Barlow’s sign is a clinical finding used to detect congenital dislocation of the hip in infants, typically within the first six weeks of life. It identifies a hip that is dislocatable but not yet dislocated, which allows for early intervention to prevent long-term complications.

Pathophysiology

Congenital hip dislocation arises from instability of the femoral head within the acetabulum due to shallow acetabular development, ligamentous laxity, or abnormal femoral head alignment.

• The posterior acetabular lip may be insufficient to maintain femoral head stability.

• Gentle pressure during the Barlow maneuver causes posterior and lateral displacement of the femoral head, producing a palpable or audible “click” as it slips out of the acetabulum.

• Early detection allows for non-surgical interventions like bracing or harnessing, promoting proper hip development.

Examination Technique

• Patient positioning: Infant supine, hips flexed to 90°, knees fully flexed.

• Hand placement:

  • Place your thumb in the femoral triangle opposite the lesser trochanter.

  • Place your index finger over the greater trochanter.

• Maneuver:

  • Bring the hip into midabduction.

  • Exert gentle posterior and lateral pressure with the thumb.

  • Apply posterior and medial pressure with the palm.

• Assessment: A click or palpable movement of the femoral head over the posterior acetabular lip constitutes a positive Barlow’s sign.

Clinical utility

• Screening tool: Standard part of neonatal hip assessment.

• Early intervention: Detects hips at risk for dislocation before permanent deformity occurs.

• Adjunct assessment: Often used with Ortolani’s sign, which confirms relocation of a dislocated hip.

Differential Diagnosis

Management

• Positive Barlow’s sign: Requires early referral to a pediatric orthopedist.

• Non-surgical intervention:

  • Pavlik harness or other abduction orthoses to maintain femoral head in the acetabulum.

  • Regular monitoring via ultrasound or radiographs.

• Surgical intervention: Considered only if orthoses fail or diagnosis is delayed.

• Follow-up: Frequent evaluation of hip stability, range of motion, and acetabular development until normal growth is confirmed.

Pediatric considerations

• Perform gentle maneuvers to avoid injury to the hip joint or femoral head.

• Early detection maximizes success of non-invasive treatment.

• Educate parents on harness use, positioning, and follow-up schedules.

Geriatric considerations

• Not applicable, as Barlow’s sign is specific to neonates and early infancy.

• Unrecognized congenital hip dislocation may present later in adolescence or adulthood with gait abnormalities or early osteoarthritis.

Key points

• Barlow’s sign identifies a dislocatable hip in neonates, allowing for early, non-surgical management.

• Positive findings should prompt pediatric orthopedic referral.

• Gentle, precise technique is critical to avoid iatrogenic injury and ensure accurate detection.

References

1. Barlow TG. Early diagnosis and treatment of congenital dislocation of the hip. J Bone Joint Surg Br. 1962;44-B:292–301.

2. Ortolani M. Technique for the early detection of congenital hip dislocation in the newborn. Clin Orthop. 1937;24:26–33.

3. Shaw BA, Segal LS. Evaluation and referral for developmental dysplasia of the hip in infants. Pediatrics. 2016;138(6):e20163107.

4. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

5. MacEwen GD. Congenital dislocation of the hip: the pediatric perspective. Orthop Clin North Am. 1990;21(4):585–598.