Transcript Neonatal Orthopedic Issues - Welcome! — Pediatrics

Neonatal Orthopedic
Issues
Mikelle Key-Solle, MD
May 22, 2006
Objectives
 Recognize
common orthopedic issues
which present in the neonatal period
 Generate appropriate differential
diagnoses
 Identify appropriate interventions
from a general pediatric perspective
Overview
 Cased-based
discussion of five of the
more common neonatal orthopedic
and musculoskeletal conditions
– Typical physical exam findings
– Management strategies
– When to consult an orthopedic surgeon
Case 1
 You
are examining a 3 hour old term
male infant
 Mother had unremarkable pregnancy
and delivery with normal prenatal
labs
 Infant appears nondysmorphic with a
normal exam except for the following
feet findings:
Case 1
Case 1:
Metatarsus Adductus
AKA Metatarsus varus
 Hindfoot normally positioned, but forefoot
adducted
 Flexible versus non-flexible
 85% spontaneously resolve
 Gentle stretching exercises may help

Metatarsus Adductus
 If
does not
spontaneously
resolve, can lead to
classic foot
deformity
–Sole crease
–Lateral bony
prominence
 May require shoes,
casting
Time for Trivia
What is the origin of the phrase
“getting off on the wrong foot”?
Putting the left foot down on the floor
first when getting out of bed
Case 2
 You
are examining a 3 hour old term
male infant
 Mother had unremarkable pregnancy
and delivery with normal prenatal
labs
 Infant appears nondysmorphic with a
normal exam except for the following
feet findings:
Case 2
Talipes Equinovarus
 AKA
Clubfoot
 Malalignment of
the talocalcaneal,
talonavicular and
calcaneocuboid
joints
Talipes Equinovarus
 Fixed
plantar flexion (equinus) of
the ankle (talipes)
– inability to bring to foot to a
plantigrade (flat) standing position
 Inversion/adduction
of the heel (varus)
 Metatarsus adductus
Talipes Equinovarus
 2:1
male to female
 50% bilateral
 Usually idiopathic
 More severe if associated with
neurological, connective tissue, or
mechanical conditions
Talipes Equinovarus
 Requires
urgent orthopedic referral
 Treated using Ponseti method of
serial casting +/- Achilles tendon
release
–Followed by nighttime bracing for
2 years
 Outcomes typically very good
Summary
 Case
1: Metatarsus Adductus
– Forefoot adduction; most spont resolve
 Case
2: Talipes Equinovarus
– 3 components; early ortho referral
 Case
3:
 Case 4:
 Case 5:
Time for Trivia
What do Kristi Yamaguchi, Mia Hamm, and
Troy Aikman all have in common?
All had congenital clubfoot treated with
Ponseti method
Case 3
 You
are examining a 4 week old term
female, born by c-section (breech)
 NBN course unremarkable
 Parents report infant seems to prefer
keeping head tilted towards the right
shoulder
Case 3
 What
do you expect to
find on physical exam?
 What is a common
association with this
condition?
Congenital Muscular Torticollis
(CMT)
 AKA
“wryneck”
 Unilateral deformity of the
sternocleidomastoid (SCM) muscle
resulting in chin pointing away and
head tilting towards the affected side
 Within first few weeks, may be able
to palpate a firm, non-tender SCM
mass
CMT
 Associations:
– 80-90% with contralateral
plagiocephaly and ipsilateral facial
flattening
– 20% with hip
dysplasia
CMT
 Differential
diagnosis: 3 categories
– Osseous
Klippel-Feil syndrome, congenital
scoliosis
– Non-osseous
Sandifer syndrome
– Neurogenic
CNS tumors, Chiari malformation
Ocular torticollis
Paroxysmal torticollis
CMT
CMT

Treatment consists of passive stretching
– PT referral by 2-3 months if >10° dec ROM
85% will correct by 18 months
 Persistence after 18 months warrants
orthopedic referral

Summary
 Case
1: Metatarsus Adductus
– Forefoot adducted; most spont resolve
 Case
2: Talipes Equinovarus
– 3 components; early splinting
 Case
3: Cong. Muscular Torticollis
– Head tilt; SCM mass early; stretching
 Case
4:
 Case 5:
Time for Trivia
(or maybe just “triviality”)
Case 4
 You
are examining a 3 hour old term
male born by c-section for failure to
progress
 Mother’s history is significant for
bilateral clubfoot s/p correction, s/p
pelvic stabilization surgery,
malignant hyperthermia, and
rheumatoid arthritis; father healthy
Case 4
 Infant
exam remarkable for
– Diffuse hypertonicity and limited ROM
– Bilateral finger and toe deformities,
ulnar deviation of fingers
– Bilateral elbow extension, forearm
pronation
– Bilateral flexion deformity of knees
– Bilateral clubfoot
– Few skin creases over joints
Case 4
Arthrogryposis Multiplex Congenita
(AMC)
 Collection
of >150 conditions leading
to >2 joint contractures
 Non-progressive
 Fibrosis of connective tissue and
muscle
 Etiology unknown, multifactorial
AMC

Etiologic categories: neurologic vs. non-neuro
– Neuropathic
 Amyoplasia
 Meningomyelocele
 Spinal
muscular atrophy
– Muscle abnormality
 Cong
muscular/myotonic dystrophy, myasthenia
 Intrauterine myositis
 Mitochondrial disorders
– Connective tissue abnormality
 Dwarfism
 Multiple
pterygium syndorme
 Distal arthrogryposis
– Intrauterine abnormality
 Limited
fetal space
 Vascular compromise
AMC
 Only
30% genetic
– All forms of inheritance
– Examples: Trisomy 18/21, Holt-Oram,
Mobius, nemaline myopathy, Zellweger,
Pfeiffer, Poland
 Most
common form is amyoplasia
(40%)
AMC:
Amyoplasia
shoulder--internal rotation deformity
 elbow--extension and pronation deformity
 wrist--volar and ulnar deformity
 hand--fingers in fixed flexion, and thumbin-palm deformity
 hip--flexed, abducted and externally
rotated, often dislocated
 knee--flexion deformity
 foot--clubfoot deformity

AMC
 Associations
– Midface hemangiomas
– Scoliosis
– Growth retardation
– Abdominal hernias
 Typically
normal intelligence
AMC
 Cause
determines prognosis
– If neurologic deficit, brain/spine MRI
– If dysmorphic features, karyotype and
genetics consult
 Early
orthopedic referral necessary
– Non-surgical measures used in neonatal
period
 Splinting/casting
 PT
and ROM exercises
Summary

Case 1: Metatarsus Adductus
– Forefoot adducted; most spont resolve

Case 2: Talipes Equinovarus
– 3 components; early splinting

Case 3: Cong. Muscular Torticollis
– Head tilt; SCM mass early; stretching

Case 4: Arthrogryposis Multiplex
Congenita
– Multiple contractures; neuro vs non-neuro;
amyoplasia most common; splinting/casting in
neonatal period

Case 5:
More Triviality
Case 5
 You
are examining a 4 week old term
female born by c-section (breech)
 NBN course was unremarkable
 Parents have no concerns
 Growth parameters all 50%th
percentile
Case 5
 Previous
exam revealed a right hip
click with Barlow maneuver, but now
this has progressed to a “clunk”
– What are Barlow and Ortolani
maneuvers?
Case 5:
Barlow and Ortolani
Infant must be relaxed
 Examine one hip at a time
 Hip flexed 90°, gentle manipulation
 Barlow=Back + adduction
 Ortolani=Out + anterior
 Positive if “clunk”
palpable/heard

Case 5
 What
additional physical exam
findings would suggest hip dysplasia?
– Asymmetric gluteal/thigh folds
– Leg length discrepancy (3-6 months)
– Limited hip abduction (3-6 months)
Developmental Dysplasia of the
Hip (DDH)
 Definitions
– Dysplasia: abnormal
formation/development of hip joint
– Subluxated: Femoral head is partially
out of proper articulation with
acetabulum
– Dislocatable: ability to force femoral
head out of articulation with acetabulum
– Dislocated: femoral head is not
articulating normally with the
acetabulum at baseline
DDH
 DDH
recently coined due to the
progressive nature of the problem,
ie. Many hips normal at birth, but
become unstable during the ensuing
weeks/months
DDH
 Why
worry?
– Premature degenerative joint disease
– Impaired walking
– Chronic pain
DDH
 What
other historical factors would
increase your suspicion?
– Breech female: 20 per 1000
– FHx + female: 12 per 1000
– Female, no risk factors: 5 per 1000
– Breech male: 4 per 1000
– Male, no risk factors: 0.3 per 1000
Bache CE, Clegg J, Herron, M. Risk factors for developmental
dysplasia of the hip: ultrasonographic findings in the
neonatla period. J Pediatr Orthop B. 2002; 11:212-218.
DDH
 Screening
controversy
– No direct evidence that screening
improves functional outcomes
– Studies show ↓, unchanged, and  rates
of surgery among screened infants
– Variable definitions of “positive”
– No gold standard
– Poor quality evidence for effectiveness
of both non-surgical and surgical
treatments
DDH
 X-ray
– Femoral head does not ossify until 3-6
months
– Radiographic outcomes have not been
shown to be valid or reliable surrogate
for functional outcomes
DDH
 Ultrasound
– High false positive rate (ie. high rate of
non-pathological hip findings)
– Intraobserver reliability moderate
– Interobserver reliability fair
– May decrease unnecessary treatment
when compared to clinical exam alone
– Reliability of classification is
questionable
DDH

AAP recommendations from 2000
still stand
– Screen during newborn period and each
subsequent WCC with physical exam
– If exam findings abnormal or breech
female, obtain ultrasound at 1 month or
when detected thereafter
DDH
 If
pt deemed to have
possible DDH, ortho
referral recommended
 Initial treatment nonsurgical
– typically Pavlik harness,
which has been shown
to reduce rate of AVN
DDH
 Pavlik
harness less successful:
– Bilateral DDH
– True dislocation
– Age >8 weeks at initiation
Atalar H, Sayli U, Yavuz OY, et al. Indicators of
successful use of the Pavlik harness in infants
with DDH. Int Ortho. Apr 2006; (epub ahead of
print).
Summary

Case 1: Metatarsus Adductus
– Forefoot adducted; most spont resolve

Case 2: Talipes Equinovarus
– 3 components; early splinting

Case 3: Cong. Muscular Torticollis
– Head tilt; SCM mass early; stretching

Case 4: Arthrogryposis Multi. Congenita
– Multiple contractures; neuro vs non-neuro;
amyoplasia most common; splinting/casting in
neonatal period

Case 5: Developmental Dysplasia of Hip
– Screen at every WCC +/- ultrasound; ortho
referral if +; Pavlik harness highly successful
References





Alfonso, I, Papazian O, Paez JC, and Grossman,
JA. Arthrogryposis Multiplex Congenita.
International Peds. 2000; 15(4):197-204.
Freed SS, and Coulter-O’Berry C. Identification
and Treatment of congenital muscular torticollis
in infants. Jour of Pros and Ortho. 2004;
16(45):18-23.
Hulme A. The management of congenital talipes
equinovarus. Early Human Development. 2005;
81:797-802.
Shipman SA, Helfand M, Moyer VA, and Yawn BP.
Screening for developmental dysplasia of the hip:
a systematic literature review for the US
Preventive Services Task Force. Pediatrics 2006;
117:557-576.
Weiner DS. Pediatric Orthopedics for Primary
Care Physicians, Second Edition. New York, NY:
Cambridge University Press; 2004