Orthopaedic Problems
James R. Kasser
This chapter considers common musculoskeletal abnormalities that may be detected in the neonatal period. Consultation with an orthopaedic surgeon is often required to provide definitive treatment after the initial evaluation.
I. CONGENITAL MUSCULAR TORTICOLLIS
Congenital muscular torticollis (CMT) is a disorder characterized by limited motion of the neck, asymmetry of the face and skull, and a tilted position of the head. It is usually caused by shortening of the sternocleidomastoid (SCM) muscle but may be secondary to muscle adaptation from an abnormal in utero position of the head and neck.
The etiology of the shortened SCM muscle is unclear; in many infants, it is due to an abnormal in utero position, and in some, it may be due to the stretching of the muscle at delivery. The result of the latter is a contracture of the muscle associated with fibrosis. One hypothesis is that the SCM abnormality is secondary to a compartment syndrome occurring at the time of delivery.
Clinical course. The limitation of motion is generally minimal at birth, but increases over the first few weeks. At 10 to 20 days, a mass is frequently found in the SCM muscle. This mass gradually disappears, and the muscle fibers are partially replaced by fibrous tissue, which contracts and limits head motion. Because of the limited rotation of the head, the infant rests on the ipsilateral side of the face in the prone position and on the contralateral occiput when supine. The pressure from resting on one side of the face and the opposite occipital bone contributes to the facial and skull asymmetry. The ipsilateral zygoma is depressed and the contralateral occiput flattened.
Treatment. Most infants will respond favorably to positioning the head in the direction opposite to that produced by the tight muscle. Padded bricks or sandbags can be used to help maintain the position of the head until the child is able to move actively to free the head. Passive stretching by rotating the head to the ipsilateral side and tilting it toward the contralateral side may also help. The torticollis in most infants resolves by the age of 1. Helmets are sometimes used to treat persistent head asymmetry after a few months of age. Patients who have asymmetry of the face and head and limited motion after 1 year should be considered for surgical release of the SCM muscle.
Differential diagnosis. Torticollis with limited motion of the neck may be due to a congenital abnormality of the cervical region of the spine. Some infants with this disorder also have a tight SCM muscle. These infants are likely to have significant limitation of motion at birth, which is not generally seen in CMT. Radiologic evaluation of the cervical region is necessary to make this diagnosis. Infection in
the retropharyngeal area may present with torticollis. The neck mass seen in torticollis in the SCM muscle may be differentiated from other cervical lesions by ultrasound.
II. POLYDACTYLY
Duplication of a digit may range from a small cutaneous bulb to an almost perfectly formed digit. Treatment of this problem is variable. Syndromes associated with polydactyly include Laurence-Moon-Biedl syndrome, chondroectodermal dysplasia, Ellis-van Creveld syndrome, and trisomy 13. Polydactyly is generally inherited in an autosomal dominant manner with variable penetrance.
Treatment
The small functionless skin bulb without bone or cartilage at the ulnar border of the hand or lateral border of the foot can be ligated and allowed to develop necrosis for 24 hours. The part distal to the suture should be removed. The residual stump should have an antiseptic applied twice a day to prevent infection. Do not tie off digits on the radial side of the hand (thumb) or the medial border of the foot.
When duplicated digits contain bone or muscle attached by more than a small bridge of skin, treatment is delayed until the patient is evaluated by an orthopedist or hand surgeon. In general, polydactyly is managed surgically in the first year of life after 6 months of age. X-rays can be delayed until necessary for definitive management.
III. FRACTURED CLAVICLE (see Chap. 6)
The clavicle is the site of the most common fracture associated with delivery.
Diagnosis is usually made soon after birth, when the infant does not move the arm on the affected side or cries when that arm is moved. There may be tenderness, swelling, or crepitance at the site. Occasionally, the bone is angulated. Diagnosis can be confirmed by radiographic examination. A “painless” fracture discovered by radiography of the chest is more likely a congenital pseudarthrosis (nonunion). All pseudarthroses occur on the right side unless associated with dextrocardia.
The clinical course is such that clavicle fractures heal without difficulty. Treatment
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