Ortolani’s sign is a clinical finding in neonates characterized by a click, clunk, or popping sensation felt and sometimes heard when the hip is flexed 90° and gently abducted. It indicates developmental dysplasia of the hip (DDH) and results from the femoral head entering or exiting the acetabulum. Early detection is crucial because timely intervention can ensure proper hip development and prevent long-term complications.

Pathophysiology

Developmental dysplasia of the hip (DDH) arises from abnormal formation or instability of the hip joint. Normally, the femoral head fits snugly within the acetabulum. In DDH:

• The acetabulum is shallow or malformed, reducing femoral head stability.

• Ligamentous laxity or abnormal muscular tone allows subluxation or dislocation of the femoral head.

• When the hip is flexed and abducted during examination, the femoral head reduces into or dislocates from the acetabulum, producing the palpable and sometimes audible clunk (Ortolani’s sign).

Risk factors include:

• Female gender (due to ligamentous laxity from maternal hormones)

• Breech presentation

• Positive family history

• Cultural practices that restrict normal hip movement (e.g., tight swaddling)

History and Physical Examination

History

• Neonates are typically asymptomatic; history is often negative for pain or deformity.

• Ask about family history of DDH or previous siblings with hip problems.

• Inquire about birth presentation (breech or cesarean section).

Physical Examination

1. Place the neonate in a relaxed supine position.

2. Flex both hips to 90° at the knees and hips.

3. Abduct the thighs gently while applying anterior pressure to the greater trochanters.

   • A click or clunk indicates the femoral head relocating into the acetabulum (positive Ortolani’s sign).

Examination Tips – Detecting Developmental Dysplasia of the Hip (DDH)

• Compare bilateral hip abduction; limited abduction suggests DDH.

• Inspect for asymmetrical gluteal or thigh folds.

• Assess for leg length discrepancy; the affected leg may appear shorter.

• Gentle palpation for hip stability helps detect subluxation.

• Ortolani’s sign is most reliable in the first 4–6 weeks of life; after this period, clunk may disappear as soft tissues tighten.

Medical causes

Special Considerations

• Timing: Ortolani’s sign can be reliably elicited only in the first 4–6 weeks of life.

• Treatment: Early intervention improves outcomes and includes:

  • Soft abduction splints (Pavlik harness)

  • Plaster hip spica cast for more severe cases

• Complications of delayed diagnosis: Degenerative hip changes, lordosis, joint malformation, soft tissue damage

Patient Counseling

• Educate parents about DDH and importance of early treatment.

• Demonstrate proper positioning and handling of the affected limb to maintain abduction.

• Explain the role of splints or casts and the expected duration of treatment.

• Emphasize adherence to follow-up appointments for monitoring hip development.

References

1. Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. USA: American Academy of Pediatrics; 2012.

2. Colyar MR. Well-Child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003.

3. American Academy of Orthopaedic Surgeons. Care of the Infant Hip. Rosemont, IL: AAOS; 2019.

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

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