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== Description ==
== Description ==
[[File:Hip dysplasia schematic.jpg|right|frameless]]
The instability of the hip may be assessed by the Ortolani and Barlow tests, which play a big role in the clinical screening for [[Developmental dysplasia of the hip (DDH)|developmental dysplasia of the hip]] <ref>Lotito FM, Rabbaglietti G, Notarantonio M. The ultrasonographic image of the infant hip affected by developmental dysplasia with a positive Ortolani's sign. Pediatric radiology. 2002 Jun;32(6):418-22. </ref>. Each hip should be examined separately <ref>Developmental Dysplasia of the Hip Available from: <nowiki>https://www.svphm.org.au/for-health-professionals/for-gps/specialist-articles/developmental-dysplasia-of-the-hip</nowiki> (Accessed, 5/4/2021)</ref>. 
[[File:Hip joint (anterolateral view) - Kenhub.png|alt=Hip joint (highlighted in green) - anterolateral view|right|frameless|500x500px|Hip joint (highlighted in green) - anterolateral view]]
An infant with a positive examination result, defined as either a positive Ortolani or Barlow sign, should be referred to an orthopedist <ref name=":1">Witt C. Detecting developmental dysplasia of the hip. Advances in neonatal care: official journal of the National Association of Neonatal Nurses. 2003 Apr 1; 3(2):65-75. </ref>.


The instability of the hip may be assessed by the Ortolani and Barlow tests, which play a big role in the clinical screening for [[Developmental dysplasia of the hip (DDH)|developmental dysplasia of the hip]] <ref>Lotito FM, Rabbaglietti G, Notarantonio M. The ultrasonographic image of the infant hip affected by developmental dysplasia with a positive Ortolani's sign. Pediatric radiology. 2002 Jun;32(6):418-22. </ref>. The '''Barlow Test''' is a physical examination performed on infants to screen for developmental dysplasia of the hip. Barlow’s test identifies posterior sublimations or dislocation. It is named after Dr. Thomas Geoffrey Barlow, who devised this test. It was clinically tested during 1957–1962 at Hope Hospital, Salford, Lancashire <ref>Barlow maneuver. Available from: <nowiki>https://en.wikipedia.org/wiki/Barlow_maneuver#cite_note-1</nowiki> ( Accessed, 25/03/2021)</ref>.  
* It has been recommended that the Barlow test should be done by gently adducting the hip while palpating for the head falling out the back of the acetabulum and that no posterior-directed force be applied. 
* The Barlow and Ortolani tests can be considered as a continuous smooth gentle maneuver. The examiner should not attempt to forcefully dislocate the femoral head <ref name=":2">Shaw BA, Segal LS. Evaluation and referral for developmental dysplasia of the hip in infants. Pediatrics. 2016 Dec 1; 138(6). </ref>.   


The '''Ortolani Test''' was first described in 1936 by an Italian pediatrician Marino Ortolani; an outstanding pioneer in the early diagnosis and treatment of hip dysplasia. He describes it as a simple test that would establish a diagnosis of congenital dislocation of the hip in children one- year- old <ref>Marino Ortolani. Available from: <nowiki>https://en.wikipedia.org/wiki/Marino_Ortolani</nowiki> (Accessed, 4/4/2021).</ref>.                                                                                                                                                                                                                                            
image 1:  Schematic depiction of hip joint structures' positions in hip dysplasia A - Normal, B - Dysplasia, C - Subluxation, D - Luxation


[[File:Hip_dysplasia_schematic.jpg|341x341px|thumb]]                                                                                                                                                                                                                        
Image 2: Hip joint (highlighted in green) - anterolateral view<ref >Hip joint (highlighted in green) - anterolateral view image  © Kenhub https://www.kenhub.com/en/library/anatomy/hip-joint</ref>


== Technique ==
== '''Barlow Test''' ==
# '''Barlow Test'''
Barlow’s test identifies posterior sublimations or dislocation. It is named after Dr. Thomas Geoffrey Barlow, who devised this test<ref>Barlow maneuver. Available from: <nowiki>https://en.wikipedia.org/wiki/Barlow_maneuver#cite_note-1</nowiki> ( Accessed, 25/03/2021)</ref>.
The Barlow test is a provocative maneuver used to reveal hip instability. The test is performed by standing at the end of the examination couch facing the baby. One hand stabilizes the pelvis whilst the other grasps the knee and flexes the hip to 90 °.  The examiner’s fingers should lie over the greater trochanter with the thumb resting on the inner side of the thigh. A posterior force is applied through the femur as the thigh is gently adducted by 10-20 ° <ref>Kumari P, Rani M. Developmental dysplasia of the hip. Ortho & Rheum Open Access. 2018;10:555794. </ref>. Mild pressure is then placed on the knee while directing the force posteriorly.     [[File:Dysplasia hip VS Normal hip.jpg|thumb|321x321px]]
The Barlow Test is considered positive if the hip can be popped out of the socket with this maneuver. The dislocation will be palpable <ref>Barlow & Ortolani Signs—DDH, Congenital Hip Dislocation. Available from: <nowiki>http://nabilebraheim.blogspot.com/2017/11/barlow-ortolani-signsddh-congenital-hip.html</nowiki> (Accessed, 5/4/2021).</ref>.     


2. '''Ortolani Test'''  
The Barlow test is a provocative maneuver used to reveal hip instability. The test is performed by:


In this test, the baby is placed in a supine position with flexed hips at 90 degrees. The examiner's index and long fingers of the examiner are kept laterally on the greater trochanter of the child and position the thumb medially near the groin crease. Stabilize the child’s pelvis is stabilized by holding the contralateral hip and using the opposite hand gently abducts the hip being tested by exerting an upward force simultaneously through the greater trochanter on the lateral side. The perception of a palpable clunk indicates a positive Ortolani test and along with this also represents the reduction of a dislocated hip into the acetabulum <ref>Kumari P, Rani M. Developmental dysplasia of the hip. Ortho & Rheum Open Access. 2018;10:555794. </ref>.                                                                                            
* Standing at the end of the examination couch facing the baby.  
* One hand stabilizes the [[pelvis]] whilst the other grasps the [[knee]] and flexes the hip to 90 °. 
* The examiner’s fingers should lie over the greater trochanter with the thumb resting on the inner side of the thigh.  
* A posterior force is applied through the femur as the thigh is gently adducted by 10-20 ° <ref>Kumari P, Rani M. Developmental dysplasia of the hip. Ortho & Rheum Open Access. 2018;10:555794. </ref>.  
* Mild pressure is then placed on the knee while directing the force posteriorly.     
* The Barlow Test is considered positive if the hip can be popped out of the socket with this maneuver. The dislocation will be palpable <ref>Barlow & Ortolani Signs—DDH, Congenital Hip Dislocation. Available from: <nowiki>http://nabilebraheim.blogspot.com/2017/11/barlow-ortolani-signsddh-congenital-hip.html</nowiki> (Accessed, 5/4/2021).</ref>.     


== Evidence ==
The sensitivity of the Barlow maneuver with experienced hands (ranging from 87 to 97 percent) and specificity varies from 98 to 99 %.
Findings according to the Ortolani and Barlow tests have been shown to vary between different examiners. Sulaiman, Yusof, Munajat, Lee, and Zak reported that Zaki that properly trained personnel perform these tests more reliably whereas other studies reported an improved Ortolani and Barlow sensitivity that Ortolani and Barlow sensitivity according to the experience of the examiner <ref name=":0">Sulaiman AR, Yusof Z, Munajat I, Lee NA, Zaki N. Developmental dysplasia of hip screening using Ortolani and Barlow testing on breech delivered neonates. Malaysian orthopaedic journal. 2011 Nov; 5(3):13.</ref>.  


In their study; Jiménez, Delgado-Rodríguez, López-Moratalla, Sillero and Gálvez-Vargas reported sensitivity and specificity of 26% and 84% for the Ortolani-Barlow maneuver respectively. A higher sensitivity was observed when all clinical maneuvers/signs were considered; however, specificity decreased, so the positive predictive value reached a similar figure to that of Ortolani-Barlow, 5% <ref>Jiménez C, Delgado-Rodríguez M, López-Moratalla M, Sillero M, Gálvez-Vargas R. Validity and diagnostic bias in the clinical screening for congenital dysplasia of the hip. Acta orthopaedica belgica. 1994 Jan 1; 60:315 </ref>.   
== '''Ortolani Test''' ==
The '''Ortolani Test''' was first described in 1936 by an Italian pediatrician Marino Ortolani <ref>Marino Ortolani. Available from: <nowiki>https://en.wikipedia.org/wiki/Marino_Ortolani</nowiki> (Accessed, 4/4/2021).</ref>.   


Witt (2003) explained that a negative Barlow maneuver has a high negative predictive value (0.99), but a low positive predictive value (0.22). This means that a negative result effectively rules out hip dislocation or subluxation. Nevertheless, a high number of infants will require rescreening because of false positives with this technique. When both the Barlow and Ortolani maneuvers are combined, the specificity of the test increases from 0.98 to 0.99 <ref name=":1">Witt C. Detecting developmental dysplasia of the hip. Advances in neonatal care: official journal of the National Association of Neonatal Nurses. 2003 Apr 1; 3(2):65-75. </ref>. 
The test is performed bu                                                                                           


The significance and safety of the Barlow test are still questioned even though widely used in the literature and in practice, Barlow stated in his original description that the test is for the laxity of the hip joint rather than for an existing dislocation. The Barlow test has no proven predictive value for future hip dislocation <ref name=":2">Shaw BA, Segal LS. Evaluation and referral for developmental dysplasia of the hip in infants. Pediatrics. 2016 Dec 1; 138(6). </ref>.
Placing the baby in a supine position with flexed hips at 90 degrees.                                                                                            


== Clinical notes and recommendations ==
* The examiner's index and long fingers of the examiner are kept laterally on the greater trochanter of the child and position the thumb medially near the groin crease.                                                                                            
* The Barlow and Ortolani tests are used to assess for hip instability. Each hip should be examined separately <ref>Developmental Dysplasia of the Hip Available from: <nowiki>https://www.svphm.org.au/for-health-professionals/for-gps/specialist-articles/developmental-dysplasia-of-the-hip</nowiki> (Accessed, 5/4/2021)</ref>.  For proper Ortolani and Barlow technique, there should also be a proper positioning of the infant to be tested and a proper maneuver must be used. The examiner must have the ability to differentiate ‘click’ or ‘clunk’ <ref name=":0" />.  
* Stabilize the child’s pelvis by holding the contralateral hip and using the opposite hand to gently abduct the hip being tested whilst exerting an upward force simultaneously through the greater trochanter on the lateral side.                                                                                            
* An infant with a positive examination result, defined as either a positive Ortolani or Barlow sign, should be referred to an orthopedist <ref name=":1" />.
* The perception of a palpable clunk indicates a positive Ortolani test and along with this also represents the reduction of a dislocated hip into the acetabulum <ref>Kumari P, Rani M. Developmental dysplasia of the hip. Ortho & Rheum Open Access. 2018;10:555794. </ref>.                                                                                            
* Professionals should be aware that hip dysplasia manifests differently according to age. Therefore, the Ortolani's sign researched in the first 48 hours of life will be more sensitive but will disappear around two months, to be replaced by limitation of hip abduction (Hart's sign), gluteal fold asymmetry (Peter-Bade’s sign), and shortening (Galeazzi’s sign) <ref>Cruz MA, Volpon JB. Orthopedic and ultrasound assessment of hip stability of newborns referred by pediatricians with suspected Developmental Dysplasia. Revista do Colegio Brasileiro de Cirurgioes. 2020 Jan 31;46(6):e20192284. </ref>.
* The Ortolani and the Barlow tests are no longer positive from week eight to twelve <ref>Bordbar A, Mohagheghi P, Yoonesi L, Kalani M, Kashaki M, Ghassemian A, Farhadi S. Value of physical examination in the diagnosis of developmental hip dislocation in preterm infants. Journal of Comprehensive Pediatrics. 2018; 9(2). </ref>.  
* It has been recommended that the Barlow test should be done by gently adducting the hip while palpating for the head falling out the back of the acetabulum and that no posterior-directed force be applied. The Barlow and Ortolani tests can be considered as a continuous smooth gentle maneuver. The examiner should not attempt to forcefully dislocate the femoral head <ref name=":2" />. 


== Watch ==
The 5 minute videos show these tests.                                                                                            {{#ev:youtube|mv_kLqZSGdo|250}}<ref>Dr. Anisuddin Bhatti. Ortolani's Click & Barlow's Maneuver. Available from: http://www.youtube.com/watch?v=mv_kLqZSGdo [last accessed 04/05/13]</ref>
{{#ev:youtube|v=imhI6PLtGLc|300}}<ref>nabil ebraheim. Barlow & Ortolani test, Congenital Hip Dislocation- Everything You Need To Know - Dr. Nabil Ebraheim. Available from: http://www.youtube.com/watch?v=jZ-U-2v9X6U[last accessed 4/4/2021]</ref>
== In Infants, the Degree of Instability Can Be Described As: ==


{{#ev:youtube|v=imhI6PLtGLc|300}}<ref>nabil ebraheim. Barlow & Ortolani test, Congenital Hip Dislocation- Everything You Need To Know - Dr. Nabil Ebraheim. Available from: http://www.youtube.com/watch?v=jZ-U-2v9X6U[last accessed 4/4/2021]</ref>
# Dislocated and reducible (+ Ortolani)
# Dislocated and irreducible (- Ortolani)
# Dislocatable (+ Barlow)
# Subluxed (a hip with mild instability or laxity with a – Barlow maneuver)
 
== Hip Dysplasia Presentations in the Infant 2 Months or Older ==
After 2-3 months of age, the Ortolani test and Barlow maneuvers are less sensitive but several other physical exam findings become more apparent:


* Unilateral dysplasia presenting as asymmetric shortening on the side of the dislocation (Galeazzi sign)
* The leg on the affected side may turn outward
* Tight hip adductors/decreased hip abduction
* Asymmetric thigh or gluteal folds
* The space between the legs may look wider than normal<ref>Nationwise Childrens [https://www.nationwidechildrens.org/conditions/hip-dysplasia Presentation of DHD] Available:https://www.nationwidechildrens.org/conditions/hip-dysplasia (accessed 13.10.2021)</ref>


== Resources ==
This 7 minute video is a good summary of the hip joint.<ref>Hip joint video -  © Kenhub https://www.kenhub.com/en/library/anatomy/hip-joint</ref>{{#ev:youtube|RhDOCdZf1Fk}}


== References ==
== References ==

Latest revision as of 13:07, 14 March 2023

Original Editor - Kirenga Bamurange Liliane Top Contributors - Kirenga Bamurange Liliane, Lucinda hampton, Joao Costa and Kim Jackson

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work!



Description[edit | edit source]

Hip dysplasia schematic.jpg

The instability of the hip may be assessed by the Ortolani and Barlow tests, which play a big role in the clinical screening for developmental dysplasia of the hip [1]. Each hip should be examined separately [2].

Hip joint (highlighted in green) - anterolateral view

An infant with a positive examination result, defined as either a positive Ortolani or Barlow sign, should be referred to an orthopedist [3].

  • It has been recommended that the Barlow test should be done by gently adducting the hip while palpating for the head falling out the back of the acetabulum and that no posterior-directed force be applied.
  • The Barlow and Ortolani tests can be considered as a continuous smooth gentle maneuver. The examiner should not attempt to forcefully dislocate the femoral head [4]. 

image 1: Schematic depiction of hip joint structures' positions in hip dysplasia A - Normal, B - Dysplasia, C - Subluxation, D - Luxation

Image 2: Hip joint (highlighted in green) - anterolateral view[5]

Barlow Test[edit | edit source]

Barlow’s test identifies posterior sublimations or dislocation. It is named after Dr. Thomas Geoffrey Barlow, who devised this test[6].

The Barlow test is a provocative maneuver used to reveal hip instability. The test is performed by:

  • Standing at the end of the examination couch facing the baby.
  • One hand stabilizes the pelvis whilst the other grasps the knee and flexes the hip to 90 °.
  • The examiner’s fingers should lie over the greater trochanter with the thumb resting on the inner side of the thigh.
  • A posterior force is applied through the femur as the thigh is gently adducted by 10-20 ° [7].
  • Mild pressure is then placed on the knee while directing the force posteriorly.     
  • The Barlow Test is considered positive if the hip can be popped out of the socket with this maneuver. The dislocation will be palpable [8].     

The sensitivity of the Barlow maneuver with experienced hands (ranging from 87 to 97 percent) and specificity varies from 98 to 99 %.

Ortolani Test[edit | edit source]

The Ortolani Test was first described in 1936 by an Italian pediatrician Marino Ortolani [9].

The test is performed bu

Placing the baby in a supine position with flexed hips at 90 degrees.

  • The examiner's index and long fingers of the examiner are kept laterally on the greater trochanter of the child and position the thumb medially near the groin crease.
  • Stabilize the child’s pelvis by holding the contralateral hip and using the opposite hand to gently abduct the hip being tested whilst exerting an upward force simultaneously through the greater trochanter on the lateral side.
  • The perception of a palpable clunk indicates a positive Ortolani test and along with this also represents the reduction of a dislocated hip into the acetabulum [10].

Watch[edit | edit source]

The 5 minute videos show these tests.

[11]

[12]

In Infants, the Degree of Instability Can Be Described As:[edit | edit source]

  1. Dislocated and reducible (+ Ortolani)
  2. Dislocated and irreducible (- Ortolani)
  3. Dislocatable (+ Barlow)
  4. Subluxed (a hip with mild instability or laxity with a – Barlow maneuver)

Hip Dysplasia Presentations in the Infant 2 Months or Older[edit | edit source]

After 2-3 months of age, the Ortolani test and Barlow maneuvers are less sensitive but several other physical exam findings become more apparent:

  • Unilateral dysplasia presenting as asymmetric shortening on the side of the dislocation (Galeazzi sign)
  • The leg on the affected side may turn outward
  • Tight hip adductors/decreased hip abduction
  • Asymmetric thigh or gluteal folds
  • The space between the legs may look wider than normal[13]

Resources[edit | edit source]

This 7 minute video is a good summary of the hip joint.[14]

References[edit | edit source]

  1. ↑ Lotito FM, Rabbaglietti G, Notarantonio M. The ultrasonographic image of the infant hip affected by developmental dysplasia with a positive Ortolani's sign. Pediatric radiology. 2002 Jun;32(6):418-22. 
  2. ↑ Developmental Dysplasia of the Hip Available from: https://www.svphm.org.au/for-health-professionals/for-gps/specialist-articles/developmental-dysplasia-of-the-hip (Accessed, 5/4/2021)
  3. ↑ Witt C. Detecting developmental dysplasia of the hip. Advances in neonatal care: official journal of the National Association of Neonatal Nurses. 2003 Apr 1; 3(2):65-75. 
  4. ↑ Shaw BA, Segal LS. Evaluation and referral for developmental dysplasia of the hip in infants. Pediatrics. 2016 Dec 1; 138(6). 
  5. ↑ Hip joint (highlighted in green) - anterolateral view image © Kenhub https://www.kenhub.com/en/library/anatomy/hip-joint
  6. ↑ Barlow maneuver. Available from: https://en.wikipedia.org/wiki/Barlow_maneuver#cite_note-1 ( Accessed, 25/03/2021)
  7. ↑ Kumari P, Rani M. Developmental dysplasia of the hip. Ortho & Rheum Open Access. 2018;10:555794. 
  8. ↑ Barlow & Ortolani Signs—DDH, Congenital Hip Dislocation. Available from: http://nabilebraheim.blogspot.com/2017/11/barlow-ortolani-signsddh-congenital-hip.html (Accessed, 5/4/2021).
  9. ↑ Marino Ortolani. Available from: https://en.wikipedia.org/wiki/Marino_Ortolani (Accessed, 4/4/2021).
  10. ↑ Kumari P, Rani M. Developmental dysplasia of the hip. Ortho & Rheum Open Access. 2018;10:555794. 
  11. ↑ Dr. Anisuddin Bhatti. Ortolani's Click & Barlow's Maneuver. Available from: http://www.youtube.com/watch?v=mv_kLqZSGdo [last accessed 04/05/13]
  12. ↑ nabil ebraheim. Barlow & Ortolani test, Congenital Hip Dislocation- Everything You Need To Know - Dr. Nabil Ebraheim. Available from: http://www.youtube.com/watch?v=jZ-U-2v9X6U[last accessed 4/4/2021]
  13. ↑ Nationwise Childrens Presentation of DHD Available:https://www.nationwidechildrens.org/conditions/hip-dysplasia (accessed 13.10.2021)
  14. ↑ Hip joint video - © Kenhub https://www.kenhub.com/en/library/anatomy/hip-joint
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