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Orthopedic problems in neonates

Congenital disorders are commonly screened by pediatricians and certain disorders like club foot needs early intervention to get satisfactory results .I have tried to present common disorders in neonates for early diagnosis.

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Orthopedic problems in neonates

  1. 1. J K Laik DNB(Ortho),MNAMS
  2. 2. Common Pediatric Foot Deformities
  3. 3. Anatomy/Terminology 3 main portion 1.Hindfoot – talus, calcaneus 2.Midfoot – navicular, cuboid, cuneiforms 3.Forefoot – metatarsals and phalanges
  4. 4. Anatomy/Terminology • Important joints 1. tibiotalar (ankle) – plantar/dorsiflexion 2. talocalcaneal (subtalar) – inversion/eversion • Important tendons 1. achilles (post calcaneus) – plantar flexion 2. post fibular (navicular/cuneiform) – inversion 3. ant fibular (med cuneiform/1st met) – dorsiflexion 4. peroneus brevis (5th met) - eversion
  5. 5. Anatomy/Terminology • Varus/Valgus
  6. 6. Calcaneovalgus foot
  7. 7. Calcaneovalgus foot • Ankle joint dorsiflexed, subtalar joint everted • classic positional deformity • more common in 1st born, twins • 2-10% assoc b/w foot deformity and DDH • treatment requires stretching: plantarflex and invert foot • excellent prognosis
  8. 8. • true congenital deformity • 60% assoc w/ some neuro impairment • plantarflexed ankle, everted subtalar joint, stiff • requires surgical correction (casting is generally ineffective)
  9. 9. • Boat shaped
  10. 10. Talipes Equinovarus (congenital clubfoot) 3 basic components 1. Ankle joint plantarflexed/equines 2. Subtalar joint inverted/varus 3. Forefoot adducted
  11. 11. Talipes Equinovarus (congenital clubfoot) • Incidence - approx 1/1,000 live births -M>F -1st born - usually sporadic - bilateral deformities occur 50% • Etiology - unknown - ?defect in development of talus leads to soft tissue changes in joints, or vice versa
  12. 12. Talipes Equinovarus (congenital clubfoot) • Diagnosis/Evaluation - distinguish mild/severe forms from other disease - Look for associated anmalies • Spina bifida • DDH
  13. 13. Talipes Equinovarus (congenital clubfoot) Ponsetti’s Kite
  14. 14. Pes Planus (flatfoot) A. General - refers to loss of normal medial long. arch - usually caused by subtalar joint assuming an everted position while weight bearing B. Evaluation - painful? - flexible? (hindfoot should invert/dorsiflex approx 10 degrees above neutral - arch develop with non-weight bearing pos?
  15. 15. •Refers to loss of normal medial long. arch • usually caused by subtalar joint assuming an everted position while weight bearing •Flexible •Rigid
  16. 16. Pes Planus (flatfoot)
  17. 17. Pes Planus (flatfoot) Treatment • Flexible/Asymptomatic - no further work up/treatment is necessary! - no studies show flex flatfoot has increased risk for pain as an adult • rigid/painful - must r/o tarsal coalition – congenital fusion or failure of seg. b/w 2 or more tarsal bones - usually assoc with peroneal muscle spasm - need AP/lat weight bearing films of foot
  18. 18. • Incidence:1 per 100,000 general population • Female > Male 10:3 ratio, One-third bilateral, equal right and left • Etiology: • Environmental: Fetal position, increased in Breech • Fetal knee: round condyles, tibial plateau slope 35 degrees posterior • quadriceps fibrosis acquired
  19. 19. • Treatment Serial casting
  20. 20. • 1/1,000 born with dislocated hip • 10/10,000 born with subluxation or dysplasia • 80% Female • First born children • Family history (6% one affected child, 12% one affected parent, 36% one child + one parent)
  21. 21. • Oligohydramnios • Breech (sustained hamstring forces) • Left 60% (left occiput ant), Right 20%, both 20% • Ranges from mild dysplasia --> frank dislocation • Bony changes *Shallow acetabulum *Typically on acetabular side *Femoral anteversion
  22. 22. Key physical findings • Skin folds • Limb length- Galeazzi • Abduction ROM
  23. 23. • Barlow’s test B for Birth B for dislocataBle • Ortolani test Out After 3 months of age tests become negative
  24. 24. • Some cases still missed • At risk groups should be further screened American association of paediatrics *Recs further imaging (e.g. US) if exam is “inconclusive” AND *First degree relative + female *Breech *Positive provocative maneuver (Ortolani or Barlow) *Referral to Orthopaedist
  25. 25. *X-rays *Femoral head ossification center *4 -7 months *Ultrasound *Operator dependent
  26. 26. • Ultrasound • Introduced in 1978 for evaluation of DDH • Operator dependent • Useful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum, documenting reducibility • Prox Femoral Ossification Center interferes • Requires a window in spica cast (avoid)
  27. 27. Femoral head Abductors Ilium
  28. 28. Femoral head Abductors Ilium
  29. 29. Femoral head Abductors Ilium
  30. 30. •Graf’s alpha angle >60° = normal Beta angle formed between the vertical cortex of the ilium and the triangular labral fibrocartilage (echogenic triangle).
  31. 31. As a general rule, the alpha angle determines the type and in some instances the beta angle is used to determine subtype.
  32. 32. • Pavlik harness • Flexion abduction orthosis • Be aware of safe and unsafe zones
  33. 33.  Injuries to the infant that result from mechanical forces (i.e., compression, traction) during the birth process are categorized as birth trauma.  Even though most women give birth in modern hospitals surrounded by medical professionals, seven of every 1,000 births result in birth injuries.  Birth injuries account for fewer than 2% of neonatal deaths.
  34. 34. • Prolonged or rapid delivery • Cephalopelvic disproportion, small maternal stature, maternal pelvic anomalies • Deep transverse arrest of presenting part of the fetus • Oligohydramnios • Abnormal presentation (breech)
  35. 35. •Use of midcavity forceps or vacuum extraction •Very low birth weight infant or extreme prematurity weeks •Large babies – birth weight over about 4,000 grams • Fetus anomalies
  36. 36. • Large birth weight • Average vertex: 3.8-5 Kg • Average breech: 1.8-3.7 Kg • Breech presentation • Maternal diabetes • Multiparity • Second stage of labor that lasts more than 60 minutes • Assisted delivery (mid/low forceps, vacuum extraction) • Forceful downward traction on the head during delivery • Previous child with OBPP • Intrauterine torticollis • Shoulder dystocia
  37. 37. •C5-C6 • internally rotated, adducted •elbow extended •forearm is pronated, •wrist is flexed and adducted • fingers are flexed. Policeman’s tip
  38. 38. •C5-C6-C7 •Difference with Erb’s palsy: •wrist is in neutral position (wrist flexor and extensors are equally weak)
  39. 39. •C8-T1 •Floppy hand: wrist is flexed, fingers extended following the forces of gravity •Horner’s syndrome
  40. 40. •One muscle or a group of muscles in the arm •Due to injury of a small group of motor fibers
  41. 41. • The total plexus palsy (Kerer’s paralyses) is the most disturbing of all. Its clinical features are: adynamy muscle hypotony • Kofferate syndrom (C 3-4) − is the diaphragm paralysis. Because of irregular breathing, cyanosis pneumonia can be suggested mistakenly.
  42. 42. • Rest period of 7 days → pin the sleeve of neonate’s shirt to hold the elbow in a flexed position • Physical Therapy Goals: minimizing bony deformities and joint contractures, while optimizing functional outcomes • Passive and Active ROM exercise • Static and dynamic splints • Instructing parents and family: home exercise program
  43. 43. • Degree of future improvement cannot be determined during a single evaluation, especially if performed immediately after birth. • Improvement during the first few weeks is a relatively good indicator of final outcome. • Incidence of permanent sequelae: 3-25% • Findings consistent with severe initial injury (Horner’s syndrome) portend a less favorable prognosis • Peripheral nerves re-myelinate at a rate of 1mm/day. If nerve is not transected, recovery can be expected by: • 4-5 months in Erb’s palsy • 6-7 months in upper-middle trunk palsy • 14 months for a total BPP.
  44. 44. • Spinal cord injury incurred during delivery results from excessive traction or rotation. • failure to establish adequate respiratory function, • the baby usually is posing as frog, • “oscillation” symptom is positive (if to prick leg of the newborn with needle − leg will flex and extense in all joints several times).
  45. 45. • most frequently bone injure in the neonate during birth • most often is an unpredictable unavoidable complication of normal birth • The infant may present with pseudoparalysis • Examination may reveal crepitus, palpable bony irregularity, and sternocleidomastoid muscle spasm • Desault's bandage should be used for 7-10 days.
  46. 46. • The incidence of humerus femur and tibial fractures (in this order) 0.056% • Treatment-Conservative
  47. 47. • Extremely rare • Epiphyseal injury • Treatment-Conservative
  48. 48. Recognition of trauma necessitates a careful physical and neurologic evaluation of the infant to establish whether additional injuries exist. Occasionally, injury may result from resuscitation.
  49. 49. • Bone andjoint sepsis in the first month oflife is rare. • Diagnosis is difficult and often delayed as the clinical features differ significantly from infections occurring in older children. • In the post-antibiotic era, survival rates are high but the survivors are frequently left with permanent bone and joint damage. • The hip is especially at risk.
  50. 50. • Prematurity • Skin and umbilical sepsis • Meningitis • Pneumonia
  51. 51. • Pseudoparalysis • Abnormal local swelling • Abnormal posture • Painful passive movement
  52. 52. • Surgical drainage • IV antibiotics

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