Barlow & Ortolani Signs—DDH, Congenital Hip Dislocation

In order to remember these tests, remember that “B” comes before “O” in the alphabet and will go in this order for these procedures as well. The “B” stands for Barlow and “O” for Ortolani. When reading the word “barlow” think: “We are going out tonight!”, because the hip can be popped out of the acetabulum with this maneuver. To remember Ortolani, think: “Once we have been out, now it is time to go home!”—during the Ortolani maneuver, the femoral head is reduced back into the acetabulum.

The Barlow maneuver identifies the unstable hip that is in a reduced position that the clinician can passively dislocate. When performing the Barlow Test, the examiner will flex the hip and knees to 90 degrees. The maneuver is performed by bringing the thigh towards the midline (adducting the hip). Mild pressure is then placed on the knee while directing the force posteriorly. The femoral head will be pushed out of the socket. The Barlow Test is considered positive if the hip can be popped out of socket with this maneuver. The dislocation will be palpable.

The Ortolani Test is used to confirm the findings of the Barlow test. The Ortolani maneuver is performed following the Barlow test to determine if the hip is actually dislocated. The Ortolani test is performed by the examiner flexing the hips and knees to 90 degrees. Reduction is done by abduction of the hip and pushing the thigh anteriorly. The test is positive is a palpable and audible clunk is heard from the hip being reduced. A hip click is a nonspecific finding.

In summary, The Barlow Test is performed when the hip is reduced and is used to dislocate the hip. The Ortolani Test is performed only after the Barlow Test has been performed and the hip has been dislocated. The Ortolani Test will reduce the hip.

Both of these tests are used for screening newborns during the neonatal period. The hips are examined one at a time and usually the hips are flexed during these maneuvers. Early diagnosis by these tests and preferably with ultrasound is essential to detect hip instability and dislocation in the neonatal period.

Treatment is directed at stabilizing the hip that has positive Barlow and Ortolani Signs. The first born female with a breach presentation and a positive family history are at risk of developing developmental dysplasia of the hip (DDH). If the hip remains dislocated for weeks, these two tests are usually not reliable. Barlow and Ortolani are not positive after 3 months due to the soft tissue contracture around the hip region. Limitation of abduction becomes the most consistent clinical findings. Children older than 12 months will have other findings which include asymmetry of hip abduction, a positive Trendelenburg gait and a positive Galeazzi sign.

Froment's Sign

The Froment’s sign occurs due to weakness of the adductor pollicis muscle in ulnar nerve palsy. The adductor pollicis muscle has two heads:

1. Transverse Head
   1. Originiates from the anterior body of the third metacarpal
2. Oblique Head
   1. Originates from the base of the second and the third metacarpals as well as the trapezoid and capitate bones

The two heads of the adductor pollicis muscle then insert into the base of the proximal phalanx of the thumb and the ulnar sesamoid bones. The muscle is innervated by the deep branch of the ulnar nerve. The function of the adductor pollicis muscle is to adduct the thumb. It is important in pinch strength. When the ulnar nerve is injured, the adductor pollicis function is lost and thumb adduction will not occur.

The Foment’s Sign is used to test the function of the adductor pollicis muscle. When pinching a piece of paper between the thumb and index finger against resistance, the thumb IP joint will flex if the adductor pollicis muscle is weak. The flexion of the thumb occurs by the flexor pollicis longus, which is innervated by the median nerve. The flexor pollicis longus, which is innervated by the median nerve, substitutes the function of the adductor pollicis which is innervated by the ulnar nerve.

Bulbocavernosus Reflex and Spinal Shock

The bulbocavernosus reflex indicates the absence or presence of spinal shock. Spinal shock usually occurs between 24-72 hours after a spinal injury. Spinal shock is manifested by the absence of the bulbocavernosus reflex, hypotension, bradycardia, and complete loss of motor sensation and reflexes. When the reflex is absent, this means that the patient is in spinal shock because the anal sphincter will not contract when the reflex is absent.

When the reflex is present, this signals the end of spinal shock; the anal sphincter will contract when the reflex is present. The reflex is check by monitoring anal sphincter contraction in response to squeezing of the penis of clitoris, or by pulling on an indwelling Foley catheter. It is a polysynaptic response mediated by S2-S4.

What is Spinal Shock?

Spinal shock is the loss of sensation and motor power following a spinal cord injury. Spinal shock is the loss of sensation and motor power following a spinal cord injury. After an injury to the spine, if the patient has no motor or sensory below the level of the lesion, the physician must determine if the patient is in spinal shock by checking the bulbocavernosus reflex.

If there is no anal contraction (absent bulbocavernosus reflex), this indicates that the patient is still in shock and the prognosis cannot be determined. If anal contraction is present (positive bulbocavernosis reflex), this indicates the end of spinal shock. The patient’s condition and prognosis at this point can be determined by examining sacral sparing (positive sacral sparing indicates an incomplete lesion).

Loss of sensation and motor power below the level of injury indicates complete spinal cord injury. Once the diagnosis of neurogenic shock is established, the blood pressure should be managed with vasopressors to prevent fluid overload. With the end of spinal shock, the prognosis can be determined. Examine the patient thoroughly, including sacral sparing. The patient may have normal, partial, or complete indications.