Ortolani Test for DDH Overview

Ortolani Test is used in Developmental dysplasia of the hip in newborn. It is performed to determine whether the hip is dislocated and can be reduced (i.e., whether the femoral head can be reduced to the acetabulum if it’s dislocated).

It was first described by Marino Ortolani (1904- 1983) an Italian pediatrician who developed it in 1937.

See Also: Developmental dysplasia of the hip DDH

How do you perform the Ortolani test?

• Ortolani Test must be carried out on a relaxed child, preferably after feeding.
• Flex the knees and encircle them with the hands so that the thumbs lie along the medial sides of the thighs and the fingers over the trochanters laterally.
• In neonates, it is usually possible to reduce the dislocated femoral head temporarily by gently abducting the hip and lifting the upper leg forward.
• A distinct clunk will be felt as the head is reduced.

When pressure on the leg is released, the femoral head will dislocate again. If the hip is dislocated, physical findings may include limited abduction (normal abduction is approximately 90 degrees), asymmetric thigh folds (excess on the affected side), and shortening of the leg compared with the opposite side.

See Also: Barlow Test

What does a positive Ortolani Test mean?

• If a hip is dislocated, as full abduction is approached the femoral head will be felt slipping into the acetabulum. An audible click may accompany the reduction.
• Note that restriction of abduction may be pathological, and represent an irreducible dislocation.
• A positive Ortolani sign is indicative of neonatal instability of the hip (NIH), and is usually an indication for splintage.

The examination detects instability of the hip and also allows one to define the degree of instability present. Tönnis differentiates four grades of instability:

1. Slightly unstable hip without a snap.
2. Dislocatable hip: The hip can be fully or largely reduced by abduction alone (with a snap).
3. Hip that can be dislocated and reduced.
4. Dislocated hip that cannot be reduced. The acetabulum is empty, and the femoral head can be palpated posteriorly; abduction is severely limited and reduction is not possible.

Sensitivity & Specificity

A study by AR Sulaiman ¹ found that the incidence of positive Barlow and Ortolani tests among breech babies was 2.8%, the sensitivity & specificity of these two tests were as following:

• Sensitivity: 66 %
• Specificity: 95 %

The Ortolani test, performed by a specialist at the maternity ward, has a high positive predictive value for developmental dysplasia of the hip. The positive predictive value was 39-61% for the Ortolani test and 4%-16% for the Barlow test depending on the true positive definition.

Notes

• A “dry click” without dislocation can often be provoked during the first days of life, but disappears thereafter.
• One point to emphasize regarding Barlow and Ortolani test is that the examiner cannot elicit both the Barlow and Ortolani signs from the same hip.
• Either the femoral head is sitting in the acetabulum and can be temporarily dislocated on examination (Barlow sign), or the head is dislocated and can be temporarily reduced on examination (Ortolani sign).
• If the physical examination findings are equivocal and the patient is considered to be at high risk for Developmental dysplasia of the hip, ultrasound studies should be ordered.

The clinical presentation of congenital dysplasia of the hip varies according to the age of the child:

1. In newborns (<6 months old), it is especially important to perform a careful clinical examination because radiographs are not always reliable in making the diagnosis of congenital dysplasia of the hip in this age group. The use of ultrasound screening of newborns is preferred for early diagnosis of congenital dysplasia of the hip.
2. As the child reaches age 6 to 18 months, several factors in the clinical presentation change. When the femoral head is dislocated, and the ability to reduce it by abduction has disappeared, several other clinical signs become obvious. The radiographs x-ray is preferred for this age group.

Reference

1. AR Sulaiman, Zakaria Yusof, I Munajat, NAA Lee, Nik Zaki. Developmental Dysplasia of Hip Screening Using Ortolani and Barlow Testing on Breech Delivered Neonates. Malays Orthop J. 2011 Nov; 5(3): 13–16. PMID: 25279029. Pubmed
2. Maikku M, Rantala T, Valkama M. The Ortolani test has a high positive predictive value in clinical hip screening for developmental dysplasia of the hip. Acta Paediatr. 2023 Jul;112(7):1586-1591. doi: 10.1111/apa.16757. Epub 2023 Mar 25. PMID: 36928888. Pubmed
3. Campbel’s Operative Orthopaedics 13th edition book.
4. Clinical Tests for the Musculoskeletal System 3rd Edition.
5. Tachdjian Pediatric Orthopaedics 5th Edition book.