Orthopedic Problems in Babies From Birth to Three Months

Fortunately orthopedic problems at birth or during the first few months of life are rare. But when they occur, an orthopedic surgeon is consulted. Knowing what's normal at this age and what can happen to cause musculoskeletal problems is important.

But even a specialist in children's orthopedic problems may be challenged. The conditions presented in this article occur infrequently, but the surgeon must be prepared to deal with them and be ready to answer parents' questions. The authors, who are orthopedic surgeons from Children's Hospital in Los Angeles, offer information that will help.

The first thing they say to remember is that children are not little adults. And newborns are not just little children. They have unique anatomy and physiology that requires some special attention. The first step is to perform an exam. Proper lighting in the exam area and positioning of the baby are important.

The exam begins with observation of the skin and body contours. The surgeon feels or palpates the soft tissues and bones looking for any signs of damage such as fractures, dislocations, or loss of motion. Movement is observed and infant reflexes are tested. Three of the more common primitive reflexes (e.g., grasp reflex, Moro reflex, and walking or stepping reflex) along with testing procedures for each are described.

The most common areas for problems to develop (or appear at birth) include the arm, foot, hip, knee, and neck. The authors discuss several of the major diseases and disorders to watch out for. These include flail extremity, infection, brachial plexus palsy, and fracture.

Specific conditions of the foot are presented separately. These include metatarsus adductus, clubfoot, calcaneovalgus foot, and congenital vertical talus. Hip or knee dislocation, torticollis (of the head and neck), and unusual findings on X-rays round out the contents of this report. Let's take a look at some of these topics.

Flail limb or extremity refers to an arm or leg that the child doesn't seem to be moving. The cause of the problem must be determined. It could be a broken bone, damaged nerve (resulting in a condition called brachial plexus palsy), or infection. X-rays may help rule out fractures or dislocations. Lab values can be used to assess for infections. An undiagnosed infection can spread and cause considerable bone and joint damage, so time is of the essence.

Damage at birth to the nerves in the upper limb can cause brachial plexus injuries. The child doesn't move the affected arm and the arm may be in a characteristic position that tips the examiner off as to the underlying problem. For example, with damage to the nerves at C5 and C6 in the neck, the wrist and hand may end up stuck in the waiter's tip position. The wrist is bent and the forearm is turned with the hand facing backwards (as if holding the hand out behind the back waiting for a tip).

A painful broken bone anywhere from the collarbone down can be the reason a child doesn't move the arm. The cause of bone fractures must be determined. It could be from prolonged labor, forceps delivery, or child abuse.

Fortunately, bone healing is fast in infants this young. A makeshift sling out of soft stockinette may be all that's needed in the way of treatment. Even easier and possibly safer is to pin the sleeve of the infant's shirt to the main body of the shirt.

Next, the authors take a look at foot problems in the newborn. These are the most common deformities present at birth. Metatarsus adductus refers to a bean shape of the foot as the forefoot curves outward. This foot deformity occurs as a result of positioning during development inside the uterus (mother's womb).

Many people have heard of clubfoot. The medical term for this deformity is talipes equinovarus. The foot is positioned in a toe pointed down position and ankle curved inward. It may occur by itself or it could be part of a bigger congenital problem (present at birth). Congenital conditions such as arthrogryposis, spina bifida, or Larsen syndrome often come with clubfoot deformities.

With all of these foot problems, treatment is started early with gentle stretching, serial casting, serial manipulation and casting, and sometimes surgery. For very mild problems, a wait-and-see approach may be all that's needed.

Calcaneovalgus foot and congenital vertical talus describe two separate conditions of misalignment of the bones of the foot. Both of these problems are easily recognizable just by looking at the child's foot. In the case of calcaneovalgus foot, the bones and soft tissues are still flexible. With a vertical talus, the bone is dislocated resulting in a rigid deformity requiring surgery.

Hip dislocations are not uncommon, occurring in about one out of every 1000 births. A more common hip problem is hip dysplasia, a shallow hip socket with partial dislocation of the hip. One or two simple tests are performed on every newborn to check for this problem. If there's suspicion of an early developmental dysplasia of the hip, X-rays or ultrasound can be used to tell for sure.

In the first month, a special soft harness called the Pavlik harness is used to position the leg and hip to help hold it in place. If the harness fails to correct the problem, then an abduction brace is tried. If all else fails, then surgery may be needed to put the hip back in place and/or reconstruct the hip socket to help hold it there.

Only rarely is a baby born with a dislocated knee. No one knows for sure what causes this to happen. There is some soft tissue involvement as the quadriceps muscle along the front of the thigh is tightly contracted.

Knee dislocation is usually accompanied by other orthopedic problems such as clubfoot or hip dislocation on the same side. Treatment ranges from nonoperative manipulation and traction techniques to serial casting to surgery for cases that don't get better with conservative care.

The last congenital problem presented in this review article is congenital muscular torticollis. The head is tilted to one side and the chin turned toward the opposite side. The muscles are tight holding the head and neck in this position. The problem develops while the child is developing in-utero (inside the mother's womb).

Physical therapy is the first step in treatment. The therapist will teach the parents or care giver how to massage, stretch, and move the tight muscles. Positioning in bed, car seat, backpack, and stroller are important strategies in this condition. The therapist will also provide tips on techniques for holding and handling the baby that will help overcome this positional fault. Problems that persist may require surgery later on.

In summary, the authors of this article provide a review of orthopedic conditions that can be present at birth or develop shortly after birth. Knowing how to examine, identify, and diagnose the problem is the orthopedic surgeon's responsibility.

Once the diagnosis has been made (the earlier the better), then treatment can be determined and delivered. Management of most of these conditions is a process over time. As the child grows, treatment such as stretching, serial manipulation, and serial casting is reapplied to help shape the structures and keep them in neutral alignment. When the child is older, surgery may be required.

The information presented in this article should be enough to get the surgeon started. Further investigation and study may be needed for conditions rarely encountered.

Reference: 

Wudbhav N. Sankar, M.D., et al. Orthopaedic Conditions in the Newborn. In Journal of the American Academy of Orthopaedic Surgeons. February 2009. Vol. 17. No. 2. Pp. 112-122.

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