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02/03/2017

Miss Camille Quan Soon MBBS, AFRCS(Ed), DM Ortho


Consultant Orthopaedic Surgeon
Lecturer in Orthopaedics

Introduction
 Orthopaedic problems at
birth or during the first
few months of life are
rare.

 Just as children are not


little adults, newborns
are not just little
children.

 Careful history and physical examination with an


understanding of neonatal development is essential to
making the proper diagnosis.

 Accurate and timely diagnosis must be made to


minimise long-term morbidity as a result of delayed
or incorrect treatment.

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02/03/2017

Common Neonatal Orthopaedic Conditions


1. The Flail Limb
2. The Neonatal Foot
3. Torticollis
4. Polydactyly
5. Syndactyly
6. Amniotic Band Syndrome

The Flail Limb


 Refers to an arm or leg that the child does not seem to
be moving

 May be due to:


 Infection
 Brachial Plexus Injury
 Fracture

Infection
 Early diagnosis and treatment of neonatal infections is
critical.

 Considerable morbidity

 Septic Arthritis and Osteomyelitis


 physeal destruction,
 secondary limb-length inequality,
 post-infectious arthritis,
 osteonecrosis of the epiphysis

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Brachial Plexus Injury


 One or two of every 1,000 babies

 Often caused when an infant's neck is stretched to the


side during a difficult delivery.

 Most infants will recover both movement and


sensation in the affected upper limb spontaneously.

Brachial Plexus Injury


 Risk factors include
 maternal diabetes,
 high birth weight,
 prolonged labour,
 forceps delivery,
 shoulder dystocia.

Erb’s palsy
 Most common type

 Upper trunk involvement


(C5 and C6)

 Characteristic “waiter’s tip”


appearance

 Shoulder internal rotation,


elbow extension, forearm
pronation, and wrist
flexion.

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Klumpke’s palsy
 Lower trunk involved
(C8 and T1)
 Less common than Erb’s
but worse prognosis
 “Claw hand”
 Flexion and supination
at elbow, hyper-
extension at wrist and
MCP joints, flexion at IP
joints

Brachial Plexus Injury - treatment


 Only 1 of 10 infants with plexus palsies require surgical
intervention

 Goal of initial management is to maintain passive


range of motion (ROM) while motor function is
recovering

 ROM exercises should be deferred for 10 to 14 days


after birth to allow pain to subside.

Brachial Plexus Injury - treatment


 Timing of surgical intervention is controversial

 Surgical exploration after 18 months is of little benefit

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Neonatal Fractures
 Common

 Risk factors include breech position, macrosomia, and


vaginal delivery

 Most commonly: clavicle, humerus, and femur

Clavicle fracture Humeral shaft fracture

Neonatal Fractures
 Rapid healing

 Immobilisation
for only 7-10 days

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Multiple Neonatal Fractures


Skeletal Survey Consider:

 Child abuse
 Osteogenesis imperfecta,
 Neonatal rickets and
 Neonatal
hyperparathyroidism

The Neonatal Foot

Metatarsus Adductus
 One of the most
common foot
deformities
 Related to intrauterine
positioning.
 Characteristic “bean
shape” sole of the foot
 Flexible or Rigid

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Metatarsus Adductus - treatment


 Flexible deformities
 observation or stretching
 90% to 95% will resolve spontaneously regardless of
treatment

 Rigid deformities
 serial manipulation and casting should be done before
age 6 months
 surgery is rarely required

Congenital Talipes Equinovarus or “Club Foot”

 Usually obvious at birth

 1 to 10 in 1,000 births

 30-50% are bilateral

Club Foot
 2 Types
 Postural or flexible
 Rigid or fixed

 Most idiopathic, but rule out any spine or


neuromuscular pathology

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Clinical Features of Club Foot


 C.A.V.E
 Cavus
 Forefoot adductus
 Hindfoot varus
 equinus

Treatment of Club Foot


 Criteria of successful treatment
 Plantigrade foot
 Ability to wear normal shoes
 Preservation of joint mobility

 Most rigid clubfeet can be treated nonsurgically by the


Ponseti method of serial manipulation and casting.

 Stretching and strapping (for flexible CTEV)

Ponseti method

 The order of correction:


 Cavus
 Adduction
 Varus
 Equinus

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Ponseti method

Surgical Treatment
 Primary- soft tissue
releases postero-
medially, lengthening of
Tendo Achilles.

 Secondary for recurrence


of deformity

Bracing until Age 4


Denis-Browne “boots and
Iowa Brace
bar”

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Advice to Parents
 CTEV alone will not
prevent child from
walking.
 Foot cannot be made
normal.
 Foot will always be
smaller and stiffer, and
calf thinner.

Congenital Muscular Torticollis


 Painless deformity caused
by contracture of the
sternocleidomastoid
muscle (SCM)

 Aetiology controversial,
most likely arises from
intrauterine or perinatal
compartment syndrome,
which causes fibrosis of
the SCM

Congenital Muscular Torticollis


 Head tilted toward the
involved muscle and the
chin rotated toward the
contralateral shoulder

 Olive-shaped mass can


sometimes be felt in the
SCM.

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Congenital Muscular Torticollis


 Risk factors
 breech position
 difficult delivery

 Associated conditions
 DDH
 Metatarsus adductus

Congenital Muscular Torticollis - treatment


 Initial treatment consists of a massage and
stretching programme

 Successful in most cases when started in the first 6


months of life.

 Children who present at an older age and those with


torticollis refractory to therapy may require a surgical
release of the SCM, usually around age 5

Polydactyly
 6 or more digits per limb
in one or more limbs

 Extra digit on the little


finger/toe side
(postaxial) most
common

 May be family history

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Types of Polydactyly
Type B - vestige of a digit with
Type A - Intact digit threadlike thin tissue that
contains no bone

Polydactyly - treatment
 Excision of the duplicated digit and reconstruction of
any abnormalities in the remaining fingers or toes.

 The patient must be monitored and evaluated for


residual or future deformity.

Polydactyly of the foot - treatment


 Goal is to excise the toe which provides the toe with
the most normal contour, in order to facilitate shoe
wear.

 Surgery recommended after 1 year to reduce


anaesthetic risks but prior to walking age.

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Syndactyly
 Failure of
differentiation in
which the fingers or toes
fail to separate into
individual appendages

 Common

 Can be an isolated
finding, or in association
with other abnormalities

Types of Syndactyly
 Simple
 involves soft tissues only

Types of Syndactyly

 Complex
 involves the bone or nail
of adjacent fingers

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Syndactyly - treatment
 Unreleased syndactyly can significantly impair finger
and hand function

 Treatment is by surgical separation of digits

 Full-term infants can be scheduled for elective surgical


procedures after 6 months of age to decrease
anaesthetic risks

Syndactyly - treatment
Preoperative Postoperative

Polydactyly/Syndactyly

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Amniotic Band Syndrome


 Ruptured amniotic
membrane forms into
encircling strands
which then cause
extrinsic compression
on the head or limb,
leading to the formation
of bands.

Amniotic Band Syndrome


 Abnormality could be as
little as a minor cosmetic
band.

 Deeper bands may cause


lymphatic obstruction
leading to oedema, and
vascular compromise.

Amniotic Band Syndrome - treatment


 Tight constriction bands with gross lymphoedema
and/or vascular compromise need immediate surgical
release.

 Excision is not indicated for superficial bands due to


the potential complications of wound infections and
neurovascular compromise.

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Conclusion
 Careful history and physical examination are required
in the orthopaedic evaluation of a neonate.

 Essential to make a proper and timely diagnosis to


minimise long-term morbidity as a result of delayed or
improper treatment.

Thank You and Merry Christmas

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