From the Guidelines
A positive Ortolani sign in a newborn indicates developmental dysplasia of the hip (DDH), a condition where the hip joint is unstable or improperly formed, and treatment should be initiated promptly to prevent long-term complications, with the primary treatment being a Pavlik harness for newborns and infants under 6 months 1.
Diagnosis and Treatment
The Ortolani sign is detected during physical examination when the examiner feels a "clunk" as the dislocated femoral head reduces into the acetabulum when the infant's thighs are abducted while applying gentle pressure over the greater trochanters.
- The condition occurs due to a combination of genetic factors and intrauterine positioning, with higher prevalence in firstborn females, breech presentations, and those with family history of DDH 1.
- For newborns and infants under 6 months, a Pavlik harness is the primary treatment, worn continuously for 6-12 weeks to maintain the hip in a flexed and abducted position, allowing the joint to develop properly 1.
- The harness is adjusted regularly by an orthopedic specialist to ensure proper positioning while allowing some movement.
- For older infants or those who don't respond to harness treatment, closed reduction under anesthesia followed by spica casting may be necessary.
- In severe or resistant cases, surgical intervention might be required.
Importance of Early Detection and Treatment
Early detection and treatment are crucial, as untreated DDH can lead to limping, pain, and early-onset arthritis 1.
- The American Academy of Pediatrics recommends selective screening of children with risk factors or based on physical examination findings 1.
- A positive Barlow or Ortolani test implies an unstable femoral head that can be dislocated or relocated, respectively, and requires prompt attention 1.
Recent Guidelines and Recommendations
Recent guidelines suggest that good outcomes for DDH can still be achieved by either conservative or surgical approaches beyond 4 months of age, but early treatment is still preferred to prevent complications 1.
- Consideration should be given to provide extensive educational tools and guidance to parents on hip healthy swaddling techniques and hip healthy baby carriers 1.
From the Research
Definition and Indication of a Positive Ortolani Sign
- A positive Ortolani sign in a newborn indicates a dislocated but reducible hip, which is a sign of developmental dysplasia of the hip (DDH) 2.
- The Ortolani test is a clinical screening method used to assess hip instability in infants, and a positive sign implies a severe form of DDH that requires emergency treatment to reduce and stabilize the hip 2.
Treatment of a Positive Ortolani Sign
- The Pavlik harness is a common treatment for infants with DDH, including those with a positive Ortolani sign 3, 4, 5.
- The Pavlik harness treatment regimen may vary, but studies have shown that a 23-hour wear duration is as effective as a 24-hour wear duration, and frequent clinic visits may not be necessary for all patients 3.
- Reapplication of the Pavlik harness may be considered for patients who fail initial treatment, particularly in cases of left-side dislocation and a positive Ortolani sign 5.
- Ultrasound imaging of the hip is an important part of the initial assessment for Ortolani-positive hips, as it can provide prognostic information and guide treatment decisions 6.
Factors Associated with Treatment Failure
- Male sex and Graf Type IV ultrasound classification are independent predictors of failure of Pavlik treatment among Ortolani-positive hips 6.
- Patients with Graf Type IV hips, particularly males, may be at higher risk of Pavlik harness treatment failure and may require alternative treatment strategies 6.
- The overall success rate of Pavlik harness treatment for Ortolani-positive hips is high, ranging from 85% to 93% in some studies 3, 4.