Hip Screening (Ortolani and Barlow Manoeuvres)

Clinical hip screening examines newborns and infants for developmental dysplasia of the hip, which covers a spectrum from instability to dislocation. The Ortolani manoeuvre tests whether a dislocated hip can be reduced, and the Barlow manoeuvre tests whether a stable hip can be dislocated.

Clinical examination detects many cases but misses some, particularly in the first weeks of life. Ultrasound is used for infants with risk factors and when clinical examination is uncertain.

Usage. It is performed at birth and at the newborn review, and repeated at the 6-week check where indicated.

Indications. Routine clinical hip examination of all newborns, and ultrasound for infants with risk factors such as breech presentation, family history, and oligohydramnios.

Preparation and technique. The infant is examined supine, with the hips and knees flexed to 90 degrees. The examiner places the fingers on the greater trochanter and the thumb on the inner thigh. The Ortolani manoeuvre lifts the femur forward into the acetabulum with a palpable or audible clunk. The Barlow manoeuvre pushes the femur backward to test for dislocation.

Contraindications and precautions. Hip examination is performed gently, and excessive force is avoided. Infants with severe muscle tension or recent hip treatment require specialist examination.

Interpretation.

• A positive Ortolani sign is a reduction of the dislocated hip with a clunk.
• A positive Barlow sign is a dislocatable hip, which indicates instability.
• Limited abduction in one hip, with asymmetric thigh or gluteal skin folds, is a further sign, but skin folds alone are unreliable.
• A positive examination requires urgent specialist referral.

Causes of a positive finding. Developmental dysplasia of the hip, with or without dislocation, and neuromuscular disorders in rare cases.

Critical values and findings needing immediate action.

• A dislocated or dislocatable hip requires same week referral for specialist assessment.
• A hip that cannot be assessed because of severe tension or pain requires urgent review.

Limitations and artefacts. Clinical examination has limited sensitivity in the first weeks, and asymmetric skin folds have low specificity. Excessive force can cause injury, and the manoeuvres are not valid after the infant is older than the age at which the hip has stabilised.

Follow up tests. Hip ultrasound, which is generally performed when the hip is more readable, usually around 6 weeks of age, and plain radiograph in older infants where ultrasound is not possible.

Special groups. Breech presentation, family history and oligohydramnios increase the risk of developmental dysplasia, and ultrasound is considered in these infants. Girls are affected more often than boys.