Monday, October 30, 2017

Some Limb Deformities in a Newborn

1. Metatarsus adductus. In metatarsus adductus, the forefoot is deviated medially and is slightly supinated. In the normal foot, a line drawn through the hindfoot will pass between the second and third toe. With metatarsus adductus, this line will pass lateral to the third toe. The prognosis is excellent, with most cases of metatarsus adductus resolving spontaneously.

2. Calcaneovalgus. Calcaneovalgus deformity of the foot is commonly associated with lateral tibial torsion. The forefoot is abducted, and the ankle is severely dorsiflexed to where the foot folds against the anterolateral surface of the tibia. The deformity is usually flexible, and the foot can be passively placed in the normal position. Calcaneovalgus deformity of the foot usually resolves spontaneously.

3. Talipes equinovarus. Talipes equinovarus, or club foot, has an incidence of approximately 1.5 in 1,000. Fifty percent of the time, the condition is bilateral. It can be associated with other conditions such as spina bifida and arthrogryposis. The foot turns inward and downward and remains tight in this position. Talipes equinovarus requires immediate evaluation since the timing of corrective casting, if necessary, can affect optimal outcome.

The Hip Joint
The hips require special attention in the newborn period. Early detection of developmental dysplasia of the hip (DDH) is associated with better outcome. In general, developmental dysplasia of the hip refers to an abnormal relationship between the femoral head and the acetabulum. This encompasses instability, subluxation, acetabular dysplasia, and frank dislocation. Risk factors include first-born, female, left side, breech delivery, and family history. DDH can be associated with torticollis, foot abnormalities, and other musculoskeletal disorders.
A complete exam of the hips is imperative. In the older infant, limited range of motion is a common presenting sign.
However, in the newborn, examination of range of motion in the newborn is not adequate for checking stability of the hip.
Two maneuvers are essential to the newborn exam, the Barlow and Ortolani maneuvers . The
optimal method in examining the hips of the newborn is when the infant is relaxed. Always examine the infant with a released diaper. Each hip should be examined separately.

The Ortolani maneuver reduces a dislocated hip. With the infant lying supine, the Ortolani is performed with the index and third finger positioned on the greater trochanter and the thumb positioned on the inner thigh. The other hand should be used to stabilize the pelvis. While the hip is flexed at a 90-degree angle and the leg is kept in a neutral position, abduct the hip and raise the leg anteriorly. With a positive Ortolani sign, this maneuver reduces an already dislocated hip and will produce a “clunk” sensation. This sign is produced by the head of the femur sliding over the edge of the acetabulum and into the socket. The term “click” should not be used and is not a diagnostic term.

The Barlow maneuver is a provocative test to detect those hips that are unstable, that is, able to be displaced from the acetabulum to a dislocated position. As with the Ortolani, one hand performs the maneuver and the other stabilizes the pelvis. The hand positioning is also similar to the Ortolani. Gently adduct the hip while applying a posterior pressure with the weight of the hand. The normal hip will not dislocate but the dislocatable hips will move very smoothly and subtly out of the socket. The second part of the Barlow maneuver is the classical Ortolani test,
that is, abducting the hip and lifting the dislocated femoral head over the rim of the socket.


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