Barlow and Ortolani test: Technique, interpretation, and referral

Key Takeaways

The Barlow test attempts to provoke dislocation of a located hip; a positive result is a palpable clunk or pistoning movement, not a benign soft-tissue click.

It is always performed alongside the Ortolani maneuver: Barlow dislocates, Ortolani reduces. Both are done at every newborn and well-baby check up to 3 months.

Sensitivity for experienced examiners ranges from 87 to 97% and specificity from 98 to 99%, though pooled study estimates run far lower, so a negative exam does not rule out late-presenting DDH in high-risk infants.

Pabau’s structured clinical templates and digital forms let pediatric and primary care practices document Barlow test findings, ultrasound results, and orthopedic referral status in one connected workflow.

Missed developmental dysplasia of the hip (DDH) is one of the most litigated conditions in pediatric primary care. The Barlow and Ortolani test is the frontline screen used to catch it.

Most cases are detectable at birth with a careful physical examination. However, clinical audit data consistently shows that examination technique varies widely between practitioners. The structured consultation documentation that catches subtle instability depends entirely on knowing what you are feeling for and why.

This guide covers how to perform and interpret the Barlow test and its paired Ortolani maneuver. In addition, it explains what the findings mean clinically and when to escalate.

What the Barlow test is and why it matters?

The Barlow test is a provocation maneuver. It detects a hip that sits in the acetabulum but that applied force can dislocate.

Thomas Geoffrey Barlow described the test in 1962. Alongside the Ortolani maneuver, it forms the cornerstone of neonatal hip screening. Clinicians use both across the UK, US, and most of Europe. A positive Barlow test indicates a dislocatable hip. However, it does not mean the hip is currently dislocated.

About 1 in 10 newborns has some hip instability at birth. However, only around 1 in 100 has hip dysplasia that needs treatment, according to the International Hip Dysplasia Institute (IHDI). Left undetected, DDH leads to progressive acetabular dysplasia, early osteoarthritis, and often surgical hip replacement before age 40. By contrast, early treatment changes the outcome. When clinicians detect DDH within the first weeks and treat it with a Pavlik harness, most hips normalize without surgery.

Clinicians perform the Barlow test at the newborn exam and every well-baby check until the infant turns 3 months old. After that point, ossification and muscle tone reduce its sensitivity. After 3 months, the Galeazzi sign and limited hip abduction become the primary clinical indicators.

Risk factors for DDH: Who needs closer scrutiny?

Certain infants carry a significantly elevated risk of DDH. The three strongest predictors are female sex, breech presentation, and a positive family history in a first-degree relative. Clinical guidelines consistently identify these three factors.

• Female sex: girls are 4 to 8 times more likely to develop DDH than boys. This is likely related to greater ligamentous laxity in response to maternal estrogen.
• Breech presentation: frank breech (extended knees) carries the highest risk. That’s because the extended position limits normal hip flexion and acetabular molding in utero.
• Family history: a first-degree relative with DDH increases risk roughly 12-fold compared to the general population.
• First-born: the nulliparous uterus provides less room, restricting fetal hip movement.
• Oligohydramnios and multiple pregnancy: reduced amniotic fluid or crowding from twins similarly restricts fetal positioning.
• Foot deformities: talipes equinovarus and metatarsus adductus link to DDH and should always prompt a careful hip exam.

Infants with any of these risk factors warrant ultrasound screening at 6 weeks regardless of clinical examination findings. This follows IHDI and American Academy of Pediatrics (AAP) guidance. Standardized clinical assessment tools, combined with structured risk stratification, help ensure no high-risk infant slips through during a well-baby visit.

How to perform the Barlow test: Step-by-step technique

Correct technique is critical. The Barlow test is examiner-dependent: operator experience is one of the primary drivers of false-negative rates. Perform the examination with the infant calm, supine, and hips and knees flexed to 90 degrees.

1. Position the infant: lay the baby supine on a firm, flat surface. The infant must be relaxed; crying increases muscle tone and can mask instability.
2. Stabilize the pelvis: place your non-testing hand flat across the infant’s lower abdomen and pelvis. This prevents pelvic rotation during the maneuver.
3. Grasp the thigh: with your testing hand, cup the infant’s thigh. Your thumb should lie along the inner thigh. In addition, your index and middle fingers rest over the greater trochanter.
4. Flex and adduct: gently bring the hip to 90 degrees of flexion, then adduct the thigh to midline. Keep movement smooth and controlled.
5. Apply posterior pressure: while holding the adducted position, apply a gentle posterolateral force along the shaft of the femur. Direct this force toward the examination table. You are attempting to push the femoral head out of the acetabulum.
6. Interpret the response: a positive Barlow test produces a palpable clunk or a sense of pistoning movement. This happens as the femoral head exits the acetabulum. This is instability. A soft click without movement is not a positive Barlow test and is usually a benign soft-tissue sound.

Repeat on the contralateral hip. Always examine each hip independently. Never apply bilateral pressure simultaneously.

How to perform the Ortolani maneuver: Step-by-step technique

Examiners perform the Ortolani maneuver immediately after the Barlow test, starting from the same position. Where the Barlow test dislocates a located hip, the Ortolani reduces one that is already out of place. Together, they provide complementary information about hip stability.

1. Starting position: hip flexed to 90 degrees, thigh adducted to midline. Your hand position mirrors the Barlow grip: thumb on inner thigh, fingers over the greater trochanter.
2. Abduct the thigh: gently rotate the thigh outward (abduction), moving the knee toward the examination table laterally.
3. Apply anterior lift: as you abduct, use your middle finger over the greater trochanter to apply a gentle anterior lift. This directs the femoral head back toward the acetabulum.
4. Interpret the response: a positive Ortolani test produces a clunk as the femoral head relocates into the acetabulum. This confirms the hip was dislocated prior to the maneuver.

A positive Ortolani at birth indicates an already-dislocated hip. By contrast, a positive Barlow indicates a hip that can dislocate. Both require prompt referral to pediatric orthopedics.

Barlow test and Ortolani test: Key differences at a glance

Clinicians often conflate these two maneuvers. The table below clarifies their distinct purposes, techniques, and what each positive finding means clinically.

The clunk vs click distinction matters: examiners feel a clunk as a definite mechanical movement. The femoral head crosses the acetabular rim during this movement. A click is a high-pitched, soft sound without accompanying movement, usually from periarticular soft tissue. Clicks are common and benign. That’s why documenting this distinction clearly in the clinical record prevents unnecessary referrals and avoids missed true positives.

Complementary signs: Galeazzi sign and asymmetric skin folds

The Galeazzi sign and asymmetric skin folds are adjuncts to the Barlow test and Ortolani, not replacements. They become more clinically significant after 3 months. That’s because the Barlow and Ortolani maneuvers lose sensitivity as hip muscle tone increases and the hip capsule tightens.

Galeazzi sign (also called Allis sign): lay the infant supine with hips and knees flexed to 90 degrees. Keep the feet flat. Look at knee height from the side. Apparent shortening of the femur on one side shows as one knee sitting lower than the other. This indicates a dislocated hip on that side.

This sign is more reliable for unilateral DDH. However, bilateral DDH can produce a falsely normal Galeazzi.

Asymmetric skin folds: extra or asymmetric gluteal, thigh, or labial folds raise suspicion but have poor specificity. Approximately 30% of normal newborns have asymmetric folds, so this sign alone does not warrant referral.

In addition, it should prompt a careful Barlow test and Ortolani examination and, in combination with risk factors, consideration of ultrasound.

Diagnostic accuracy: Sensitivity, specificity, and the limits of the Barlow test

No screening test is perfect. Understanding the Barlow test’s diagnostic performance characteristics helps clinicians calibrate their threshold for further investigation. This matters particularly for high-risk infants who have a negative clinical examination.

According to StatPearls (NCBI Bookshelf NBK563157), the Barlow and Ortolani maneuvers together have a sensitivity of 87 to 97%. In experienced hands, they also show a specificity of 98 to 99%.

Reported sensitivity varies widely with examiner experience and study design. For example, pooled meta-analytic estimates across multiple studies have found sensitivity as low as 36% (PMC9194706). Clinicians should never treat a negative exam in a high-risk infant as reassuring on its own.

The practical takeaway: a negative Barlow test in a high-risk infant (breech, family history, female) should not stop your investigation. This is where clinical decision rules, like evidence-based clinical decision frameworks, demonstrate their value. They make threshold decisions explicit and consistent across your team.

When to order imaging: Ultrasound and X-ray guidance

Imaging extends clinical examination. The choice of modality depends on the infant’s age. The threshold for ordering it depends on exam findings and risk factors. Per IHDI and AAP guidance, the framework is as follows.

• Ultrasound at 6 weeks: clinicians should order this for a positive Barlow test or Ortolani at any age. They should also order it for high-risk infants with a negative clinical exam (breech, family history, or equivocal examination findings).
• Ultrasound before 6 weeks: not routinely recommended because neonatal physiological laxity can produce transient instability that resolves spontaneously. Early scanning increases false positives and unnecessary treatment.
• X-ray after 4 to 6 months: preferred once ossification of the femoral head allows adequate radiographic visualization. An anteroposterior pelvis X-ray can assess acetabular index, Shenton line, and femoral head position.
• Graf classification: used in ultrasound screening to grade acetabular maturity. Graf IIa is physiologically normal in infants up to 12 weeks. Graf IIc or worse requires orthopedic input.

Practices running high volumes of well-baby checks benefit from physical therapy and pediatric practice software. This software can link imaging results directly to the original clinical examination record. As a result, the referral, result, and follow-up action all stay in one place instead of scattering across disconnected systems.

When to refer to pediatric orthopedics?

Timely referral is the intervention that most directly determines treatment outcome. The earlier DDH is identified and referred, the greater the likelihood of successful non-surgical management with a Pavlik harness.

• Positive Barlow test at any age: refer immediately to pediatric orthopedics. Do not wait for the 6-week check if instability is detected at the newborn examination.
• Positive Ortolani at any age: refer immediately.
• Equivocal exam with risk factors: refer or arrange urgent hip ultrasound at 6 weeks, depending on local pathways.
• Abnormal ultrasound (Graf IIc or worse): refer to pediatric orthopedics regardless of clinical exam findings.
• Late-presenting DDH (limited abduction after 3 months, Galeazzi positive, limp in a walking child): refer urgently. Treatment options narrow significantly with age.

Practices that use automated referral workflows can trigger a referral task in the clinical record at the point of examination. This generates the referral letter automatically and tracks it through to follow-up, instead of relying on manual processes. Clinical forms management supports systematic screening documentation. Structured workflows therefore reduce the administrative burden that leads to referral delays.

Booking the six-week ultrasound and the orthopedic referral from the child’s record keeps the entire screening pathway on one timeline. So a positive Barlow or Ortolani finding never stalls between visits.

Document every hip examination finding, imaging result, and referral in one place

Pabau’s structured consultation templates and digital forms help primary care and pediatric practices run systematic newborn hip screening workflows without paper. See how it works.

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Treatment overview: Pavlik harness and beyond

Treatment is specialist-managed. Primary care clinicians should understand the treatment landscape to counsel families. However, Pavlik harness fitting and management belongs with pediatric orthopedics.

• Pavlik harness (first-line, under 6 months): a dynamic abduction brace that positions the hips in flexion and abduction. This encourages spontaneous reduction and acetabular remodeling. Success rates exceed 90% when started before 6 weeks. As the infant grows, success rates fall and the treatment window narrows.
• Harness failure: approximately 5 to 10% of infants do not reduce with the Pavlik harness. The next step is typically a rigid abduction brace or closed reduction under general anesthesia with a hip spica cast.
• Closed reduction: performed under anesthesia, often with an arthrogram to confirm reduction. Followed by spica casting for several months.
• Open surgical reduction: reserved for late-presenting cases (typically over 18 months) or failed closed reduction. Involves capsulorrhaphy and sometimes femoral or pelvic osteotomy. Recovery is significantly longer and outcomes less predictable than early harness treatment.

The message for referring clinicians: earlier is better. Every month of delay past 6 weeks reduces the probability that a harness alone will achieve reduction.

How Pabau supports newborn and well-baby examination workflows?

None of the top-ranking clinical resources on the Barlow test address how practices actually manage the documentation trail. That trail runs from examination to imaging to referral. In busy primary care and pediatric practices, this is where DDH cases slip through. Staff note the positive Barlow test on paper, the ultrasound request gets lost, and the referral letter goes unsent.

Practice management software like Pabau supports systematic newborn hip screening through several connected workflows. Digital intake forms can be configured to capture structured hip examination findings at each well-baby visit. These include the Barlow test result, Ortolani result, Galeazzi sign, and any complementary signs. These feed directly into the patient record without transcription, creating a complete longitudinal screening record.

Structured clinical consultation templates also help reduce examiner variability.

For practices managing compliance documentation across multiple well-baby clinicians, Pabau’s audit trail date-stamps every Barlow test result. It also attributes each result to the examining clinician. This means the result stays retrievable if a case is later reviewed.

The platform also supports follow-up task creation. When staff order a hip ultrasound, an automated task confirms that someone has received and acted on the result. As a result, it never sits filed away without a next step. Pabau’s marketing tools can also automate recall reminders, so families book the next well-baby hip check on time.

Continue your research

Need a template for structuring clinical notes? APSO Note Template reorders SOAP documentation to put the assessment and plan first, with specialty-specific examples.

Want a ready-made patient intake form? Client Information Sheet captures demographics, medical history, emergency contacts, and consent signatures in one document.

Screening for a different condition that needs standardized scoring? DASS-21 screening tool shows how to score and interpret a validated 21-item severity scale.

Conclusion

The Barlow test is one of the few neonatal examinations where correct technique directly prevents a surgical outcome. A missed positive finding in the first weeks can mean a child faces open hip surgery at 18 months. Instead, early detection means a harness at 6 weeks.

The technique is learnable, and the clinical criteria are clear. IHDI and AAP guidance clearly define the referral threshold.

The documentation trail is where DDH referrals most often break down. Specifically, exam findings go unrecorded in a structured format, ultrasound referrals go untracked to completion, and orthopedic letters go unconfirmed.

Pabau’s digital forms and automated clinical workflows connect examination documentation, imaging requests, and referral letters in one auditable record instead. To see how it works in a pediatric or primary care setting, book a demo.

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