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.

Most cases are detectable at birth with a careful physical examination, yet 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, 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 used to detect a hip that is located in the acetabulum but can be dislocated with applied force.

It was described by Thomas Geoffrey Barlow in 1962 and, alongside the Ortolani maneuver, forms the cornerstone of neonatal hip screening in the UK, US, and most of Europe. A positive Barlow test indicates a dislocatable hip; it does not mean the hip is currently dislocated.

About 1 in 10 newborns has some hip instability at birth, but 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. Detected in the first few weeks of life and treated with a Pavlik harness, most hips normalize without surgery.

The Barlow test is performed at the newborn examination and at every well-baby check until the infant is 3 months old, when 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, consistently identified across clinical guidelines, are female sex, breech presentation, and a positive family history in a first-degree relative.

• Female sex: girls are 4 to 8 times more likely to develop DDH than boys, likely related to greater ligamentous laxity in response to maternal estrogen.
• Breech presentation: frank breech (extended knees) carries the highest risk; 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 are associated with 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, per IHDI and American Academy of Pediatrics (AAP) guidance. Using standardized clinical assessment tools alongside structured risk stratification helps ensure no high-risk infant is missed during a busy 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 to prevent pelvic rotation during the maneuver.
3. Grasp the thigh: with your testing hand, cup the infant’s thigh so your thumb lies along the inner thigh and 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, directed 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 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

The Ortolani maneuver is performed immediately after the Barlow test, starting from the same position. Where the Barlow test dislocates a located hip, the Ortolani reduces a hip that is already dislocated. 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, directing 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. A positive Barlow indicates a hip that can be dislocated. 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: a clunk is felt as a definite mechanical movement of the femoral head crossing the acetabular rim. A click is a high-pitched, soft sound without accompanying movement, usually from periarticular soft tissue. Clicks are common and benign. 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, when the Barlow and Ortolani maneuvers lose sensitivity due to increasing hip muscle tone and tightening of the hip capsule.

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

This sign is more reliable for unilateral DDH. 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.

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, particularly in 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% and a specificity of 98 to 99% in experienced hands.

Reported sensitivity varies widely with examiner experience and study design: pooled meta-analytic estimates across multiple studies have found sensitivity as low as 36% (PMC9194706). A negative exam in a high-risk infant should never be treated 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 by making 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, and 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: indicated for a positive Barlow test or Ortolani at any age, or 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 that can link imaging results directly to the original clinical examination record, ensuring the imaging referral, result, and any follow-up action are all captured in one place rather than 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 from within the clinical record at the point of examination, ensuring the referral letter is generated, tracked, and followed up without relying on manual processes. For context on how clinical forms management supports systematic screening documentation, structured workflows reduce the administrative burden that leads to referral delays.

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, but 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, encouraging 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 from examination to imaging to referral. In busy primary care and pediatric practices, this is where DDH cases slip through: the positive Barlow test is noted 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, including 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.

For teams wanting to improve their note quality overall, safer clinical note-writing practices and structured clinical consultation templates provide frameworks that reduce examiner variability.

For practices managing compliance documentation across multiple well-baby clinicians, Pabau’s audit trail means every Barlow test result is date-stamped, attributed to the examining clinician, and retrievable if a case is later reviewed.

The platform also supports follow-up task creation: when a hip ultrasound is ordered, an automated task confirms the result has been received and acted on, so it never sits filed away without a next step.

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 of life can mean a child faces open hip surgery at 18 months instead of a harness at 6 weeks.

The technique is learnable, the clinical criteria are clear, and the referral threshold is well defined by IHDI and AAP guidance.

The documentation trail is where DDH referrals most often break down: exam findings not recorded in a structured format, ultrasound referrals not tracked to completion, and orthopedic letters not confirmed as sent.

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.

Frequently Asked Questions