A nurse is assessing a 3-day-old newborn and observes asymmetric gluteal folds and limited abduction of the left hip. Which assessment finding would be most concerning and require immediate notification of the healthcare provider?

A positive Ortolani sign with an audible click is a definitive indicator of developmental dysplasia of the hip (DDH) requiring immediate notification for treatment to prevent long-term complications. Other findings like asymmetric folds or limited abduction are concerning but less specific for urgent intervention.

Clinical Context and Initial Assessment
The nurse's observation of asymmetric gluteal folds and limited hip abduction in a 3-day-old newborn raises immediate suspicion for Developmental Dysplasia of the Hip (DDH). DDH encompasses a spectrum of anatomical abnormalities, from mild acetabular dysplasia to frank hip dislocation, where the femoral head loses contact with the acetabulum. Early diagnosis during the neonatal period is critical because it allows for effective, non-surgical management, such as harness therapy, and prevents long-term sequelae including residual acetabular dysplasia, premature arthritis, and gait disturbances ^[1][4]. The initial clinical screening, as highlighted in universal programs, is the cornerstone of timely detection, and any positive finding warrants prompt escalation ^[2][3].

Analysis of Assessment Findings
To determine the most concerning finding, it is essential to distinguish between signs that are sensitive screening tools and those that are specific diagnostic indicators of a dislocatable or dislocated hip.

• Positive Ortolani sign with audible "click" (Option 1): The Ortolani maneuver is a specific test for DDH. A positive sign is the tactile and often audible sensation of the femoral head reducing into the acetabulum as the hip is abducted. This finding represents an unstable hip that is dislocated at rest but reducible. It is a definitive pathological sign that confirms hip instability and requires immediate orthopedic referral for initiation of treatment, making it the most concerning finding in this context ^[1][3].




• Slight asymmetry in leg length (Option 2): This finding, known as the Galeazzi sign, is observed when the hips and knees are flexed. A visible shortening of one femur suggests a dislocated hip where the femoral head rests superiorly and posteriorly to the acetabulum. While it is a classic sign of DDH, it is typically more apparent in a unilateral, high-riding dislocation that has been present for some time. In a 3-day-old newborn, a subtle asymmetry may be a less specific finding than a positive Ortolani sign, which directly demonstrates active instability.




• Mild resistance to passive range of motion (Option 3): Limited abduction, often defined as less than 60 degrees, is a key screening finding for DDH and is already present in the initial scenario. While it increases the index of suspicion, it is not as definitive for acute instability as a positive Ortolani sign. The resistance can sometimes be due to normal physiologic muscle tone, making it a less specific standalone indicator for immediate notification compared to a palpable reduction.




• Unequal gluteal folds when prone (Option 4): Asymmetric thigh or gluteal folds are a common and sensitive screening sign for DDH. However, this finding has low specificity; it is present in a significant percentage of normal infants without any hip pathology. In the context of the initial assessment, this finding has already been noted and, on its own, does not confirm instability or the need for emergency intervention like a positive Ortolani sign does.

Rationale for Immediate Notification
The positive Ortolani sign is the most concerning finding because it provides direct, physical evidence of a dislocated and reducible hip. This represents an unstable joint that is at high risk for remaining dislocated without intervention, leading to the development of secondary soft-tissue contractures and residual acetabular dysplasia (RAD) ^[4]. National screening programs, such as the NHS Newborn and Infant Physical Examination (NIPE) programme, emphasize the importance of the initial clinical examination within 72 hours of birth to detect such instability early ^[2]. A positive Ortolani sign is an unequivocal indication for immediate referral to a pediatric orthopedist for confirmatory imaging, typically ultrasound, and the prompt initiation of treatment with a Pavlik harness, which maintains the hip in a flexed and abducted position to stabilize the joint and promote normal acetabular development ^[1][3]. Delaying notification of this specific finding directly compromises the window for successful non-surgical management.