Stanisavljevic, Stanko

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Henry Ford Hospital Medical Journal Volume 10 Number 1 Article 27 3-1962 Clinical Findings In Examination Of Hips In Newborn Babies Stanko Stanisavljevic Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Stanisavljevic, Stanko (1962) "Clinical Findings In Examination Of Hips In Newborn Babies," Henry Ford Hospital Medical Bulletin : Vol. 10 : No. 1 , 245-252. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol10/iss1/27 This Part II is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Bull. Vol. I 0, March . pt. 2, 1962 CLINICAL FINDINGS IN EXAMINATION OF HIPS IN NEWBORN BABIES STANKO. STANISAVIJEVIC, M.D. DURING TII E period 1958- 196 1 the author personally exa mined the hips o f 5 125 newborn babies. Examination was performed two to 'iilX days after bir th. Some im-pressions based on th i experience are recorded here The e<tamincr ~hould know the clinical features of no rmal hips and it i taken for granted that this is the case. · Ortolt111i's Sign (Of The "Click")'·' To e lici t Ortolani 's sign the baby should be examined upine. While supi ne both hands of the examiner grasp 1he IO\\ Cf extremities at the knees with thighs flexed 90° in neutra l rotation and knees flexed 90-100° . The thumbs a re placed on the medial side and the fingers on the lateral side of the child 's knees. The index finge rs arc placed a long the femoral shaft poin ting toward the greate r trochanters. To examine the left hip, the examiner holds the right hip pressed firmly against the examining table and exerts moderate pressure on 1he left knee downward a long the femo ral axi5 to transmi t pressure posteriorly from the femur across 1he hip.' Al this moment the examiner feels an inaudible click. This is the click of the fe moral head exiting from 1he acetabulum. The examiner now abduct the same hip (left), keeping the index finger along the grea ter trochantcr and mainta ining the !;ame posteriorly directed pressure on the k~ee. (This moment is important. If the examiner diminishes pressure on the knee and removes the index finger from the greater trochanter he will be unable to detect the second click accompanying re·cn trance of the femoral head into the acetabulum. ) The abduction of the hip is gradual. At approximately 45-50 the examiner should feel a slight resistance and immediately afterward the second click should be felt with the finger. This is the c lick of re-entrance, which is mo re pronounced 1han the click of exi t, but still inaudible. This sequence o f events is Ortolani's sign. It is empahsized that the fir t click (of exit) is correlated with a fee ling o f giving way; this i the moment when part of the femoral head displaces over the ridge of the acetabulum . This position of partial subluxa tio n of the femora l head has to be main tained by conti nued pressure on 1hc knee, the index finger remaining on the greater trochanter. In subsequent abducuo n of the hip the feeling o f slight •From the Dep:artmcnt o r Onhoped1c Sur.gcry and the Orthopedic Research Laboratory. Work aided by the fo llow,~g grant : Orthopedic Research and Educahon Foundation; A-4186 Surg .. N.I.H., Bethesda, Md ., 29) Hen ry Ford Hospita l. 245 STANISAVLJEVIC Figure I Anatomo-pathological characteristic in a hip with telescoping . rc)isiancc mentioned is due to pressure of part of the femoral head against the aceiabular ridge and perhaps in part by tension of the ligamcntum teres and antero-infcrior articular capsule. At this moment the tip of the index finger must press medially on the greater trochanter to produce the click of entrance which results from jumping of the femoral head over the acetabular ridge accompanying reduction into the acctabulum. These details are noted to permit differentiation of Ortolani 's sign from clicks 1n normal hip 1 \.\hich are due to sliding of the iliopsoas tendon over an enlarged ,ho-pecuneal bursa, or to knee clicks transmitted to the hip through the femur. 246 HIPS IN NEWBORN BABIES Figure 2 Range o( abduc tion of the thighs in thh, 3 day o ld girl (born in occiput posilion) wa.s 85°. The hips "ere normal. There ha1:1 been no limitation of abduction in hips of newborn babies wilh positive Ortolani's sign. A11momict1l Findings A .rsociated wi1h Ortolani's Sign Two hundred and forty hips in 120 stillborn babies were dissected. Examination of these hips prior to dissection yielded a positive Ortolani's sign in three hips of two babies. Anatom1cal·pathological features of the!te three hips \\ere: a) A defect on the supero-posterior aspect of the ridge of the acetabulum. b) The articular capsules \\ere enlarged, permilling displacement of part of the femora l head over the aforesaid defective ridge of the accrnbulum. In normal hips of stillbo rns the femora l head could not be displaced out of the acctabulum . It was easier in normal hips to produce a traumatic cpiphyscoly~is of the proximal femora l epiphysis than to dislocate or subluxate the femoral head when the articular cap.!tule was intact. c) Ligamentum tcrcs \\3S thicker and longer than normally. Among 5125 newborn babies positive Ortolani's sign was found in 33 hips of 24 babies. It is hard to derect Orto lani's sign if unfamiliar wi th the proper technique. It is well to get acquainted Y+ ith the smooth. regular morion of normal hips in new-247 ST A /SA VLJEVIC Figure 3 Rjngc or abduct ion of this 4 driy old girl (born m breech po ition was 85•. The hips were normal (note ecchmos,., m the gluteal region which 1s chornc1eris11c for breech born babies). born babies to be able to recognize and differentiate belier the abnormal from the normal findings . 1 e/ercopmg Sign Telescoping is extreme mobility and wa nderi ng of the femoral head. Piston motion of the femoral head is produced by flexing the 90° with neutral rotation; mm1m,1I po,tcriorly direc1ed pressure on the knee produces supero·posterior displace-ment of the femora l head "• ith an accompanying feeling of complete looseness of the hip. Push-pull force on the hips "uh hip extended gives lhe same sensation. In lclcscoping hips of newborn babies Or1olani's sign usually cannot be produced bccau\C the femoral head is nm reduced into lhc ace1abulum by the maneuver. h is necc,,ary lO U1ffercntrate clearly the ~ign of lclescoping fro m Ortolani's sign. Only one among 240 dbsected hips ex hibited telescoping on clinical examinalion.5 Am,ramical Fitu/ings Associmec/ with Telescoping Ille anJlomical-pathological charactcris1ics of the single hip with telescoping "ere ( Figure o. I) a) Ver) mall, defom,ed, shallo" acetabulum which could not retain the femoral head 248 HIPS IN NEWBORN BABll:.S Figure 4 Range of abduction in 1h1s 3 day old boy (born in occiput posi1ion) "'as 1~· . The hips \\Crc normal. b) Large, lax articular capsule wit hin which the femoral head was hypcrmobi le . c) Long, lax ligament um teres permiuing h) permobility of the femoral head In the hip with these anatomical-pathological characteristics it was not possible to reduce the femora l head into the small, shallow and deformed acetabulum. The femora l head probably was oul of the acetabu lum constantly. This was the reason for the negative Ortolani's sign. Among 5 125 newborn babies fo ur hips ( in two newborn habies) wit h telescoping '-"tre detected. There was no limi1ation of abduction, probably for these reasons : a) Spasm and shortening of the adduc1or muscles were observed to slart after the second or third week of age. b) Mobili ty of the head with in the articu lar capsule wa so great that during the abduction maneuver the femoral head would slide easily and palpably in to the reg ion of the acetabu lu m (without true reduct io n ). No limitation of abduction of the hip occurred as a result . The author's statistics indicate that telescoping is a rare sign 1n the newborn. Limitmion of A bduc1io11 in Newborn Babies The value of limitation of hip abduction in neY+ borns .,s a pathognomonic or premonitory sign of congenita l hip dislocation or subluxation is controver!!iial. 1 This ~1gn is ubjective, depending on the force the examiner uses to abduct the hips. 249 STAN/SA VLJJ:.VIC Figure 5 I n normal nc" born girls abduc11on of the hips is slightly easier than in newborn hoys. The r~rngc of abduc1ion in normal newborn girls is 75-85 , and in normal ne"horn boys 70- 0 . In babies born in the breech position hips could be ab-ducted 85 ea;il) ( figures 2, 3, 4.) In 1958 nine newborn babies (3 male~ and 6 females) with limirntion of abducuon 10 60-65 "ere found. X-rays of these hips "ere considered norma l, and I 2 m nth, clinical and x-ray follm,-up did not disc lose any subsequent hip ob-normaht) • Tht• flip-Knee-Hip Trnitl \ ith the bah) liupinc. the c,cami ncr first cxtcnd<ii the hips, fo llowed by extension of the knee , after which the thighs arc abducted 75-80 The force normally required 10 extend the hips is greater thrm that required to extend the knees . The force rcqu1rcll 10 ~hducr 1hc hip\ is less than tha t required 10 extend the knees. In umm<tr}, le" force ,; required 10 abduct the hip, than 10 complctel) e.iend the hips and the knee, in the ,ame n rmal ne"bom baby. (Figure 5. 6, 7.) These findings arc u uall) the ,ame whether the ne"bom bab) 1 rela.ed. or crying and resisting 250 e II h tt lo b1 IS H di ho th, wi HIPS IN NEWBORN BABIJ:.S examination . The aut ho r h~1s ca lled 1h is sign 1hc norma l hip-knee-hip 1raid,' and it has been uniformly present in over 4000 normal newborns. An abnormal triad was found in 4 babies. The force required 10 abduct the hips in each of these 4 newborn babies was greater than that req uired 10 extend the hips and knees. Fo llow-up of these 4 babies revealed development of a dis-located left hip in one case. and de \ elopmcnt of hip subluxati n m the other 3 babies, a ll within 3 months of birth. It is emphasized that the hip-knee-hip triad 1s not considered uncquivocably diagnostic of congenital prcdisloca1ion or disloca1ion. However, it sems to be a promi~ing sign for prognosticating development of hip dislocation or subluxation. The anatomical-pathologica l find ings in hips with abnormal hip-knee-hip triad 1s a matter of speculation, because for obviot11i reasons the auth r did not find th i5t sign in any stillborn baby. The author suggests that the 4 babies w11h abnormal hip-knee-hip iriad were born with normal hip joi nl s but had an inborn e rro r in muscle balance around the hips, ( tightness o f the adducto rs) \\hich was al leas t in part the reason that within three months hip subluxa1ion or dislocation developed. SUMMAR, The author describes three clinical sign51 "h1ch help in di,co,·cring congenilal hip pa1hology in newbo rn babie~. These sign, are Onolani"s ,ign , lclc,coping. and hip-knee-hip triad. It is felt that limita tion of abduclion i,; an unre liable indication of hip dysplasia or disloca11on. 251 STAN/SA VLJEVIC Figures 5, 6, 7 Three poses or examination for hip-knee-hip tri ad . F1rs1 pose : Ex tension of the hips. Second pose: Ex1ention of the knees. Third pose: Abduction or the hips. ( Reproduced from Archivio de Orthopcdia ) The examiner of hips in newborn babies should be aware of and search for these signs. Proper technique in testing for Ortol ani 's sign, telescoping and abnormal hip-k nee-hip triad can avoid later discovery of congenital hip dislocation or subluxation. REFERENCES I. Caffey, J., Ames, R .. Silverman, W. A., Ryder, C. T ., and Hough. G.: Contradiction of the congenillll dysplasia~predislocation hypolhesis o f congenit a l disloca tion of the hip through a siudy of the normal variation in acetabu lnr angles at successive periods in infancy, Pediatrics 17 :532, 1956. 2. Ortolani. M.: Le diagnostic cliniquc, fail par l:l rccherche du signe du ressaut. est le seul moyen pcrmeuan1 le traitement vraiment prCCoce et total de la Ju:imtion congEnitale de la hanche, Bull . Acad. nat. nicd. Paris 141 : 188, 1957. 3. Or1olani, M. : Lussazione Congenita Del l'anca, Bologna, Cappelli, 1948. 4, Stnni a\ljevic, S.: E~nminntion of hips in newborn babies and results, Henry Ford Hosp. Med. Bull . 9 :2 15, 1961. 5. Stuni.'invljevic, ., and M11chell, C. L : Congcnirnl hip dysplasia, subluxation nnd dislocation in the still and newborn infants : ana1omica l-p21hologicnl study . (To be pub lished) 6. Sum, a\llJevic, S. : Hip-knee-hip triad ; a helpful clinical sign in examination of hips in newbo rn babies, Arch . Onhop. ( Milano) 74 :577, 1961. 252 I 

Clinical Findings In Examination Of Hips In Newborn Babies

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Clinical Findings In Examination Of Hips In Newborn Babies

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