rate exam in atio ns at sho rt tim e in te r-v als o n th e sam e day .D elayed posit ive T rende lenburg sign . S ev era l p eop le hadan in itia l n eg a tive te st. bu t a fte r stan d ing fo r a sho rt tim ew ith the non -stance sid e o f the pe lv is ra ised , it g rad ua llyb eg an to fall and they w ere no t ab le to m a in ta in the irin itia l po stu re . Th is has been ca lled a de lay ed po sitiveT rende lenbu rg sig n ; M itch ell (19 73) sug gested tha t thetim e at w h ich the pe lv is began to d rop sho u ldb e reco rd ed . In p eo p le w ith a d elay ed po sitiveT rende lenb urg sig n the g ait can be norm a l, bu t w henth ey a re asked to w a lk q u ick ly , it becom es ap pa ren t tha tth ey fa tigu e easily and a lim p , w ith a ll the cha rac te ris tic so f the so -ca lled T rend e len burg ga it, becom es obv ious .

    Tw o sub jec ts w ith seve re sco lio sis had false -pos itivere spo nses becau se o f im p in gem en t b etw een the low er

  • 7/28/2019 Coxa Vara Pdf3

    4/6

    F ig . 7 F ig . 8 F ig . 9 F ig . 1 0 F ig . I I F ig . 12Th e su gg este d m e tho d ofper form in g the T rend elenbu rg test : F igure 7-T he ex am iner stan ds beh in d the patien t . F ig ure 8-T he p atie n t is a sked torais e o ne leg off the g rou nd w ith the h ip flex ed betw een 0 an d 30 and to b alance h erself. F igu re 9-T he pa tien t is asked to ra ise the no n-s tan ceside as h ig h as possib le . F ig ure lO -Th e ex am ine r m ay su pport the pat ien t by ho ld ing th e a rm on th e o th er side. F ig ure I I-T he exam iner m ay Pzo tsup por t th e n on -sta nce a rm a s th is m ay act a s a fu lcrum for la tis sim us do rsi . qu adratu s lum borum , an d th e p arasp in al m uscle s. F igure 1 2-- If th ereis sign ifican t trun k sh ift to the s tan ce sid e th is is c orrected by g ently al ign ing th e trun k over th e sta nce -sid e h ip an d w atch in g th e rela tio n of the

    pelv is to the ground .

    74 4 P . M . HARDCA STLE , S . M . L . N ADE

    THE JOURNA L O F BON E AND JO IN T SURGERY

    costa l m arg in and the ilia c c re st w hen th ey a ttem pted toe leva te th e pe lv is .

    A STANDARD TRENDELENBURG TESTA s a re su lt o f o u r ob se rv atio ns, w e h av e fo rm u lated astand ard m eth od of pe rfo rm in g the T rend elen burg te st;if th is is used th e respon se can be in te rp reted in a c lin i-ca lly m ean in g fu l w ay . T o pe rfo rm the te st p ro pe rly do estak e tim e , and its accu rate a sse ssm en t dem ands the fu llund e rstand ing and co -o pe ra tion ofth e pa tien t.

    H ow to do th e te st1 . The exam ine r stand s beh in d th e pa tien t and ob se rves

    the ang le be tw een th e pe lv is (th e line jo in ing the ilia ccre sts) and the g ro und (F ig . 7 ).

    2 . T he p a tien t is a sk ed to ra ise from the g ro und the foo to f the side n o t be ing te sted , ho ld ing the h ip jo in t a tbe tw een n eu tra l an d 3 0 of f lex ion . T he k nee sh ou ldbe flexed enough to a llow the fo o t to be c lear o f theg rou nd in o rd e r to nu llify the e ffec t o f th e rec tusfem o ris m uscle . Th e p osition o f th e p elv is is aga inno ted (F ig . 8 ) . A su ppo rtin g s tick can b e used inthe hand on ly on the side o f the w eig h t-bearing h ip ;a lte rna tive ly . bo th sh ou ld e rs can b e su ppo rted by theex am in e r so as to m ain tain b alance w ithou t a s tick(F ig . 1 2 ) .

    3 . O nce b a lan ced , the pa tien t is then ask ed to ra ise th en on-stance side o f the pe lv is a s h igh as p ossib le(F ig . 9 ). T he exam in e r m ay su ppo rt the pa tien t byho ld ing the a rm on the s t ance side (F ig . 1 0 ; com parew ithF ig . II) .

    4. If th e p atien t lean s too fa r o ve r to th e side o f the

    w eig h t-b earing h ip , the ex am ine r co rrects th is b ygen tle p re ssu re o n th e shou lde rs to b ring the ve rteb rap rom inen s ap prox im ate ly o ve r the cen tre o f the h ipjo in t an d the w e igh t-b ea ring foo t (F ig . I 2) .

    Interpreta tion(a) T he respo nse is N ORM AL (i.e . the te st is nega -

    tive) if th e pe lv is on th e no n-stance side can be elev atedas h igh as h ip abdu c tio n on the stance side w ill a llow ,and pro v id in g th is p ostu re can b e m a in ta ined fo r 30second s w ith the ve rteb ra p rom in ens cen tred ov er the h ipand foo t.

    (b ) T he re spo nse is A BNORMAL (i.e . the tes t ispo sitive ) if th is cann o t be do ne . Th is in clu desre spo nses w h ere th e p elv is is e lev ated on th e no n-s tan ceside ab ove th e stance side , bu t w he re th is e leva tion is no tmaximal .

    (c ) T he resp on se is a lso A BNORM AL if the pe lv iscan be lifted on comm and , b u t can n o t be m a in ta ined intha t po sition fo r 3 0 seco nds . T he tim e taken be fo re th epe lv is sta r ts to fa ll is reco rded . B y in tro duc ing a tim e e le -m en t, the T rend elenb urg tes t can b e ob jec tive ly reco rdedfo r com parison purposes . O bv io usly the re spo nsedesc rib ed in (b ) con stitu te s a zero tim e T rende lenbu rgtest .N on-va lid re sp onses . In the p re sence o f back or leg pa ino r o f de fo rm ity . o r if the pa tien t is uncoope ra tivebecause o fage or m en ta l s tatu s, inapp ro pria te re spo nsesm ay a rise (T ab le II) . A n ab norm a l re sp onse (p ositivete st) in these c ircum stances can be m islead ing . H ow ev er ,if the te st is n eg ativ e tha t is s ign if ican t-it m ean s tha t thesub jec t does no t have abnorm a l h ip m echan ics.

  • 7/28/2019 Coxa Vara Pdf3

    5/6

    F ig . 1 4 F ig . 15A n teropo ste rio r ra d io graph ofa 1 0-y ear-o ld bo y w ith cox a m agn a an dhip jo in t incong ru i ty as a sequ el of P erth es d isea se . H e had a d elay ed

    p osi tive te st a t 20 second s.

    TH E SIG N IFICANCE O F THE TREND ELENBURG TEST 74 5

    VOL . 6 7-B . N o . 5, NOVEMBER 1985

    Sign if icanceN euro lo g ica l d isord ers. M RC G rade 5 abdu cto r m u sc lestren g th w as requ ired to p rod uce a norm a l respon se. A llsu b jec ts w hose h ip abd uc to r p ow er w as G rad e 4 o r le sshad abnorm al respon ses at tim es be tw een 0 an d 25seco nds . S om e pa tien ts in th is g rou p w ere ab le to eleva tethe pe lv is , bu t no t to th e fu ll ex ten t. W e con side red th isto be a p ositive T rende lenb urg te st a t 0 second s.O n e sub jec t w ho had G rade 5 s treng th o n c lin ica ltestin g h ad a de layed (o r tim ed) p ositive T ren de len burgtest at 1 5 seco nd s. O n ly o ne su b ject w ith G rade 3 h ipabdu cto rs had an in itia l nega tive re sp onse w h ich becam epos itive a t 5 secon ds (a de lay ed pos itive te st). H e had agood rec tus fem oris m usc le w hich p ro bab ly h e lped . T hetw o sub jec ts w ith iso la ted ne rve roo t en trapm en t o f L5or S I had nega tiv e re sp onses.M echan ica l d isord ers. C ong en ita l d is loca tio n o f the h ip .The T rend elenb urg te st w as a lw ays po sitive in sub jec tswith cong en ital d is locatio n of the h ip (F ig . 13 ). O nep atien t w ho had b een trea ted by b ila tera l rep lacem en t

    F ig . 1 3A 48-y ea r-o ld w om an w ith co ngenita l d is -loca tio n of th e h ip show ing a po sitiveT rende len bu rg respo nse desp ite sup po rt-

    in g h er bo dy w eig h t w ith he r h and s.

    a rth rop las ty had a norm a l re spQ nse w hen exam inedth ree yea rs af te r su rge ry .Su b luxa tin g h ip s . M itche ll (197 3) has d escr ibed theim por tan ce o f thed elayed (tim ed) T rende lenb urg te st ina sse ssing c lin ica l de te rio ra tion in ado le scen ts w ith ace t-abu la r dy sp la sia . O ur tw o pa tien ts w ith sub luxa ting h ip sbo th had po sitive (tim ed ) T rend e len burg te sts , o ne at ISand one a t 20 second s (F ig . 14 ).(oxa vara . The te st m ay b e pos itiv e o r nega tive depend-ing on th e fem ora l n eck ang le and the p re sence o fdegen era tiv e ch an ges. W ith fem ora l neck an g le s o f up to100 the re sp onse can be no rm a l. O ne ch ild w ith an ang leo f 9 0 afte r a v arus osteo tom y had a p ositive te st a t 20seconds.S lipped jem ora l ca p ita l ep ip hrsis . The T ren de len burg te stw as no t a ltered by th e ro tatio n of th e fem o ra l h ead inrela tio n to the fem oral neck an d th e sub jec ts exam in eda ll h ad n eg a tiv e re spon ses if they w ere pa in free .Perth es d isease. The T rende lenb urg te st w as n o t a lte redb y the size o f the fem o ra l h ead . H ow eve r, if th ere isincongru i ty or h ing e abduc tion th e te st can becom e posi-tiv e, and a d e lay ed po sitive re sp onse w as seen in one sub-ject(F ig . 15) .A rthr itis o fth e h ip . V ariab le re spo nses w ere o bse rv ed bu tth e type o f re sp onse d id no t va ry in the sam e in d iv id ua lwhen s tu d ied a t d iffe ren t tim es. O bv io usly pa in o r p ro -g ress ion of the d isea se w ou ld b e exp ec ted to a lter there spo nse , pa r ticu la rly in re spec t to red uc tion of tim e ofth e norm a l re spo nse .L eg leng th in eq ua lity q fte r h ip a rth ro p la s tv . Two pa tien tsw ith u p to 2 cm ofsho rten in g abov e the in ter tro chan te riclin e a fte r h ip rep lacem en t h ad nega tive T rend elenb urgtests (i .e . no rm a l respon se s).A i u ls io n o f th e g rea te r trocha n te r q fte r h ip ar th rop la str .In th e ab sence of pa in , the T ren de len burg te st w as p ar-ticu la r ly va luab le som e tim e a fter op era tion . W here theosteo tom y gap w as grea te r than 2 cm th e T rend elenb urgte st w as pos itive e ithe r imm ed iate ly (ze ro tim e) o r w ith ade lay ed po sitive re spon se .Fra ctu red neck o f/em ur. Pa tien ts w ho had uns tab le fixa -tion w ith E nde r o r Z icke l na ils had a p ositive re sp onse

    An tero po ster io r ra d io graph of a n ine-yea r-o ld b oy w ith a sub lux atingh ip . H is in it ia l T ren de len burg respon se w as neg ative bu t w ith in 15

    seco nd s he had a de lay ed po sitive tes t.

  • 7/28/2019 Coxa Vara Pdf3

    6/6

    74 6 P . H . H ARDCA STLE , S . M . L . NADE

    THE JOURNAL O F BONE AND JO INT SURG ERY

    un til the frac tu re w as un ited rad io lo g ically . T hese peop lew ere te sted in itia lly 8 to 1 0 w eeks after o pe ra tion an dh ad no p ain a t the tim e o f the ir in itia l T ren de lenbu rgrespon se , w h ich w as p ositive . Tw o n ialu n ited frac tu re sa lso had positive re sp onses.A va scu lar necro sis o f the jem o ra l head . H ip p ain m ad eproper assessm en t o f the se case s d iff icu lt. H ow eve r, on eo fo ur fo u r pa tien ts h ad on ly m ild sym p tom s; h is test w aspo sitive a t 20 seco nds on th e firs t exam in atio n , and a t 25second s on th e nex t day . In th e o the r pa tien ts p ain p re -v en ted adequ ate asses sm en t.S pin al d is or der s. St i f f l iess . T ota lly stiff sp in es, a s in ank y-lo sin g s po nd ylitis , d id no t affec t the te st u n le ss th ere w asa lso abn orm a lity o f the h ip o r g ross sp in al de fo rm ity .

    F ig . 1 6Th is 43 -ye ar-o ld lady s h ipab du ctors h ad no rm alstren g th . H ow ever , she w a sun able to rais e h er pelv is o nthe lef t ab ov e th e h oriz on talbec au se of im pin gem en t be-tw een th e ilia c cres t and cos -ta l m arg in a s the resu lt o f

    s ev er e s co li os is .

    Deformi t i . Kypho sis d id no t a ffect the ou tcom e . S eve resco lios is , how ever, m ay le ad to im pin gem en t be tw een thelow er co stal m arg in an d th e iliac cre st and g ive a fa lse-pos itive test (F ig . 1 6 ) .Pain . Nerve roo t irri ta tion c an le ad to fa lse-po sitiveresults, bu t back pa in itse lf d id no t lead to abno rm alresponses .

    DISCUSS IONW hen asked to stand o n one leg , an d fo llow a stand ardro u tin e to en sure h ip abd uc to r m u sc le con tractio n o n th es ame sid e , pa tien ts m ay respond to the stand ard isedT ren de len burg te st in on e o f th ree w ays. O n ly oneresponse is norm al; the o the r tw o are abn orm al. A nab ility to assum e th e norm a l re spo nse m u st be abso lu te ,an d if the pe lv is d ro ps on the n on-stance s ide w ith in 30seconds th e T ren de len burg te st is p ositiv e. T he u se o f atim er is an essen tial p ar t o f th e T rend elenb urg te st, an d ,in deed , m akes it an ob jectiv e m easu re o f seve rity o fa lte red h ip m ech an ic s.

    H ow ev er , th e p re sence o f pa in , poor ba la nce an deither lack o f co -op era tion or und erstand in g b y th ep atien t can lead to fa lse-po sitive te sts , becau se the tes tcanno t be prop erly pe rfo rm ed . T he reason fo r fa lse-nega tive tests is tha t the su b ject use s m u scle s abov e th e

    p elv is to e leva te th e non -w e igh t-bea rin g sid e o f the pe l-v is , o r sh if ts the to rso w e ll ov e r the w e igh t-b ea ring s ide ;th ese can be ca lled tr ick m ovem en ts . V ariab lerespon ses w ere no ted in som e pa tien ts le ss than seveny ears o f ag e , an d the te st is o f n o va lue in ch ild ren u nde rfou r . N eve rth ele ss , if th e T rende lenb urg te st is care fu llyp erfo rm ed , it is an accu rate clin ica l s ign w ith p ro gno sticimp licat ions.Inm an (1947) m easu red th e to rqu e streng th ab ou tth e h ip w ith the pe lv is in d ifferen t p ostu re s w ith respectto the g round . O u r e lec trom yograph ic resu lts con firm h isf ind in gs tha t little abd uc to r m usc le streng th /activ ity isneces sary to m a in ta in a ba lanced p ostu re w ith th e pe lv isd rop ped (a s in R esp onse 3 ) on th e non -w e igh t-bea rin gside . A s the p e lv is r ise s on th is side the re is in crease o fabdu cto r m uscle activ ity p ro v ided th at the to rso iscen tred ove r th e h ip .

    F u nc tiona l a sse ssm en t o f a jo in t is im portan t in thec lin ica l a sse ssm en t o f p atien ts . O b se rva tion o f ga it isp robab ly p e rfo rm ed le ss o ften th an is desirab le b ecauseo f lim ita tion of sp ace . Th e T rend e len burg te st a llow s fo rfu nc tiona l a sse ssm en t in a con fined space, and is a m oreva luab le c lin ica l s ign than m any sta tic tes ts . I t c an a lsobe easily reco rded on film or v ideo tape .

    It is our be lie f th at a pa tien t w ho has an a b n o rma lre spo nse to the T rend elenb urg te st a s d escr ibed in th ispape r has an ine ffic ien t ga it, and the re fo re b ecom eseasily fa tigued . W ith a little p rac tice , the te st is no t d iff i-cu lt to pe rfo rm and in te rp re t. T im ing is an essen tial p ar to f th e test; it p rov ides an ob jec tiv e m easu re o f im pro ve -m en t o r de te rio ra tion in the neurom uscu la r o r m echan-ica l func tion of the h ip .

    T ren de len bu rg s o rig ina l observa tion s w ere p recis ean d c lea r , and h is in te rp re ta tions accu ra te. W e Suppo rtth e need fo r m eticu lo us c lin ica l exam in atio n in o rde r top rov id e co rrect d iagn osis and w e recomm end the u se o fth e standa rd ised tim ed T ren de lenbu rg te st in th e asse ss-m en t o ffu nc tion and m alfun ctio n o fth e h ip .

    Conc lu s io n sI . The T rende lenbu rg te st is a use fu l pa rt o f c lin ica l

    exam in a tion if p erfo rm ed and in te rp re ted co rrec tly .W e hav e d escr ib ed a standa rd m ethod for p erform ingthe te st.

    2 . F als e-po sitive and fa lse -nega tiv e re sp onses m ayoccur , bu t th eir in terp reta tion can be c la rif ied if thetes t is p ro perly perfo rm ed .

    3 . T he use o f a tim er w hen p e rfo rm ing the te st is e ssen -tial, and a llow s m easu rem en t o f a de layed abnor-m al respon se.

    REFERENCESInm an V I. F un ctiona l asp ects of the abductor m usc les o f the hip . J

    B on ef oi nt S ur g[ Br ] l947;29:607-19.Mitchel l GP . Th e de lay ed T rend elen bu rg h ip test . m t Congr S er 1973 ;

    291 : 111 3 .R ang M . Antho /ogy o f o rth op aed ics . Ed inb urg h : E& S L iv in gstone ,

    1 96 6; 1 39 -4 3.