Ortolani and Barlow Maneuvers: Two Tests Every Newborn Needs
The Ortolani and Barlow maneuvers are two of the simplest tests in newborn medicine, each taking about 30 seconds to perform at the bedside. Together, they screen for developmental hip dysplasia, a condition in which the hip joint doesn’t form properly and the ball of the femur sits loosely in or completely outside the socket. When caught early, hip dysplasia is highly treatable, often requiring nothing more than a soft harness worn for a few weeks. But when it’s missed, the consequences can follow a child for years, making these simple but decidedly crucial tests that every newborn is supposed to be screened with before leaving the hospital.
What Are the Ortolani and Barlow Maneuvers?
These two tests are the standard bedside screening tools used to check whether a newborn’s hips are stable and properly seated in the socket. Understanding what each one does, how it’s performed, and what the results tell the provider is the first step toward understanding why they matter so much and what it means when they’re skipped.
The Ortolani Maneuver Explained
The Ortolani maneuver tests whether a dislocated hip can be guided back into the socket. The provider places the baby on a flat surface with the hips and knees bent at 90 degrees, then wraps their hands around each thigh with the fingers resting over the greater trochanter, the bony prominence on the outer side of the hip. From that position, the provider gently lifts and rotates the leg outward, away from the midline of the body. If the hip is dislocated, the examiner will feel a distinct “clunk” as the femoral head slides back into the acetabulum, the cup-shaped socket of the pelvis.
A positive Ortolani result means the hip was sitting outside the socket and could be manually reduced, or put back into place. This is the more serious of the two findings because it indicates that the joint has already become displaced. The clunk is different from the small, harmless clicks that many newborn hips produce during routine movement, and experienced providers know the difference. When the Ortolani is positive, further imaging and an orthopedic referral are the expected next steps.
What Is the Barlow Maneuver
The Barlow maneuver is the companion test, and it asks the opposite question: can a hip that’s currently in the socket be pushed out of it? The provider starts from the same position, with the baby’s hips and knees flexed, then applies gentle downward and inward pressure on each thigh, pushing toward the exam table and slightly across the body. If the hip is unstable, the examiner will feel the femoral head slip partially or fully out of the socket under that pressure.
A positive Barlow result means the hip is currently seated in the socket but is loose enough to be displaced with minimal force. This tells the provider that the joint isn’t developing the stability it should have, and that without intervention the dysplasia may worsen over time. Like the Ortolani, a positive Barlow warrants follow-up imaging and specialist evaluation. The two tests together take less than a minute to perform, and they give the provider a clear, immediate picture of whether each hip is stable, unstable, or actively dislocated.
What the Results Mean
The combination of both maneuvers produces one of three general outcomes. If the Ortolani is positive, the hip is dislocated but reducible, meaning it can be put back into place. This is the finding that calls for the most urgent follow-up, because the hip is already out of position and the longer it stays that way, the harder it becomes to treat without surgery. If the Barlow is positive but the Ortolani is negative, the hip is currently in the socket but unstable, a warning sign that the joint may not be developing properly and could displace on its own. If both tests are negative, the hip is stable and seated normally.
A positive result on either test doesn’t necessarily mean a baby will need surgery or face long-term problems. It means the provider has caught something early, which is exactly the point. Most cases of hip dysplasia identified in the first few weeks of life are treated with a Pavlik harness, a soft brace that holds the hips in a flexed, outward position to encourage proper hip development in the infant and allow the joint to stabilize. Treatment at this stage is non-invasive, well tolerated, and highly effective. The problems start when a positive finding is ignored, dismissed, or never identified in the first place.
Why These Tests Matter
The Ortolani and Barlow maneuvers exist because the window for easy, effective treatment of hip dysplasia is narrow, and what happens on either side of that window looks very different. This section covers what early detection makes possible, what a missed diagnosis can cost a child, and which babies are most at risk in the first place.
What Happens When Hip Dysplasia Is Caught Early
When hip dysplasia is identified in the first few weeks of life, treatment is straightforward. The standard approach is a Pavlik harness, a soft brace that holds the baby’s hips in a flexed, outward position to encourage the socket to deepen and the joint to stabilize on its own. Babies typically wear the harness for six to twelve weeks, and success rates are high, often above 90 percent when treatment starts early. The harness is non-invasive, doesn’t require anesthesia, and most babies adjust to it quickly.
At this stage, the condition is more of a developmental concern than a medical crisis. Regular follow-up imaging tracks the joint’s progress, and in most cases the hip matures normally with no lasting effects. The baby hits their milestones on time, moves without restriction, and grows up with no memory of ever wearing a brace. That’s the outcome every family should be able to expect when their provider does their job and catches the problem when it’s easiest to fix.
What Happens When It’s Missed
A missed diagnosis changes the picture dramatically. When hip dysplasia goes undetected past the first few months, the Pavlik harness is no longer effective, and treatment escalates quickly. Closed reduction under general anesthesia, where a doctor manually repositions the femoral head into the socket, becomes the next step. If that doesn’t hold, the child may need a spica cast that immobilizes them from the waist down for months. In the most severe cases, open surgery is required to reshape the socket or reposition the bone, sometimes more than once as the child grows.
The long-term consequences of a late diagnosis extend well beyond the operating room. Children with untreated or late-treated hip dysplasia often experience delayed walking, a noticeable limp, leg length discrepancy, chronic pain, and early-onset arthritis that can require a hip replacement before they reach middle age. All of it traces back to a screening test that takes less than a minute to perform and a treatment that, when started on time, is simple and highly effective.
Who Is Most at Risk
Certain newborns carry a significantly higher risk of hip dysplasia, and providers are expected to factor those risks into their screening decisions. Breech positioning is one of the strongest predictors, particularly frank breech, where the baby’s legs are folded up against the body in the womb. The sustained pressure on the hip joints in that position can interfere with normal socket development and lead to instability that needs to be caught early. Other well-documented risk factors include a family history of hip dysplasia, female sex (girls are affected at roughly four times the rate of boys), being a firstborn, and oligohydramnios, a condition in which low amniotic fluid limits the baby’s ability to move freely in the womb.
When any of these risk factors are present, providers should be watching closely for birth injury symptoms during the newborn exam, including hip instability on the Ortolani and Barlow tests. Clinical guidelines also recommend a hip ultrasound at around six weeks of age even if those tests were negative at birth, because some cases of dysplasia don’t become detectable on physical exam until the joint has had more time to develop. Skipping that additional screening when the risk factors are clearly documented is where many negligence cases begin.
When a Missed Diagnosis Becomes Medical Negligence
When a provider fails to screen for hip dysplasia or ignores the results, the consequences fall entirely on the child and their family. This section covers how those failures happen, what they cost in real terms, and why families in this situation need an attorney who understands both the medicine and the law.
How Providers Fail to Meet the Standard of Care
The Ortolani and Barlow maneuvers are not optional. They are part of the standard newborn physical exam, expected at every hospital and at routine well-baby visits in the first several months of life. Negligence enters the picture when a provider skips the tests entirely, rushes through them without applying proper technique, or gets a positive or equivocal result and fails to order the follow-up imaging that clinical guidelines call for.
These kinds of diagnostic errors don’t just mean a missed finding on a chart. They mean a child who needed a simple harness at two weeks old is now facing surgery at two years old. The failure is compounded when documented risk factors are present and the provider still doesn’t take extra precautions. A baby born in frank breech with a family history of hip dysplasia should receive a hip ultrasound at six weeks regardless of what the physical exam shows. When that ultrasound never gets ordered because nobody reviewed the chart carefully enough, the provider hasn’t just made an oversight. They’ve fallen below the standard of care that every family has a right to expect.
The Cost of a Delayed Diagnosis
The gap between early and late treatment for hip dysplasia is enormous, and it’s measured in surgeries, pain, and years of diminished quality of life. A baby whose dysplasia is caught at birth wears a Pavlik harness for a few weeks and moves on with no lasting effects. A child whose dysplasia isn’t caught until they start walking may face closed reduction under anesthesia, months in a body cast, and one or more open surgeries to reshape the hip socket or reposition the bone. Some of these children develop a permanent limp, chronic pain, or arthritis severe enough to require a hip replacement decades earlier than it should ever be necessary.
The financial toll compounds the physical one. Multiple surgeries, extended hospital stays, physical therapy, adaptive equipment, and lost parental income add up fast. And none of it had to happen: the injury, the cost, and the suffering all trace back to a 30-second test that someone either skipped or got wrong.
Why the Right Attorney Makes All the Difference
Missed hip dysplasia cases are failure-to-diagnose claims, and they require an attorney who can walk a jury through exactly what should have happened during that newborn exam and why it didn’t. Joseph Lichtenstein has built his career on that kind of case. He’s nationally recognized for his work in birth injury litigation, has lectured to the American Association for Justice on complex injury claims, and has a courtroom record that speaks for itself: an undefeated streak of eight-figure verdicts over the last four years and recognition as New York’s Medical Malpractice Attorney of the Year three times. If your child’s hip dysplasia went undiagnosed, contact the Law Offices of Joseph Lichtenstein. Your child shouldn’t pay the price for someone else’s negligence.