Ortolani Test

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.

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 %

Telescope Sign

Telescope Sign is another test for congenital hip dislocation.

The examiner grasps the affected leg with one hand and passively flexes the hip and knee. The other hand rests posterolateral to the hip. The examiner palpates the greater trochanter with the thumb of this hand and the motion of the femoral head with the index finger. The hand guiding the leg alternately applies axial compression and traction to the femur.

In a hip dislocation, the leg will appear to shorten or lengthen. The palpating hand follows the motion of the greater trochanter and fem oral head into the dislocated position and back to reduction.

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.
2. Campbel’s Operative Orthopaedics 13th edition book.
3. Clinical Tests for the Musculoskeletal System 3rd Edition.
4. Tachdjian Pediatric Orthopaedics 5th Edition book.