Newborn Period And Infancy

Enormous changes in the musculoskeletal system occur during infancy. Much of the newborn musculoskeletal exam focuses on detection of congenital abnormalities, particularly in the hands, spine, hips, legs, and feet. With a little practice, you will be able to combine the musculoskeletal examination with the neurologic and developmental examination.

The newborn's hands are clenched. Because of the palmar grasp reflex (see the discussion on the nervous system), you will need to help the infant extend the fingers. Inspect the fingers carefully, noting any defects.

Skin tags, remnants of digits, poly-dactyly (extra fingers), or syndactyly (webbed fingers) are congenital defects noted at birth.

Palpate along the clavicle of the newborn, noting any lumps, tenderness, or crepitus; these may indicate a fracture.

Inspect the spine carefully. While major defects of the spine such as menin-gomyelocele are obvious and often detected by ultrasound prior to birth, subtle abnormalities may include pigmented spots, hairy patches, or deep pits. These abnormalities, if present within 1 cm or so of the midline, may overlie external openings of sinus tracts that extend to the spinal canal. Do not probe sinus tracts because of the potential risk of infection. Palpate the spine, particularly in the lumbosacral region, noting any deformities of the vertebrae.

Examine the newborn and infant's hips carefully at each examination for signs of dislocation. The following photos demonstrate the two major tech-

A fracture of the clavicle can occur during a difficult delivery.

Spina bifida occulta (a defect of the vertebral bodies) may be associated with defects of the spinal cord, which can cause severe neurologic dysfunction.

niques, one to test for the presence of a posteriorly dislocated hip (Ortolani A soft audible "click" heard with test), and the second to test for the ability to sublux or dislocate an intact but these maneuvers does not prove a unstable hip (Barlow test). dislocated hip, but should prompt a careful examination.

Newborn Barlow Test

Make sure the baby is relaxed for the next two techniques, using a bottle or With a hip dysplasia, you feel a pacifier if appropriate. For the Ortolani test, place the baby supine with the "clunk" as the femoral head, which legs pointing toward you. Flex the legs to form right angles at the hips and lies posterior to the acetabulum, knees, placing your index fingers over the greater trochanter of each femur enters the acetabulum. and your thumbs over the lesser trochanters. Abduct both hips simultaneously until the lateral aspect of each knee touches the examining table. A palpable movement of the femoral head back into place constitutes a positive Ortolani sign.

For the Barlow test, place your hands in the same position as for the Ortolani test. This time, press in the opposite direction with your thumbs moving down toward the table and outward. Feel for any movement of the head of the femur laterally. Normally there is no movement and the hip feels "stable." If you feel the head of the femur slipping out onto the posterior lip of the acetabulum, this constitutes a positive Barlow's sign. If you do feel this dislocation movement, abduct the hip by pressing with your index and middle fingers back inward and feel for the movement of the femoral head as it returns to the hip socket.

A positive Barlow's sign is not diagnostic of a dysplastic hip, but it indicates laxity and a dislocatable hip progressively, and the baby needs to be reexamined in the future.

Negative Ortolani Sign

Children older than 3 months may have a negative Ortolani or Barlow sign and still have a dislocated hip due to tightening of the hip muscles and ligaments.

In addition to examining the hips, it is important to examine a newborn or infant's legs and feet to detect developmental abnormalities. Assess symmetry, bowing, and torsion of the legs. There should be no discrepancy in leg length. It is common for normal infants to have asymmetric thigh skinfolds, but if you do detect asymmetry, make sure you perform the instability tests because dislocated hips are commonly associated with this finding.

Most newborns are bowlegged, reflecting their curled up intrauterine position. During early infancy, there is a common and normal progression of increased bowlegged growth (as shown below, left), which begins to disappear at about 18 months of age, often followed by transition toward knock-knees. The knock-knee pattern (as shown below, right), is usually maximal by age 3 to 4 years, and gradually corrects by age 9 or 10 years.

Severe bowing of the legs (genu varum) may still be physiologic bowing and will spontaneously resolve. Extreme bowing or unilateral bowing may be due to pathologic causes such as rickets or tibia vara (Blount's disease).

Another finding after 3 months of age is apparent femoral shortening (positive Galeazzi or Alice test). The picture below demonstrates this technique. Place the feet together and note any difference in knee heights.

Some normal infants exhibit twisting or torsion of the tibia inwardly or out- Pathologic tibial torsion occurs wardly on its longitudinal axis. Parents may be concerned about a toeing in only in association with deformities or toeing out of the foot and an awkward gait, all of which are usually nor- of the feet or hips. mal. Tibial torsion corrects itself during the second year of life after months of weight bearing.

The presence of tibial torsion can be assessed in several ways; one method is shown above. Have the toddler lie prone on the examination table, with the knees flexed to 90°, as shown. Note the thigh-foot axis. Usually there is ±10° of internal or external rotation.

Children may toe in when they begin to walk. This may increase up to 4 years and then gradually disappear by around 10 years of age.

Now examine the feet of newborns and infants. At birth, the feet may ap- True deformities of the feet do not pear deformed from retaining their intrauterine positioning, often turned return to the neutral position even inward as shown on the following page. Manipulate the affected foot—a with manipulation.

normal foot should be easy to correct to the neutral and even to an over-corrected position. Also, you can scratch or stroke along the outer edge to see if the foot assumes a normal position.

Normal Feet Posture

The normal newborn's foot has several features that may initially concern you. These features, shown on the next page, are benign. The newborn's foot appears flat because of a plantar fat pad. There is often inversion of the foot, elevating the medial margin. Other babies will have adduction of the forefoot without inversion, called metatarsus adductus. Still others will have adduction of the entire foot. Finally, most toddlers have some pronation during early stages of weight bearing, with eversion of the foot. In all of these normal variants, the abnormal position can be easily overcorrected past midline. They all tend to resolve within a year or two. The series of illustrations on the next page shows examples of pathologic foot deformities of newborns and infants.

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