Muscles Skeleton and Hips

The initial musculoskeletal examination should be the observation of the infant. All limbs should appear symmetric and move equally, and any deficit should lead to further evaluation.

Palpate both clavicles to evaluate for fracture or dislocation that might have occurred during delivery. In the event of a traumatic vaginal delivery, it is important to pay special attention to the potential for a brachial plexus injury. An infant with brachial plexus injury often has the affected arm straight down at the side and might have the wrist slightly bent, the fingers straight, and the forearm pronated (Thureen et al., 2005). Inspect hands and feet for syndactyly (fusion of fingers or toes), polydactyly (extra digits), clubfoot, and other congenital anomalies.

The incidence of developmental dysplasia of the hip (DDH) is estimated to be between 1.5 and 20 cases per 1000 infants (Shipman, 2006). Female gender, breech position, and family history are all reported risk factors for DDH; however, only a minority of cases of DDH are found in infants with identifiable risk factors (Shipman, 2006). In addition, as many as 80% of infants with an abnormal hip examination at birth resolved by 6 weeks, and 90% of mild dysplasia identified by ultrasound resolved between 6 weeks and 6 months (Shipman, 2006). The U.S. Preventive Services Task Force concluded that there was insufficient evidence to recommend routine screening for DDH in newborns (USPSTF, 2006). AAP (2000b) continues to recommend serial clinical examinations of the hip for the first 12 months of life.

There are two maneuvers in the neonatal hip examination: the Ortolani maneuver and the Barlow maneuver (Fig. 22-2). Each hip should be examined separately using gentle but firm pressure. Too much force can injure the hip in a normal infant.

The Barlow maneuver begins with flexion and adduction of the hip. The examiner should place the palm of the hand just below the infant's knee and the fingertips over the greater trochanter of the femur. The examiner exerts gentle pressure toward the examination table, and in a positive test the examiner can feel and often hear the femur slip posteriorly out of the acetabulum (Weinstein et al., 2004). This is often

Barlow's maneuver: "Clunk" of exit as the femur is dislocated from the acetabulum

Ortolani's maneuver: "Clunk" of entry as the dislocated femur reenters the acetabulum

Figure 22-2 Physical examination maneuvers for developmental dysplasia of the hip.

Barlow's maneuver: "Clunk" of exit as the femur is dislocated from the acetabulum

Ortolani's maneuver: "Clunk" of entry as the dislocated femur reenters the acetabulum

Figure 22-2 Physical examination maneuvers for developmental dysplasia of the hip.

called the "clunk of exit" or "click of exit" (Vain et al., 2004). The terminology used to describe the positive test can cause confusion to the inexperienced examiner. Benign adventitial sounds and high-pitched clicks often occur with flexion and extension of the extremities in a normal newborn and are mistaken for hip dysplasia (AAP, 2000b). If the newborn hip is already dislocated, the Barlow test will be negative because the femur is already outside the acetabulum.

The Ortolani maneuver is performed by abducting the hip and firmly pressing the greater trochanter up away from the examination table. In a positive test, a "clunk of entry" is heard and felt as the head of the femur reenters the acetabulum (Weinstein et al., 2004).

Newborn infants with any positive or equivocally positive result should be reexamined at 2 weeks of age. If at 2 weeks the examination remains positive, pediatric orthopedic consultation should be considered. Some newborns have liga-mentous laxity that can be mistaken for hip dysplasia, but this should resolve in the first 2 weeks of life. A child with a history or physical examination suspicious for developmental dysplasia of the hip can be evaluated with serial hip examinations, hip ultrasound at 6 weeks of age, or pelvic radiographs at 4 months of age, and pediatric orthopedic referral should be considered (AAP, 2000b).

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