## Clinical Examination in DDH ### Ortolani and Barlow Tests **Key Point:** These are the gold-standard clinical tests for detecting DDH in infants under 3 months of age. | Test | Position | Maneuver | Finding | |------|----------|----------|----------| | **Ortolani** | Hip flexed 90°, knee flexed 90° | Abduction + external rotation | 'Clunk' = reduction of dislocated head | | **Barlow** | Hip flexed 90°, knee flexed 90° | Adduction + internal rotation | 'Clunk' = posterior dislocation | ### Secondary Signs (After 3 Months) **High-Yield:** After 3 months of age, the hip capsule tightens and Ortolani/Barlow become unreliable. Secondary signs become more important: 1. **Limitation of hip abduction** — becomes a reliable sign after 3 months due to capsular tightness and muscle contracture [cite:Campbell's Operative Orthopaedics 13e Ch 32] 2. **Asymmetry of skin folds** — inguinal, thigh, and gluteal folds may be asymmetric, but this is **NOT a sensitive or specific sign** and can occur in normal infants without DDH 3. **Shortening of limb** — apparent or true limb length discrepancy 4. **Positive Galeazzi sign** — knee height discrepancy when hips and knees flexed ### Why Skin Fold Asymmetry Is Unreliable **Warning:** Asymmetry of skin folds is present in approximately 25–30% of normal newborns and has poor sensitivity and specificity for DDH. It should NOT be used as a standalone screening criterion. Many normal infants have asymmetric folds without any hip pathology. **Clinical Pearl:** The combination of clinical examination (Ortolani/Barlow in infants <3 months) and imaging (ultrasound before 4–6 weeks, X-ray after 4 months) is the gold standard for diagnosis. ### Screening Recommendations **Key Point:** Universal clinical screening at birth and 6–8 weeks is recommended. Selective ultrasound screening is offered to infants with risk factors (family history, breech presentation, female gender).
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