Barlow and Ortolani Tests

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

Description

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 . 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 .  

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 .                                                                                                                                                                                                

                                                                                                                                                                                               

Technique

1. Barlow Test

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 ° . 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 .     

2. Ortolani Test  

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 .

Evidence

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 .

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% .

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 .

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 .

Clinical notes and recommendations

• The Barlow and Ortolani tests are used to assess for hip instability. Each hip should be examined separately . 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’ .
• An infant with a positive examination result, defined as either a positive Ortolani or Barlow sign, should be referred to an orthopedist .
• 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) .
• The Ortolani and the Barlow tests are no longer positive from week eight to twelve .
• 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 .