July/August 2016
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the newborn supine on the examining table. In the classic descrip-
tion, the pelvis is stabilized by placing the thumb and ring/long
finger of one hand on top of both anterior iliac crests simultane-
ously while performing the maneuver with the opposite hand. In
common practice and recommended by the authors, the pelvis is
stabilized by holding the opposite thigh in the same manner as the
examined side. First, the index and middle fingers of the examiner
are placed along the greater trochanters of each leg while the
thumb is placed on the medial aspect of the leg. Care should be
taken to examine one side at a time while stabilizing the pelvis by
holding the opposite side in neutral abduction. While holding the
opposite hip flexed to 90 degrees, the hip gently abducted while
applying an upward force on the right greater trochanter.
A palpable “clunk” is felt as the dislocated femoral head reduces
into the acetabulum. This finding is reported as Ortolani positive.
Ortolani negative means this clunk is not felt, and, thus, the hip is
dislocated and irreducible (i.e., a fixed dislocation). In common
parlance, Ortolani negative is also often used to describe a stable
hip by many providers. To prevent this confusion, there should be
clear communication between providers. The designation of a hip as
stable, Barlow positive, Ortolani positive or fixed and dislocated are
the clearest terms to communicate one’s findings, and are also prog-
nostic of the success of Pavlik harness treatment in decreasing order.
To differentiate between a “clunk” of the Ortolani and Barlow tests
and a tendon “click” takes time and experience. With progressive
soft-tissue contractures and the increasing size of the patient after
age 3 months, both the Ortolani and Barlow tests become unre-
liable, leaving limited flexed hip abduction and the Galeazzi sign
as the best indicators of DDH. Even in larger and older infants, a
gentle force should be sufficient to elicit a clunk if an unstable hip
is present; firm pressure is never necessary.
In children of walking age, true “late-presenting” hip dislocation is
pain free. These children will start to walk at a normal age. Often,
only a minor limp or gait difference is noted by the family. Physical
examination findings for hip dislocation in the walking child include
persistent loss of flexed hip abduction, Galeazzi sign, apparent
leg length discrepancy, and a Trendelenburg gait. Other physical
examination findings, such as torticollis and metatarsus adductus,
can be associated with DDH. The initial evaluation of an infant
with an isolated finding of torticollis or metatarsus adductus should
include a careful, focused evaluation of the hips. If the hip exami-
nation is stable and no risk factors for DDH are noted, no further
evaluation is necessary beyond standard repeat hip examinations
at well-child checkups through 12 months of age.
Imaging
Imaging of the immature hip is a valuable adjunct to the physical
examination. An anteroposterior (AP) X-ray of the pelvis is difficult
to interpret before age 4 to 5 months because the femoral head is
composed entirely of cartilage until the secondary center of ossi-
fication appears. Before the appearance of the secondary center,
ultrasound examination is the method of choice for visualizing the
cartilaginous femoral head and acetabulum. Static ultrasound
images allow visualization of acetabular and femoral head anatomy,
feature
(A) The Ortolani sign. With the hip flexed to 90 degrees and the leg gently abducted.
If the hip is dislocated initially, the reduction of the hip with abduction will produce a
palpable clunk. (B) The Barlow sign. The hips are flexed to 90 degrees and adducted.
Then, a gentle downward force is placed on the leg. A clunk can be appreciated if the
hip is unstable and dislocates posteriorly. (From Guille et al.©2000 American Academy
of Orthopaedic Surgeons. Reprinted from the
Journal of the American Academy of
Orthopaedic Surgeons
, Volume 8(4), pp. 232–242.)
The Galeazzi sign. With the baby’s hips in
neutral abduction, the examiner determines if
the knees are at the same height. If one femur
appears shorter, the hip may be dislocated
posteriorly. (Image from http://englishclass.jp/
topics/Galeazzi_test)
