The Ortolani sign is a specific “clunk” felt during a newborn hip exam that indicates a dislocated hip has just been guided back into its socket. It’s one of the earliest physical tests used to screen for developmental dysplasia of the hip (DDH), a condition where the hip joint doesn’t form properly. The test is performed on nearly every newborn in the first days of life and remains part of routine well-baby checkups through the first year.
How the Test Is Performed
The baby lies on their back with the hip bent to 90 degrees. The examiner holds the leg with their index and middle fingers along the bony prominence on the outside of the hip (the greater trochanter) and the thumb along the inner thigh. From this position, the examiner gently spreads the leg outward and lifts it forward. If the hip was dislocated, this motion guides the top of the thighbone back into the hip socket, and the examiner feels a distinct clunk as it slides into place. That clunk is the positive Ortolani sign.
The sensation is different from the harmless, high-pitched clicks that many newborn hips produce. Those soft clicks are common and don’t indicate a problem. The Ortolani clunk is deeper and more tactile. As one physician described it, “Until you’ve felt it, there’s a real worry that you might miss it. Once you’ve felt one, you’ll never forget it.” It takes hands-on experience to reliably distinguish the two, which is one reason the test has limitations in practice.
What’s Happening Inside the Joint
In a healthy hip, the rounded top of the thighbone (femoral head) sits snugly inside a cup-shaped socket in the pelvis (acetabulum). In DDH, that socket is too shallow or the surrounding tissues are too loose, allowing the femoral head to slip partially or fully out of position. When the Ortolani maneuver abducts the leg and lifts it forward, it creates just the right angle and pressure to coax a fully dislocated femoral head back into the socket. The clunk is the moment of re-entry.
This is the key distinction from the related Barlow test, which does the opposite. The Barlow maneuver pushes the leg inward and backward, testing whether a hip that’s currently in the socket can be pushed out. A positive Barlow test means the hip is unstable and dislocatable. A positive Ortolani test means the hip is already dislocated but can be put back. Together, the two tests cover both scenarios of hip instability.
Ortolani vs. Barlow: Two Sides of the Same Exam
These two maneuvers are almost always performed together as a pair, but they answer different questions:
- Ortolani test: Starts with a dislocated hip and attempts to relocate it. A clunk on re-entry is positive.
- Barlow test: Starts with a hip in normal position and attempts to dislocate it. A clunk on exit is positive.
A baby can have a positive result on one test but not the other, or on both. Either positive result warrants further evaluation. The examiner also looks at other physical signs during the same exam, including whether the skin folds on the thighs are symmetrical and whether one leg appears shorter than the other.
How Accurate the Test Is
The Ortolani and Barlow tests are highly specific but not especially sensitive. A meta-analysis of 16 studies found a pooled sensitivity of 36% and specificity of 98%. In practical terms, this means a positive result almost certainly indicates a real problem (very few false positives), but a negative result doesn’t rule DDH out. Nearly two-thirds of cases can be missed by clinical exam alone.
This is why hip screening doesn’t rely on a single exam at birth. Pediatricians check the hips at every well-baby visit through the first year: at the initial newborn check, again at two weeks, then at one, two, four, six, nine, and twelve months. Ultrasound imaging is also used for babies with risk factors or equivocal exam findings, and it’s considerably more sensitive than physical examination.
When the Test Stops Working
The Ortolani maneuver is most useful in the first few weeks of life, when the baby’s muscles are relatively relaxed and the hip can move freely enough for the examiner to feel a clunk. By 8 to 12 weeks of age, increasing muscle tone and tightening of the tissues around the hip make the maneuver unreliable. The test is recommended up to 6 months of age but begins losing sensitivity well before that point.
After that window closes, clinicians look for other signs: limited range of motion when spreading the legs apart, uneven leg lengths, and asymmetric skin folds. For older infants who aren’t yet walking, ultrasound remains the primary imaging tool. Once a child is weight-bearing, X-rays become more useful because the bones have hardened enough to show up clearly.
What Happens After a Positive Result
If the Ortolani or Barlow test is clearly positive at the newborn exam, referral to a pediatric orthopedist is the standard next step. If the findings are borderline, such as a soft click without a true clunk or mild asymmetry without frank instability, the baby is typically re-examined at two weeks. A positive finding at that follow-up also leads to an orthopedic referral.
The goal of early detection is early treatment. When DDH is caught in the first few months, it’s typically managed with a soft brace that holds the hips in a flexed, outward position, encouraging the socket to develop normally around the femoral head. Most babies wear the brace full-time for 6 to 12 weeks. Success rates are high when treatment starts early, and most children go on to develop completely normal hip function. Late detection, on the other hand, can require surgery and has a higher risk of long-term joint problems, which is exactly why the Ortolani test exists as a frontline screening tool in the first place.