Musculoskeletal Examination

The purpose of the musculoskeletal examination of the newborn is to detect gross abnormalities. The appearance of the extremities at birth usually reflects the positioning of the child within the uterus, known as intrauterine packing.

Inspect the extremities and digits. Are all four extremities and 20 digits present? Polydactyly, the presence of one or more extra digits, is fairly common. It may be inherited as an autosomal dominant trait or may be part of a more complex multiple malformation syndrome. Most polydactyly is postaxial (on the small digit side of the hand or foot), and the extra digit is represented by a skin tag (called a postminimus). Hypodactyly, the absence of one or more digits, is never considered a normal variant. The absence of digits should always trigger an evaluation for associated anomalies.

Palpate the clavicle if this has not already been done. An area of crepitus over the distal third is suggestive of a fractured clavicle. Decreased motion in the upper extremity may also be associated with a clavicular fracture.

Check for a brachial palsy, which has been discussed earlier.

The most important part of the musculoskeletal examination of the newborn is the evaluation of the lower extremities. The hips are examined for the possibility of developmental dyspla-sia, in which a hip either is dislocated from the acetabulum or can be dislocated. Inspect the contours of the legs while the child is lying prone. The presence of asymmetric skin folds on the medial aspect of the thigh is suggestive of a proximally dislocated femur. The perineum should not be visible when the child is in this position, because the normal position of the thighs should cover most of it. If the perineum is visible, you must suspect bilateral hip dislocations.

With the child lying supine, place the infant's feet side by side with the soles on the examination table, allowing the hips and knees to flex. Observe the relative height of the knees. If one knee is at a lower level, you should suspect that the shortness of that knee is secondary to a dislocation of the hip on that side, a congenitally short femur, or both. This is known as Galeazzi's sign. If both knees are at the same height, either both hips are normal or both hips are dislocated.

After inspection of the knee heights, each hip is examined to determine joint stability. Two maneuvers are useful in detecting hip instability. First perform Barlow's maneuver. Flex the newborn's legs 90° at the hip and 90° at the knee. Hold the legs by placing your thumbs over the midthigh medially and your index fingers over the greater trochanters, as shown in Figure 24-22 (right). Bring the knee to midline and gently press back toward the examination table. Feel for a ''clunk'' as an unstable femoral head slips past the posterior rim of the acetabulum and dislocates from the socket. Now perform Ortolani's maneuver, which is a sign of

Figure 24-22 Ortolani's (left) and Barlow's (right) maneuvers.

Figure 24-22 Ortolani's (left) and Barlow's (right) maneuvers.


relocating the femoral head into the acetabulum. Abduct the hip (knee goes outward) while you apply gentle upward pressure over the greater trochanter and push the femoral head anteriorly, as shown in Figure 24-22 (left). A "clunk" indicates that the hip is relocating in the socket. Repeat with the other leg. If you feel a clunk in either hip, avoid repeat examinations of the hip until an expert examination can be done: movement of the femoral head in and out of the socket can damage the articular cartilage. It is common to feel clicks under your examining fingers; when in doubt, ask for expert evaluation. These tests should be performed on a relaxed infant. After the neonatal period, Ortolani's maneuver may yield a false-negative result.

Inspect the feet. Observe the foot at the sole. An imaginary line from the center of the heel through the center of the metatarsal-tarsal line should bisect either the second toe or the space between the second and third toes. If the line crosses more laterally, the forefoot is adducted (turned inward) in relation to the hindfoot. This is the common condition known as metatarsus adductus and is often the result of intrauterine packing. This condition may resolve spontaneously within the first few years of life, but early casting or exercises for passive correction may be required.

The most serious foot deformity at birth is the clubfoot, also known as talipes equinovarus. The entire foot is deviated toward the midline. There is forefoot adduction, fixed inversion of the hindfoot, and fixed plantar flexion. The Achilles tendon is foreshortened, and the foot assumes the position of a horse's hoof, hence the prefix "equino-." The calf muscles on the affected side are also smaller than those on the unaffected side. Therapy should begin within the first few days after birth. Manipulation is vital. If the deformity is not corrected by retention casting or splinting, surgical release may be necessary at a later date. The 3-week-old infant pictured in Figure 24-23 was born with bilateral clubfoot and bilateral hip dislocations. Multiple muscu-loskeletal deformities may be a clue to a neuromuscular problem in utero.

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