All neonates should be examined for the presence or absence of a congenital disorder using the Ortolani test. If the Ortolani test is negative, the Barlow test can be performed.
NB: An extra gluteal fold on the affected side (sign of hip displacement), is usually not yet clearly visible in the case of a neonate. Additionally, this gluteal fold has little diagnostic value as the predictive value at this age is low.
The Ortolani test: repositioning a dislocated hip
Procedure
- Place the child on their back, or on the parent’s lap (if necessary), and slowly stretch and adduct the legs [Figure 143].
- Next, flex the knees completely and the hips by about 90°, while holding the child’s knees together.
- Examine the right hip first by holding the right upper leg with your left hand, keeping the thumb against the inside of the upper leg and the index and middle finger against the outside.
- Stabilise the left upper leg and the pelvis with your right hand.
- Then, with the left hand, perform abduction of the right leg while retaining flexion in the hips and knees. In the case of a dislocatable hip, the examiner will feel a ‘clunk’ because the dislocated femoral head now shoots into place across the posterior rim of the acetabulum (repositioning).
- Subsequently, test the other hip in the same way.
- This test should preferably be performed between 1 and 2 weeks postpartum: not during the first week postpartum, as for 1 in 60 children the hips are dislocatable during the first week due to weakness of the soft tissues, and this leads to unnecessary referrals. Moreover, this test should only be performed once so that no iatrogenic damage is caused.
Figure 143: The Ortolani test
A The hip joint is dislocated; the hips are then flexed by 90 degrees and the knees are flexed completely.
B, C By abducting the right hip (in this case), the dislocated femoral head is pushed back over the posterior rim of the acetabulum (repositioning).
The Barlow test: dislocation provocation test
Procedure
- Steps 1 to 4 are the same as for the Ortolani test.
- Next, using the left hand, the examiner brings the right leg in abduction, while retaining flexion in the hips and knees. In this position, push dorsally with the thumb on the inside of the upper leg. In the case of weakness of the soft tissues, the femur head can be pushed over the posterior rim of the acetabulum, during which a ‘click’ will be felt if the hip is dislocated [Figure 144].
- Then, push on the outside of the greater trochanter with the middle finger. If you feel a ‘click’ again, this means that the head of the femur has been repositioned over the posterior rim of the acetabulum.
- In some cases, an adduction contracture may already be present as a result of which a dislocated hip can no longer be corrected (the Ortolani test is negative even though the hip is dislocated).
Figure 144: The Barlow test
A dislocation of the head of the femur
B repositioning the head of the femur