Ortolani Test

[Ping Weafer]

The Ortolani test is part of the physical examination for developmental dysplasia of the hip, along with the Barlow maneuver.[1] Specifically, the Ortolani test is positive when a posterior dislocation of the hip is reducible with this maneuver.[citation needed] This is part of the standard infant exam performed preferably in early infancy.[citation needed]The Ortolani test is named after Marino Ortolani, who developed it in 1937.[2]

The Ortolani test is performed by an examiner first flexing the hips and knees of a supine infant to 90, then with the examiner's index fingers placing anterior pressure on the greater trochanters, gently and smoothly abducting the infant's legs using the examiner's thumbs.[3]

Ideally, DDH is detected by routine history and physical exam in the neonatal period. Questions to the parents regarding risk factors can be important. Clinical screening is the gold standard for diagnosis with dynamic hip examinations carried out at birth and at subsequent pediatrician visits throughout childhood. The Ortolani test and Barlow maneuver should be done at each exam.

The Barlow Maneuver is done by guiding the hips into mild adduction and applying a slight forward pressure with the thumb. If the hip is unstable, the femoral head will slip over the posterior rim of the acetabulum, again producing a palpable sensation of subluxation or dislocation.

Children under 6 months of age: Beyond clinical screening exams, US (ultrasound) is the preferred technique. Though US screening of all infants is not advised, infants with identified risk factors or questionable exams should be routinely screened. With a normal exam, screening US should be delayed until at least 4-6 weeks, when hip maturation improves exam specificity. US is also used to document reduction and follow the improvement or maturity of a dysplastic hip following treatment.

Birth to 6 months: Immature, stable hips (Barlow negative) that become normal do not need treatment. Hips that are Barlow positive at birth may also become stable in the first 3 weeks of life; therefore, treatment may be delayed. In both cases, close follow-up and routine physical exams are required, plus a later US to document normal hip stability and development.

With an unstable, Ortolani positive hip, early treatment is required. Reduced hips are positioned in flexion and mild abduction to stimulate normal joint development, most commonly performed via the Pavlik harness, a dynamic brace which positions the thighs to allow and maintain hip reduction. Infants are followed bi-weekly for strap adjustment. Progress is monitored and reduction verified with subsequent US evaluations. Pavlik treatment continues until US parameters have normalized and the hip stabilized on exam, on average 2-3 months later. Follow-up through skeletal maturity is then emphasized.

6 months to 1-2 years: Children who present at this time or fail to stabilize with the Pavlik harness require genera anesthesia, followed by closed or open hip reduction and spica casting.

Over 2 years of age: Older children may require extensive open surgical reductions with possible femoral and pelvic osteotomies (cutting and realigning the bones), followed by a spica cast.

For parents, a diagnosis of Developmental Dysplasia of the Hip (DDH) brings a wide range of emotions and responses. Parents want to understand not only the condition, but what the future holds for their child after diagnosis.

Screening programs relying primarily on physical examination techniques for the early detection and treatment of congenital hip abnormalities have not been as consistently successful as expected. Since the 1980s, increased attention has been given to ultrasound imaging of the hip in young infants (less than five months of age) as a possible tool for improving patient outcomes. Although ultrasound examination may not provide advantages over careful repeated physician examination for universal screening, a growing body of evidence indicates that ultrasound surveillance of mild abnormalities can reduce the need for bracing without worsening outcomes. Radiographic documentation of hip normality after the femoral nucleus of ossification has appeared (at three to five month of age) is still appropriate to rule out hip dysplasia.

The incidence of hip dislocation in unscreened populations is estimated to be one to two cases per 1,000 children of European origin.4,5 The abnormality is rare in black Africans.6,7 It is more common in populations that practice swaddling or use infant cradle boards.8,9

The natural history of developmental dysplasia of the hip is not completely understood. Typical treatment rates in European populations are 10 to 20 cases per 1,000 screened infants5 (about 10 times the rate of dislocation seen in unscreened populations). An early British study reported that more than 80 percent of hips found to be dislocatable at birth normalized by two months of age.16

A more recent British study employing universal ultrasound examination of the hips in 14,050 newborns found that 90 percent of ultrasonographic abnormalities normalized spontaneously without treatment and that no infants with ultrasonographically normal hips at birth presented later with dislocations.10 However, even with excellent screening and treatment programs, a small number of children (not more than one in 5,000) appear to have a poor outcome and require surgical correction of the abnormality.10

The Ortolani and Barlow maneuvers have been the standard techniques for detecting hip instability in newborns9 (Figure 1). These maneuvers cannot be performed in a fussy, crying infant whose muscle activity may inhibit the movement of an unstable hip. For the examinations, the infant's hips are flexed to 90 degrees; the thumbs of the examiner are placed on the medial proximal thigh, and the long fingers are placed over the greater trochanter.

Teratologic (e.g., irreducible) dislocation is suspected by limited abduction of one thigh, if unilateral. If both hips have fixed dislocations, the only clue will be less than normal abduction of both thighs.

If an unstable hip is not detected in the newborn period, a positive Ortolani's test becomes less common. Then limited abduction is the predominant physical sign as the hip becomes fixed in the dislocated position.4 Limitation of hip abduction is the best indicator of dislocation in the older infant.31 Other signs, such as an apparent shortening of the femur, asymmetric skin folds and telescoping of the affected hip, are also clues to dislocation.31,32

In 1978, ultrasound examination was introduced as a tool for detecting developmental dysplasia of the hip and evaluating infants with an abnormal physical examination.33 Graf, the pioneer in this field, introduced a method of classifying infant hips based on the depth and shape of the acetabulum as seen on coronal ultrasonograms34 (Figure 2).

In the Graf classification, a type I hip is considered normal, and developmental dysplasia is ruled out. The type II hip, which has a slightly shallow acetabular cup and a rounded rim with the femoral head in normal position, is considered to be developmentally immature in infants less than three months of age.34 In infants older than three months, a type II hip is considered abnormal and should be treated. A type III hip is subluxated, and a type IV hip is dislocated.34

Other investigators have popularized a dynamic approach, which consists of a multipositional evaluation using real-time ultrasonography to visualize the hips during physical examination35 (Figures 3 and 4).

Both universal and selective ultrasound screening programs for developmental dysplasia of the hip have been proposed. In a Norwegian study, the surgical treatment rate did not decrease significantly in newborns screened with ultrasonography compared with those screened by physical examination alone.40 However, the nonsurgical treatment rate was almost double in the ultrasound-screened group (34 versus 18 per 1,000 infants screened). The assumption is that many children in the ultrasound group who subsequently received treatment actually had false-positive ultrasound tests.

By the time an infant reaches three to five months of age, the femoral nucleus of ossification has appeared, and the bony architecture of the hip is sufficiently well developed that a dislocated hip can be reliably detected on radiographs. Thus, radiographs are indicated when developmental dysplasia of the hip is suspected in any child more than three months old. The age at which the diagnosis can be made by radiography is, however, near the upper limit of the age for successful treatment of hip dysplasia using the Pavlik harness.46,47

Serial physical examination remains the primary method for diagnosing developmental dysplasia of the hip in infants. In many U.S. institutions, ultrasound examination is used to evaluate newborns and young infants who have an abnormal hip on physical examination. However, additional research is needed to clarify the optimal use of ultrasonography in patients with possible hip dysplasia.

The neonate who has a dislocated hip at birth (positive Ortolani test or irreducible dislocation) should be referred to a pediatric orthopedist immediately for treatment. However, when a newborn has a dislocatable hip (positive Barlow maneuver), referral can be safely deferred for two weeks. It is highly possible that the hip will stabilize during that interval. With a dislocatable hip, use of an abduction pillow for the first two to four weeks of life is an appropriate option to referral at two weeks. The infant should then be reevaluated by physical examination with or without ultrasound assessment. Treatment or further surveillance may be initiated if the presence of an abnormality is confirmed.

A small number of hips that appear stable on physical examination at birth become dislocated later. Therefore, after the newborn period, regular well-child visits should include hip examinations until a child is walking.4,6,48,49

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