Ortolani’s Sign
Colette
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Instability of the hip may be assessed by the Ortolani and Barlow tests, which are the keystone of clinical screening for developmental dysplasia of the hip (DDH). However, Ortolani's sign implies that there is strong evidence of a severe form of DDH with a completely dislocated, but still reducible, femoral head. Barlow's test addresses several different forms of "instability" of the hip that are quite difficult to describe and in 80% of cases disappear during growth. For this reason, Ortolani's sign in a baby should be considered an indication for emergency treatment to reduce and stabilise the hip while it is still reducible. The increasingly widespread use of US of the hip in newborns and infants has enabled clinicians to observe the hip from the first day of life and to establish both the static and dynamic relationships of the femoral head and acetabulum. The purpose of this paper is to describe the US pattern and relative classification of the hip affected by Ortolani's sign and examined by Graf's method, and to confirm through US that Ortolani's sign should be considered a totally reliable specific test for the identification of dislocation of the infant hip.
In a screening program, 4438 newborns were examined sonographically and clinically in the first 12 hours after birth for congenital hip dysplasia. Seventy-three hips in 54 newborns were dislocated, as evidenced by positive Ortolani's signs. According to Graf's classification, all 73 hips should be Type IIC or worse, with Angle alpha less than 50 degrees and Angle beta for Type IIC of 72 degrees-77 degrees, and for Types D, III, and IV, greater than 77 degrees. Sonographic examination of the 73 hips according to Graf's criteria showed that only 16 hips were decentring and eccentric, confirming the clinical diagnosis, and the results were consistent with Graf's conclusion because their alpha-angles were less than 50 degrees and beta was greater than 77 degrees. In the remaining 57 hips, there was a disparity between alpha-angles and beta-angles. Judging by Angle alpha, these hips were of Types IB and IIA because their Angle alpha averaged 60.8 degrees (range, 51 degrees-74 degrees). Judging by Angle beta, these hips were decentring Type D or eccentric Type IIIA because their beta-angle averaged 91.3 degrees (range, 78 degrees-110 degrees). Because these 57 hips were dislocated clinically (positive Ortolani's sign) it was concluded that the beta-angle is a more accurate reflection of hip pathology in the newborn than the alpha-angle. It represents the cartilaginous roof of the acetabulum, which is soft and malleable, and reflects immediately any change in the position of the femoral head. Angle alpha, however, represents the hard bony roof, and any change in the position of the femoral head is not reflected immediately on it, because bony changes take longer to be seen or evidenced.
While comprehensively studied and disseminated by Ortolani, clinical signs relating to hip reduction via abduction had been previously described by multiple clinicians including Wilhelm Roser in 1870:
The abduction movements are very much reduced. All the other signs are too vague to be taken into account. The diagnosis was confirmed by performing the reduction manoeuvres several times, using the Paci-Lorenz procedure. The flexion-abduction, combined with thrusts on the greater trochanter, causes each femoral head to retract into its respective cavity, with a very sharp jerk
BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital. Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane Eponyms Books Twitter
The biggest risk factor for the development of osteoarthritis of the canine hip joint is hip laxity. Laxity of the hips in young dogs can be detected by a clinical test, the Ortolani sign. The test was reportedly first described in 1938 by Marino Ortolani, who was professor and chief of pediatrics in Ferrara, Italy. The test is used to detect congenital luxation of the hip in newborn children and has been adopted by the veterinary profession to detect hip laxity in puppies. Since puppies develop hip laxity in the first few months of life, the test can be used beginning at approximately 4 months of age.
The Ortolani test is generally used in young dogs (4 to 12 months of age). The test is typically performed with the dog sedated or anesthetized because it can cause pain in dogs with hip laxity. With the patient in lateral recumbency, the test is performed in the following manner:
Put the hip at approximately a normal weight-bearing angle. Apply a dorsal force to the stifle joint, which, in a lax hip, will displace the femoral head dorsally beyond the dorsal acetabular rim. In a hip without laxity, the femoral head will not displace.While still applying this force, slowly abduct the limb and feel for the point at which the femoral head clicks, "clunks," or grates as it reduces back into the acetabulum-a positive result. If this sensation is not felt, the result is considered negative. Note the angle at which the hip reduces-the Ortolani angle.
Interpreting the Test Result1. A positive Ortolani test result indicates a lax hip. It is known that hip laxity is the biggest risk factor for development of osteoarthritis of the hip in dogs.1 The greater this hip laxity, the greater the probability that osteoarthritis will develop in this hip. However, this varies according to breed; some breeds (eg, rottweiler) are relatively more tolerant of laxity than others (eg, German shepherd).
2. In a clinical setting, if the clinician suspects that a young dog may have clinical hip dysplasia, the Ortolani test should be part of the examination and diagnostic protocol. Young dogs with hip dysplasia may be reluctant to exercise, may sit down when at exercise, may have lameness and joint stiffness, and will have pain on manipulation of the hip (full extension and often on abduction as well). If the history and clinical examination suggest hip dysplasia, the clinician should consider radiography and Ortolani testing.
Hips with No Visible Sign of DysplasiaTypically, radiographs of the hips are obtained in the ventrodorsal hip-extended position. However, although this projection is useful for determining symmetry and allows the clinician to evaluate the bony conformation and status of the hip joints, it underestimates hip laxity. This underestimation occurs because, when the hip joints are extended, the joint capsule is tightened; tightening tends to reduce subluxation of the femoral head. Other radiographic protocols, such as the PennHIP scheme, are designed to specifically measure passive hip laxity.
Severe Hip DysplasiaSince sedation is often required for good-quality pelvic radiographs in young dogs, the clinician has the opportunity to perform the Ortolani maneuver to test for hip laxity following radiographic evaluation. Hips such as the one shown above (8-month-old dog with positive Ortolani test result) are likely to have palpable laxity and a positive Ortolani test result (see Warnings). However, the Ortolani test should also be performed on hips with no visible sign of dysplasia as the hip-extended view may mask laxity that can be detected by physical examination.
SummaryIn young dogs, the Ortolani test is very useful for detecting hip laxity. The clinician needs to remember the limitations of the test but should also note the value of the test as an addition to other clinical and radiographic methods to evaluate hips.
As an instructional designer Juliana works closely with faculty in the development and design of hybrid and online courses. Juliana provides expertise in pedagogical approaches, instructional design principles and technology applications for designing effective learning experiences. She specializes is the design of On Demand courses. Juliana started working for Distance Learning in 2006 as an Independent Learning Specialist.
Ortolani, J., Digges Elliott, H., Honaker, A., (2015, November) Competencies? But this is Academia! -A Development Plan for a Competency-Based University Program. Presented at the Kentucky Convergence Conference, Bowling Green, KY.
Developmental dysplasia of the hip (DDH) is estimated to occur in 4.1 out of every 1,000 not-at-risk boys and in 19 out of every 1,000 not-at-risk girls. Patients at intermediate risk include breech-born boys and not-at-risk girls, and patients at highest risk are girls with a positive family history and girls born in breech presentation. The left hip is more commonly affected, presumably because of the left occiput anterior position of most vertex-presenting newborns. DDH includes a variety of conditions: an unstable, subluxated or dislocated hip or a malformed acetabulum. Immediately after birth, it is common for the femoral head to spontaneously dislocate and relocate. This condition should stabilize within a few days, and subsequent hip development should occur normally. If the dislocation persists, hip development may be affected, and avascular necrosis of the femoral head may occur.
Theoretically, the gold standard for DDH is arthrography of the hip, but this procedure is not recommended in newborns and infants. Consequently, radiography and ultrasonography are the imaging methods available for evaluating young children. Radiography is not useful in children up to about four months of age because the femoral head is still cartilage until the ossification of the femoral head occurs. Ultrasonography can be used in small infants, although accurate results depend on operator training and experience. During the first month of life, an ultrasound may show a variety of abnormal findings that may represent only mild instability. These abnormal ultrasound findings are not usually noted on physical examination, so ultrasound should only be used in conjunction with an abnormal physical examination or in high-risk infants. It is also used to monitor treatment of DDH. Between four and six months, radiography and ultrasonography seem to be equally reasonable choices.
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