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.

1. J K Laik
DNB(Ortho),MNAMS

4. Common Pediatric Foot Deformities

5. Anatomy/Terminology
3 main portion
1.Hindfoot – talus,
calcaneus
2.Midfoot – navicular,
cuboid, cuneiforms
3.Forefoot –
metatarsals and
phalanges

6. 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

7. Anatomy/Terminology
• Varus/Valgus

8. Calcaneovalgus foot

9. 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

10. • true congenital deformity
• 60% assoc w/ some neuro
impairment
• plantarflexed ankle, everted
subtalar joint, stiff
• requires surgical correction
(casting is generally
ineffective)

12. • Boat shaped

13. Talipes Equinovarus (congenital clubfoot)
3 basic components
1. Ankle joint
plantarflexed/equines
2. Subtalar joint
inverted/varus
3. Forefoot
adducted

14. 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

15. Talipes Equinovarus (congenital clubfoot)
• Diagnosis/Evaluation
- distinguish mild/severe forms from other disease
- Look for associated anmalies
• Spina bifida
• DDH

16. Talipes Equinovarus (congenital clubfoot)
Ponsetti’s
Kite

17. 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?

18. •Refers to loss of normal
medial long. arch
• usually caused by
subtalar joint assuming
an everted position while
weight bearing
•Flexible
•Rigid

19. Pes Planus (flatfoot)

20. 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

21. • 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

22. • Treatment
Serial casting

23. • 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)

24. • 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

25. Key physical findings
• Skin folds
• Limb length- Galeazzi
• Abduction ROM

26. • Barlow’s test
B for Birth
B for dislocataBle
• Ortolani test
Out
After 3 months of age tests
become negative

27. • 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

28. *X-rays
*Femoral head ossification center
*4 -7 months
*Ultrasound
*Operator dependent

29. • 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)

30. Femoral head
Abductors
Ilium

31. Femoral head
Abductors
Ilium

32. Femoral head
Abductors
Ilium

33. •Graf’s alpha angle >60°
= normal
Beta angle formed
between the vertical cortex
of the ilium and the
triangular labral
fibrocartilage (echogenic
triangle).

34. As a general rule, the alpha angle determines
the type and in some instances the beta angle is
used to determine subtype.

37. • Pavlik harness
• Flexion abduction orthosis
• Be aware of safe and
unsafe zones

39.  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.

40. • 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)

41. •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

44. • 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

46. •C5-C6
• internally rotated,
adducted
•elbow extended
•forearm is pronated,
•wrist is flexed and
adducted
• fingers are flexed.
Policeman’s tip

47. •C5-C6-C7
•Difference with Erb’s
palsy:
•wrist is in neutral
position (wrist flexor
and extensors are
equally weak)

48. •C8-T1
•Floppy hand: wrist is
flexed, fingers
extended following the
forces of gravity
•Horner’s syndrome

49. •One muscle or a group
of muscles in the arm
•Due to injury of a small
group of motor fibers

50. • 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.

51. • 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

52. • 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.

54. • 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).

55. • 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.

56. • The incidence of humerus
femur and tibial fractures
(in this order) 0.056%
• Treatment-Conservative

57. • Extremely rare
• Epiphyseal injury
• Treatment-Conservative

58. 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.

59. • 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.

60. • Prematurity
• Skin and umbilical sepsis
• Meningitis
• Pneumonia

61. • Pseudoparalysis
• Abnormal local swelling
• Abnormal posture
• Painful passive movement

62. • Surgical drainage
• IV antibiotics