The neonatal clinical hip examination is part of the routine new born examination. All hip joints should be examined in a systematic manner using the look, feel, move approach ideally within 24 hours and certainly before 72 hours after birth14. All hips should be re-examined at 6-8 weeks of age for DDH (usually in primary care).
History Before examination, maternal obstetric history, baby’s family history and hip risk factors should be reviewed. Family history of DDH, breech presentation after 36 weeks gestation or fixed foot deformity, are triggers for a hip ultrasound (see risk factors for screening).
Examination Clinical assessment involves an inspection (look), palpation (feel) and (move)ment approach.
‘Look’: Inspection is important to assess for symmetry of leg length and gluteals.
‘Feel’– evaluated by flexing the hips and knees. Unequal knee lengths (Galeazzi sign), is a sign of a dislocated hip. A dislocated hip is a more common cause of leg length discrepancy than any other causes.
Leg length discrepancy in a neonate is a trigger for a hip ultrasound.
Figure 215
‘Move’
Gentle abduction test
The hips should be fully flexed and abducted together, to detect any difference between the sides. The examiner's middle fingers are placed on the greater trochanter with the flexed legs contained in the palms. The thumbs rest on the inner side of the thighs opposite the lesser trochanter. Even slight limitation of abduction may be significant, indicating a hip that is starting to subluxate. Asymmetry or reduction of hip abduction of the hip in a neonate is a trigger for a hip ultrasound.
Ortolani and Barlow’s manoeuvres are then performed with the pelvis stabilised by the opposite hand.
Ortolani is a test of hip joint reducibility and Barlow’s for dislocatability. Examine one hip at a time. Ideally the baby should be relaxed and the family reassured that the test is not painful.
Ortolani’s test returns a posteriorly dislocated femoral head back into the acetabulum. It is performed by holding the hip with the thumb over the inner thigh, the middle finger over the greater trochanter and abducting the hip. An abnormal Ortolani test is when the greater trochanter is felt to move forward as the hip reduces into the acetabulum. It must be stressed that reduction of the hip almost never produces an audible sound.
In Barlow’s test, a similar hand position is used and the hips are flexed. Posterior pressure is applied in the line of the femur with the hips in neutral ab/adduction. An abnormal test is when the femur is felt to move backwards relative to the fixed pelvis, and indicates hip instability.