Review Article

Orthopaedic Conditions in the

Newborn
Abstract
Wudbhav N. Sankar, MD
Jennifer Weiss, MD
David L. Skaggs, MD

Dr. Sankar is Fellow, Childrens

Hospital Los Angeles, Los Angeles,
CA. Dr. Skaggs is Associate
Professor, Childrens Hospital Los
Angeles. Dr. Weiss is Assistant
Professor, Childrens Hospital Los
Angeles.
Dr. Skaggs serves as board
member, owner, officer, or
committee member for the Pediatric
Orthopaedic Society of North
America and the Scoliosis Research
Society. Dr. Skaggs or a member of
his immediate family has received
research or institutional support from
Medtronic Sofamor Danek and
Stryker; serves as a paid consultant
to or is an employee of Medtronic
Sofamor Danek and Stryker; is a
member of a speakers bureau or
has made presentations on behalf of
Medtronic Sofamor Danek, Stryker,
and DePuy; and has received other
financial or material support from
Wolters Kluwer Health. None of the
following authors or a member of
their immediate families has
received anything of value from or
owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article: Dr. Sankar and
Dr. Weiss.
Reprint requests: Dr. Skaggs,
Childrens Hospital Los Angeles,
4650 Sunset Boulevard, Mail Stop
69, Los Angeles, CA 90027.
J Am Acad Orthop Surg 2009;17:
112-122
Copyright 2009 by the American
Academy of Orthopaedic Surgeons.

112

The occasional consultation on a neonate can be unfamiliar

territory for many orthopaedic surgeons. Just as children are not
little adults, newborns are not just little children; rather, they have a
unique physiology that affects the presentation of their orthopaedic
concerns. Careful physical examination with appropriate
understanding of neonatal development is essential to making the
proper diagnosis. A flail extremity in the newborn is most commonly
attributed to fracture or brachial plexus palsy; however, infection
must also be considered and ruled out to prevent long-term
morbidity. Metatarsus adductus is the most common foot
abnormality, but clubfoot, calcaneovalgus deformity, and congenital
vertical talus may also be encountered. Joint contractures that
spontaneously improve are normal in the newborn, but it is
important to identify and institute proper treatment for early
developmental dysplasia of the hip, congenital knee dislocation,
and torticollis. Clavicular pseudarthrosis and periosteal reactions
may be discovered on radiographic examination. A basic
understanding of the relevant conditions will help the orthopaedist
with the initial diagnosis and management of orthopaedic issues in
the newborn.

onsultation on a newborn can

elicit anxiety for many orthopaedic surgeons. Even for the dedicated pediatric orthopaedist, neonates constitute a small fraction of
an overall practice. Newborns have a
distinctive physiology and pathology,
and many consulting orthopaedic
surgeons are relatively unfamiliar
with the diagnostic criteria and management of orthopaedic diseases and
disorders in the newborn. Fortunately, there are relatively few orthopaedic problems in this age group.
However, it is imperative to make a
proper and timely diagnosis to minimize long-term morbidity as a result
of delayed or improper treatment.
Infants from birth to 3 months of
age are most likely to be encountered

in a neonatal intensive care unit

(NICU) or newborn nursery.

Examination of the
Newborn
Evaluation of a newborn can be challenging because the surgeon may be unfamiliar with musculoskeletal conditions deemed normal in children of
this age. Proper patient evaluation begins with a careful history, including
gestational age and prenatal and birth
history. For example, difficult vaginal
delivery of a large infant can be a risk
factor for fracture or brachial plexus injury, and breech position can be associated with developmental dysplasia of
the hip (DDH).

Journal of the American Academy of Orthopaedic Surgeons

Wudbhav N. Sankar, MD, et al

Physical examination should be

performed with the patient in the supine position and away from direct
light. The skin should be evaluated
for overall integrity. Depigmented
nevi and caf-au-lait spots can be associated with tuberous sclerosis, fibrous dysplasia, and neurofibromatosis. Neck range of motion (ROM)
should be carefully assessed because
limited motion can be an indicator of
Klippel-Feil syndrome or congenital
muscular torticollis (especially when
the sternocleidomastoid muscle is
tight). The clavicles should be palpated to detect fracture or congenital
pseudarthrosis. Assessment of the
shoulders, elbows, hips, knees, and
ankles should include ROM testing;
stiffness in multiple joints may be
caused by arthrogryposis.
Newborns should be evaluated for
DDH. With the patient supine, the
examiner should grasp the infants
thigh with the thumb over the lesser
trochanter medially and the ring or
middle finger around the greater trochanter laterally. The Ortolani test is
performed by gently abducting the
hip while exerting an upward force
on the greater trochanter.1 A palpable clunk represents the reduction
of a dislocatable (but reducible) hip.
The Barlow test is performed with
the patient in the same position and
the hip in neutral or slight adduction; a gentle downward force is applied to the hip joint.1 If the femoral
head moves out of the acetabulum,
the hip is considered dislocatable. In
addition, the hips should be checked
for asymmetric abduction or unequal
leg lengths (Galeazzi test). The Galeazzi test is performed on a flat surface with the hips and the knees
flexed. Unequal knee heights suggest
the presence of a dislocated hip or a
congenitally short femur.
The feet should be methodically
examined, with the examiner taking
note of the position of both the hindfoot and the forefoot. Normally, the
February 2009, Vol 17, No 2

longitudinal arch is absent in infants,

but a high arch could be an indicator
of neurologic problems. The examiner should observe for spontaneous
movement of all extremities. Newborns should then be turned onto
their side or belly to examine the
back and gluteal cleft, looking carefully for hairy patches, dimples, and
midline defects.
Many primitive reflexes are present
in neonates and are indicators of normal development. These reflexes are
present at birth and disappear as a part
of normal maturation. The absence of
these reflexes often indicates a delay in
normal neurologic development, and
their persistence beyond the expected
time of disappearance also suggests neurologic dysfunction.2
The grasp reflex can be elicited by
placing a finger or an object in the
infants palm or foot, stimulating a
grip response because of reflexive
flexion of the digits.3 The hand grasp
reflex is strongest at birth and normally disappears between 2 and 4
months of age; the plantar response
disappears between 9 and 12 months
of age. Asymmetry or persistence beyond 4 months for the hand and 1
year for the foot may be an indicator
of cerebral palsy. Unilateral absence
of the reflex may indicate flaccid paralysis secondary to complete brachial plexus palsy.
The Moro reflex is elicited by sudden extension of an infants neck.3
This reflex can be tested for by holding the infant supine above the examining table and suddenly lowering
the hand supporting the childs head.
The first phase of the reflex consists
of sudden abduction and extension
of all four limbs, extension of the
spine, and extension and fanning of
the fingers. This is followed by adduction and flexion of all four limbs,
with the arms clasping over the
body. The Moro reflex is present at
birth and normally disappears between ages 3 and 6 months. The re-

flex may be subdued in infants with

severe hypertonicity, marked hypotonicity, or flaccid paralysis. If the reflex persists beyond age 6 months,
developmental delay from a condition such as cerebral palsy should be
suspected. The Moro reflex will be
absent when nerve injuries exist but
present in other conditions causing
decreased upper extremity movement, such as fracture or infection.
The walking or stepping reflex is
demonstrated by supporting the
trunk of the infant in an upright position.3 The plantar surfaces are
touched down on the examining table, and the child is tipped forward.
This normally results in a reflexive
alternating flexion and extension of
the lower limbs, simulating walking.
This reflex is present at birth and
disappears by 1 to 2 months. Its absence may be the result of flaccid paralysis, and its persistence beyond
normal age may signal neurologic
impairment.

Major Diseases and

Disorders
The Flail Extremity
One of the most common reasons for
orthopaedic consultation in the
NICU is failure of an infant to move
a limb, usually an arm. Although it
may be obvious to include fracture
or brachial plexus palsy in the differential diagnosis, infection is one of
the most concerning diagnoses that
must be ruled out. Lack of movement can be seen with any of these
diagnoses. The affected limb should
first be palpated to check for crepitus
or other signs of obvious fracture. If
the diagnosis is still uncertain, a way
to distinguish brachial plexus palsy
from the pseudoparalysis of an infection or fracture is to gently shake the
limb. If the infant experiences pain,
infection or fracture is likely.4 Presence of a fracture, however, does
113

Orthopaedic Conditions in the Newborn

Figure 1

Anteroposterior radiograph of the

left shoulder demonstrating
subluxation because of septic
arthritis. (Reproduced with
permission from the Childrens
Orthopaedic Center, Los Angeles,
CA.)

not completely rule out concomitant

nerve injury. One study cited a 10%
incidence of brachial plexus injury
with clavicle fractures, highlighting
the need for neurologic evaluation in
the setting of a fracture.5

Infection
The diagnosis of infection in neonates is often difficult and requires a
high index of suspicion. Infants have
underdeveloped immune systems
that affect clinical and laboratory
findings. Infected joints are usually,
but not always, red, swollen, and
hot. Fever can be an unreliable sign
of infection. At least 15% to 25% of
newborns with sepsis present with
hypothermia rather than a fever because of thermoregulatory dysfunction.4 In the first week of life, normal
white blood cell counts range from
9,000 to 30,000 cells/mL. Leukopenia (<5,000 cells/mL), rather than
leukocytosis, is often suggestive of
infection. Erythrocyte sedimentation
rate is also an unreliable indicator in
this age group. A normal C-reactive
114

Figure 2

Ultrasonographic image of the left

hip demonstrating a joint effusion
(arrow). (Reproduced with
permission from the Childrens
Orthopaedic Center, Los Angeles,
CA.)

protein value, however, is extremely

useful for ruling out infection, with a
negative predictive value of 95%.6
The positive predictive value of an
elevated C-reactive protein level is
60%, making an elevated value suggestive but certainly not diagnostic
of infection.6 At the time of orthopaedic evaluation, the index of suspicion for infection should be even
higher in neonates attached to multiple intravenous lines and central
catheters, which can serve as iatrogenic sources of infection.
Historically, Staphylococcus aureus
has been the most common offending pathogen involved in neonatal
infections, followed by group B
streptococci.7-9 A recent study, however, has cited a possible change in
the epidemiology toward gramnegative infections.10 Blood cultures
are positive in between 21% and
47% of cases, and the incidence of
culture-negative septic arthritis may
be as high as 43%.10 Multiple-site involvement is seen in as many as one
half of neonates.
Before the appearance of the secondary ossification center, the epiph-

ysis receives blood directly from

metaphyseal blood vessels. Thus,
septic arthritis is a common sequelae
of adjacent osteomyelitis. One study
indicated that in 76% of neonates
with osteomyelitis, infection led to
epiphyseal insult or septic arthritis.11
Because of the lax nature of surrounding muscles, septic arthritis in
neonates may lead to joint subluxation or dislocation visible on plain
radiographs12 (Figure 1). Metaphyseal rarefaction and periosteal reaction are other radiographic findings
that have been described.9 If the
diagnosis is uncertain, ultrasonographic examination should be performed to look for intra-articular
pus or subperiosteal abscess (Figure
2). Suspected joints should be aspirated, and infections should be surgically drained as soon as is practical.
When a septic hip is found, an ultrasound examination of the contralateral hip should be performed because
there may be bilateral involvement.
Considerable morbidity may be associated with neonatal infections.
Septic arthritis in particular can rapidly destroy joint cartilage and can
cause physeal destruction, secondary
limb-length discrepancy, postinfectious arthritis, osteonecrosis of the
epiphysis, and even epiphyseal separation.12,13 Early diagnosis and treatment of neonatal infections is critical
to avoid such severe complications.

Brachial Plexus Palsy

Another cause for lack of movement in
an upper limb is a brachial plexus palsy.
The incidence of this disorder has been
estimated to be between 0.13 and 3.6
per 1,000 live births.14-16 Risk factors
include maternal diabetes, high birth
weight, prolonged labor, forceps delivery, and shoulder dystocia. Brachial plexus palsies are associated
with clavicle and humerus fractures,
as well as torticollis.14-16
Diagnosis is based on clinical ex-

Journal of the American Academy of Orthopaedic Surgeons

Wudbhav N. Sankar, MD, et al

amination. The infant should be

evaluated both supine and prone for
spontaneous movements; muscle
groups should be palpated for tone
and voluntary contractions. The
most common type of brachial
plexus palsy with upper trunk (ie, C5
and C6) involvement is known as
Erb palsy. This palsy exhibits the
characteristic waiters tip appearance of the arm and hand caused by
shoulder internal rotation, elbow extension, forearm pronation, and
wrist flexion (Figure 3). With total
plexus involvement, the neonates
limb is often completely flaccid and
may be associated with Horner syndrome (ie, ptosis, miosis, enophthalmos) of the ipsilateral eye when the
sympathetic chain is affected.16 In
these severe cases, the surgeon
should consider obtaining a chest radiograph to check for ipsilateral diaphragmatic paralysis resulting from
phrenic nerve dysfunction. Radiographs are useful for ruling out nonphyseal fractures. The Moro test or
the shake test can be used to distinguish a brachial plexus palsy from
an infection or a fracture.4
Occupational or physical therapy
should be considered for all patients
with brachial plexus palsies, but
ROM exercises should be deferred
for 10 to 14 days after birth to allow
for pain to subside.16 Because as few
as 1 of 10 infants with plexus palsies
at birth will require surgical intervention, the goal of initial management is to maintain passive ROM
while motor function is recovering.16
Because the decision to explore the
plexus is based entirely on recovery
of muscle function, a neonate with
brachial plexus injuries should be
promptly referred to a specialist who
can follow the child with careful, sequential neurologic examinations.
Historically, surgery has been recommended when there is no recovery
in biceps function by ages 3 to 6
months.16,17 However, a recent study
February 2009, Vol 17, No 2

Figure 3

Characteristic waiters tip appearance of the left arm as the result of Erb
palsy. (Reproduced with permission from the Childrens Orthopaedic Center,
Los Angeles, CA.)

has suggested that some infants with

no biceps recovery by 3 months will
eventually achieve adequate biceps
and shoulder function without surgery.18 Although the timing of surgical intervention is controversial,
early referral is important because
surgical exploration after 18 months
is of little benefit.

Fracture
Fracture is the third major cause of a
nonmoving limb. Birth-related fractures are not uncommon; risk factors
include breech position, macrosomia, and vaginal delivery.19-21 The incidence of clavicular fractures has
been reported to be 1.1% of all live
births.20 The number of femoral fractures is smaller: one series found
0.13 instances per 1,000 live births.21
For infants whose fractures are noted
after hospital discharge, child abuse
must be considered as a potential
cause.
Diagnosis is not always straightforward because large physes and incomplete ossification of the epiphyses can make fracture visualization

difficult. In the upper limb, a major

pitfall in neonates is an unrecognized
proximal humerus physeal fracture
or, less commonly, a fracture of the
distal humerus. On physical examination, there is usually local fullness
and tenderness as well as pain with
motion of the limb. Clavicular fractures can often be diagnosed by palpating a spongy mass over the fracture site.22 Radiographs generally
confirm the diagnosis of nonphyseal
fractures. Callus is often already visible at a fracture site by the time the
fracture is diagnosed. When radiographs are normal, ultrasonographic
imaging is extremely useful for demonstrating occult fractures, particularly those about the proximal humerus.23 Ultrasonography also can
reveal joint effusion or subperiosteal
fluid accumulation characteristic of
infection. In a patient with multiple
fractures, an underlying condition
such as osteogenesis imperfecta or
neonatal rickets should be considered.
Fractures in the neonate generally
heal rapidly, and outcomes are often be115

Orthopaedic Conditions in the Newborn

more than 2,400 newborns found an

overall incidence of foot deformity of
4.2%.26 Metatarsus adductus accounted for three quarters of these
abnormalities. Talipes equinovarus,
calcaneovalgus foot, and vertical talus were less commonly seen.

Figure 4

Metatarsus Adductus
A, Lateral radiograph demonstrating a femur fracture in a 2-month-old infant.
B, Abundant callus is evident 1 month later. (Reproduced with permission
from the Childrens Orthopaedic Center, Los Angeles, CA.)

Figure 5

In newborns, a stockinette can be used to immobilize a proximal humerus

fracture. (Reproduced with permission from the Childrens Orthopaedic
Center, Los Angeles, CA.)

nign (Figure 4). Limb-length discrepancy or angular deformity following

proper fracture treatment is rare.19-21
Most neonatal fractures require immobilization for only 7 to 10 days.
The Pavlik harness is a well-accepted
treatment modality for femoral fractures in the neonate.24,25 Advantages of
a Pavlik harness compared with conventional spica casts include ease of application without the need for general
anesthesia, reliable fracture reduction,
and improved diapering and perineal
care. Certain surgeons cite higher pain
scores with the use of Pavlik harnesses
and therefore prefer single-leg Gore-Tex
(W. L. Gore, Flagstaff, AZ) soft cast spi116

cas, which are washable and provide

better compressive forces at the fracture
site.4 For upper extremity fractures,
standard slings and shoulder immobilizers are much too large to fit
most newborns. One option is to use
a cotton stockinette, although this
may migrate around the neck (Figure
5). A safe and simple alternative is to
pin the sleeve of the infants shirt to
the torso of the shirt.4

The Newborn Foot

Foot deformities are relatively common
in the newborn child. One study of

Metatarsus adductus is a common

foot deformity seen after birth, occurring in as many as 1 in 100 live
births, and is thought to relate to intrauterine positioning.26 Metatarsus
adductus consists of an adducted
forefoot, a curved lateral border, and
a neutral heel, creating the characteristic bean shape sole of the foot.
Flexible deformities may be treated
with observation or stretching; 90%
to 95% will resolve spontaneously
regardless of treatment.26,27 For rigid
deformities, serial manipulation and
casting should be done before age 6
months. Surgery is rarely required
and is indicated only for a child
older than age 3 years with a rigid
deformity that has not responded to
serial casting.27

Clubfoot
Talipes equinovarus (ie, clubfoot deformity) occurs in approximately 1
to 2 in 1,000 births. This deformity
is characterized as cavus, forefoot
adductus, hindfoot varus, and equinus (ie, CAVE).28 Clubfoot has a
wide spectrum of presentations, from
a mild, postural form to a severe,
rigid deformity. The latter is usually
associated with arthrogryposis, myelomeningocele, Larsen syndrome, or
other underlying disorder.
Most neonatal clubfoot deformities
can be treated nonsurgically. The
Ponseti method of serial manipulation and casting has gained widespread support and has revolutionized the treatment of talipes
equinovarus. Several studies have
shown excellent mid- and long-term

Journal of the American Academy of Orthopaedic Surgeons

Wudbhav N. Sankar, MD, et al

Figure 6

Figure 7

A, Photograph demonstrating calcaneovalgus deformity. Note that the apex

of the deformity is in the joint. B, Photograph demonstrating posteromedial
bowing of the tibia. Note that the apex of the deformity is in the tibia.
(Reproduced with permission from Skaggs DL, Flynn JM [eds]: Staying Out
of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)

results with decreased stiffness as a

result of using the Ponseti method of
serial casting and Achilles tenotomy
compared with feet that have been
treated surgically.29,30 Although some
centers initiate casting in the newborn nursery or NICU within a few
days of delivery, treatment is not
emergent. Dobbs et al31 demonstrated that neither the age at which
treatment was initiated nor the severity of the initial deformity was found
to have a significant effect on recurrence. As a result, many pediatric orthopaedists prefer to initiate serial
casting in a controlled, outpatient
setting after the infants have been
discharged from the hospital. Others
prefer early casting in the hospital to
take advantage of neonatal ligamentous laxity and to reassure family
members that the childs deformity is
being attended to.

Calcaneovalgus Foot
Although some believe that a mild form
of calcaneovalgus foot deformity occurs
in 30% to 40% of newborns, the estimated incidence of this deformity is 0.4
to 1.0 in 1,000 live births.32 In the
calcaneovalgus foot, the hindfoot externally rotates and dorsiflexes. In
February 2009, Vol 17, No 2

some cases, this causes the dorsum of

the foot to be in contact with the anterior tibia. It is important to distinguish the calcaneovalgus foot from
posteromedial bowing of the tibia
with an apparent calcaneovalgus
foot; in the former, the apex of the
deformity is in the ankle joint,
whereas in the latter, the apex is in
the distal tibia4 (Figure 6). Gentle
stretching of the foot into plantar
flexion and inversion can be helpful;
however, most deformities will resolve spontaneously by age 3 to 6
months regardless of treatment. In
patients with posteromedial bowing
of the tibia, parents should be counseled that a limb-length discrepancy
(usually 3 to 4 cm) is likely to result.

Congenital Vertical Talus

Congenital vertical talus (CVT) is a
rare foot deformity that can be confused with the calcaneovalgus foot.
CVT is characterized by a hindfoot
that is in equinus. The forefoot is
dorsiflexed, resulting in a midfoot
dislocation through the talonavicular
joint (Figure 7). Unlike the calcaneovalgus foot, which is flexible,
CVT is a rigid deformity with a convex plantar surface that forms a

Congenital vertical talus with

characteristic rocker-bottom
deformity. (Reproduced with
permission from the Childrens
Orthopaedic Center, Los Angeles,
CA.)

rocker-bottom deformity. Plantar

flexion lateral radiographs are useful
for distinguishing an oblique vertical
talus from a CVT (Figure 8). A genetic consultation may be considered
because up to 60% of cases of CVT
may be associated with arthrogryposis or myelomeningocele.33
During the neonatal period, serial
manipulation and casting are useful
to stretch the anterior skin as well as
the capsular and musculotendinous
soft tissues. Definitive surgical correction (ie, open release) is usually
performed between ages 6 and 12
months, and results are better when
surgery is performed before age 2
years.34 Recently, Dobbs et al31 described a new technique consisting of
serial manipulation and cast immobilization followed by percutaneous
talonavicular pin fixation and Achilles tenotomy. Early results have demonstrated excellent outcomes in
terms of clinical appearance, deformity correction, and foot function.

Dislocations and
Contractures
In the newborn, mild flexion contractures of the knee, hip, and elbow
are normal and usually resolve with
time.4 For example, one study found
that the mean knee flexion contrac117

Orthopaedic Conditions in the Newborn

Figure 8

Lateral radiographs demonstrating plantar flexion of an oblique (A) and

vertical (B) talus. In the oblique talus, the navicular (unossified) and first
metatarsus reduce on the talus. In a true congenital vertical talus, the talus
remains plantar flexed in relation to the navicular (unossified) and
metatarsus. (Reproduced with permission from the Childrens Orthopaedic
Center, Los Angeles, CA.)

ture was 21 at birth, diminishing to

11 at age 3 months and to 3 at age
6 months.35 Absence of these normal contractures may be an indicator of an underlying disorder (eg,
congenital knee dislocation).

Early Developmental
Dysplasia of the Hip
The incidence of frank hip dislocation
is 1 in 1,000 births, while the incidence
of subluxation or dysplasia is 10 in
1,000.1 Major risk factors include
breech position, congenital muscular
torticollis, and family history of
DDH. Lesser risk factors include being a first-born child and female sex.
Newborns should be evaluated for
asymmetric knee heights (ie, Galeazzi
sign) in addition to undergoing the
Barlow and Ortolani tests. The surgeon should be aware that bilateral
hip dislocation may be present without asymmetry of leg length or hip
abduction. One test that can help
identify a bilateral dislocation is the
Klisic test, in which the physician
places the middle finger over the
greater trochanter with the index finger on the anterior superior iliac
spine. An imaginary line between
these two fingers should point to the
118

umbilicus. In the patient with a hip

dislocation, the greater trochanter
moves proximally, causing this line
to point somewhere between the umbilicus and the pubis. An infant with
a unilateral hip dislocation will eventually demonstrate limited hip abduction but may appear to be normal immediately after birth.1 Severe
limitations in ROM with an irreducible hip dislocation usually indicate a
teratologic dislocation resulting from
a syndrome or neuromuscular cause.
Ultrasonography is the diagnostic
modality of choice for DDH before
the appearance of the femoral head
ossific nucleus (4 to 6 months).
However, during the early newborn
period (0 to 4 weeks), physical examination is preferred because there
is a high incidence of false-positive
sonograms in this age group.36 Ultrasonographic imaging can identify
mild subluxation and acetabular
dysplasia in addition to documenting
reducibility and stability of a hip undergoing treatment. Plain radiographs for this age group may document grossly dislocated teratologic
hips, but they cannot be used to definitively declare a hip as being located or normal.

Orthopaedic consultation to evaluate

an early hip click or a positive ultrasound image in the first few weeks of
life does not automatically mandate immediate treatment.36 Most neonates
with acetabular dysplasia or subluxatable hips may be observed until
ages 3 to 4 weeks because a significant proportion of hips will resolve
spontaneously.1,4,37 However, newborns with frank dislocations (Ortolani positive) or dislocatable hips
(Barlow positive) should be treated
at the time of diagnosis. The Pavlik
harness is the mainstay of treatment
for most cases of DDH in the newborn period (excluding teratologic
hip dislocations). Straps should be
adjusted so that the child is in approximately 100 of hip flexion and
60 of abduction. Excessive abduction can increase the risk of osteonecrosis. A follow-up ultrasonographic
examination should be performed after 2 or 3 weeks of treatment to confirm reduction of the hip. Harness
treatment should be discontinued at
4 weeks if the hip is not reduced by
that time.38 Continued use of the harness beyond this period in a persistently dislocated hip can cause Pavlik harness disease, or a wearing
away of the posterior aspect of the
acetabulum, which may make the ultimate reduction less stable.38 In one
study, investigators reported that the
use of an abduction brace for those
hips that failed Pavlik harness treatment may lead to stable hip reduction, thereby avoiding the need for
closed reduction under general anesthesia.39

Congenital Knee
Dislocation
Congenital knee dislocation is a rare
condition, with a reported incidence
of 0.017 per 1,000, or about 1% as
common as DDH.40 The etiology remains unclear, but the condition is
most likely related to contracture of

Journal of the American Academy of Orthopaedic Surgeons

Wudbhav N. Sankar, MD, et al

Figure 9

Congenital knee dislocation with

knee hyperextension. (Reproduced
with permission from the Childrens
Orthopaedic Center, Los Angeles,
CA.)

the quadriceps femoris muscle with

variable deformity of the anterior
cruciate ligament. Associated conditions include clubfoot, arthrogryposis, myelodysplasia, and Larsen syndrome. Ipsilateral congenital hip
dislocation is present in 70% to
100% of cases.41
The physical signs of congenital
knee dislocation are apparent at
birth. The knee is hyperextended, often to such a degree that the childs
foot can touch the face (Figure 9). In
true dislocations, the knee cannot be
flexed, and the femoral condyles can
often be palpated in the popliteal
fossa. Radiographs demonstrate the
position of the tibia relative to the femur and allow classification as grade
I (severe genu recurvatum), grade II
(subluxation), or grade III (complete
dislocation)41 (Figure 10). In cases
that are still unclear, ultrasonography can be helpful for delineating the
immature anatomy, classifying the
condition, and monitoring treatment.42,43
Nonsurgical treatment should be
started promptly after diagnosis.
Manipulation techniques involve
manual traction until the tibia is felt
to engage with the femoral condyles,
followed by flexion of the knee. SeFebruary 2009, Vol 17, No 2

Figure 10

Illustration demonstrating the classification for congenital knee dislocation.

A, Grade I, recurvatum. B, Grade II, subluxation. C, Grade III, complete
dislocation. (Adapted with permission from Curtis BH, Fisher RL: Congenital
hyperextension with anterior subluxation of the knee: Surgical treatment and
long-term observations. J Bone Joint Surg Am 1969;51:255-269.)

rial casting in progressive flexion

should then be performed. In children with concomitant DDH, the
congenital knee dislocation should
be treated first. As knee flexion
improves, the patient can be placed
in a Pavlik harness, allowing treatment of both the knee and the hip.44
Surgery is indicated for children who
do not respond to nonsurgical treatment and is best performed at the
age of approximately 6 months. The
procedure typically consists of open
reduction with quadriceps lengthening.

Congenital Muscular
Torticollis
Congenital muscular torticollis, a painless deformity caused by contracture of
the sternocleidomastoid muscle, is the
most common form of torticollis in
newborns. The etiology remains controversial but most likely arises from
intrauterine or perinatal compartment
syndrome, which causes fibrosis of
the sternocleidomastoid muscle.45
Risk factors include breech position

and difficult delivery; associated conditions include DDH and metatarsus

adductus.
The clinical appearance is characteristic, with the infants head tilted
toward the involved muscle and the
chin rotated toward the contralateral
shoulder. An olive-shaped mass can
sometimes be felt in the body of the
sternocleidomastoid muscle in the
first 3 months. This mass often disappears during early infancy but is
replaced by a tight fibrous band over
the length of the muscle as it fibroses.
Initial treatment consists of a massage and stretching program, which
is successful in most cases when
started in the first 6 months of life.46
For infants who do not respond to
physical therapy, plain radiographs
should be taken to rule out KlippelFeil syndrome or other cervical spine
anomaly. Children who present at an
older age and those with torticollis
refractory to therapy may require a
release of the sternocleidomastoid
muscle, usually around age 5 years.
119

Orthopaedic Conditions in the Newborn

Figure 11

Figure 13

Anteroposterior radiograph demonstrating pseudarthrosis of the right clavicle

in an 8-day-old boy. (Reproduced with permission from Skaggs DL, Flynn JM
[eds]: Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
Anteroposterior radiograph
demonstrating Caffey disease
(ie, infantile cortical hyperostosis).
This self-limited condition is
characterized by diffuse periosteal
new bone formation, soft-tissue
swelling, and fever. (Reproduced
with permission from the Childrens
Orthopaedic Center, Los Angeles,
CA.)

Figure 12

Periosteal New Bone

Anteroposterior radiograph demonstrating physiologic neonatal periosteal

reaction in a tibia. Note that the thickness is <2 mm. (Reproduced with
permission from Kwon DS, Spevak MR, Fletcher K, Kleinman PK:
Physiologic subperiosteal new bone formation: Prevalence, distribution, and
thickness in neonates and infants. AJR Am J Roentgenol 2002;179:985-988.)

Unusual Radiographic
Findings
Congenital Pseudarthrosis
of the Clavicle
Congenital pseudarthrosis of the
clavicle is a rare condition in which
the medial and lateral ossification
centers of the clavicle fail to unite.
The radiographic appearance is often
confused with that of a clavicle fracture; however, congenital pseudar120

throsis is not painful (Figure 11). A

bump may be palpable at the pseudarthrosis site. The diagnosis is confirmed by the absence of callus on
subsequent radiographs.4 The condition almost always occurs on the
right side, unless dextrocardia is
present. The natural history is benign, but surgical treatment of the
congenital pseudarthrosis may be required if there is discomfort or concern about the cosmetic appearance
of the bump.4,47

Periosteal reactions occur in a variety

of scenarios in the newborn and can
be both physiologic and pathologic.
Physiologic periosteal reactions can
be seen in 35% of infants ages 1 to 4
months.4 These are usually discovered incidentally on radiographs
taken for other reasons. Physiologic
periosteal reactions are thin, even,
and symmetric, occurring along the
femur, tibia, and humerus. Periosteal
new bone that occurs in children
younger than age 1 month or older
than age 4 months may be pathologic. Periosteal thickness >2 mm is
considered abnormal and should
prompt further work-up48 (Figure
12). The differential diagnosis for
pathologic periosteal reactions in the
neonate includes Caffey disease, congenital syphilis, infection, malignancy, child abuse, hypervitaminosis
A, history of prostaglandin infusion
or extracorporeal membrane oxygenation, and scurvy (Figure 13).

Journal of the American Academy of Orthopaedic Surgeons

Wudbhav N. Sankar, MD, et al

4.

Skaggs DL, Sponseller PD: Issues of the

newborn, in Skaggs DL, Flynn JM (eds):
Staying Out of Trouble in Pediatric
Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006, pp
134-143.

5.

McBride MT, Hennrikus WL, Malogne

TS: Newborn clavicle fractures.
Orthopedics 1998;21:317-319.

6.

Laborada G, Rego M, Jain A, et al:

Diagnostic value of cytokines and
C-reactive protein in the first 24 hours of
neonatal sepsis. Am J Perinatol 2003;20:
491-501.

Summary
Careful history and physical examination are required in the orthopaedic evaluation of a neonate. A
flail extremity is usually caused by
infection, fracture, or a brachial
plexus palsy. Metatarsus adductus is
the most common foot deformity,
but clubfoot, calcaneovalgus deformities, and CVT may be seen. Flexion contractures early in the newborn period are common and are not
pathologic. However, congenital dislocation of the hips or the knees may
occur. Congenital pseudarthrosis of
the clavicle and periosteal reactions
are a few of the unusual radiographic findings in this age group.
Armed with a basic understanding of
the common orthopaedic issues in
the newborn, the consulting orthopaedist should be comfortable making an initial diagnosis and managing
most conditions.

7.

8.

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Journal of the American Academy of Orthopaedic Surgeons