Common Limb Problems

Summary
Introduction
Upper Extremities
Lower Extremities

Summary

most cases of brachial plexus palsy resolve spontaneously. Infants without signs of recovery at 1 month of age should be referred to a brachail plexus injury clinic
metatarsus adductus with a rigid foot, 'fixed' talipes equinovarus, polydactyly and syndactyly should be referred for orthopaedic opinion

Introduction

Anomalies of the musculoskeletal system may be evident as

the absence of a part
extra parts
malformed part
malfunctioning tissue

Anomalies may be congenital or acquired (eg birth trauma) and usually affect the infant's movement, muscle tone, or posture.

Upper Extremities

Obstetric Brachial Plexus palsy is seen most often in large babies who are vulnerable to stretching injuries to the components of the brachial plexus. Erb's palsy and total plexus palsy are the two most common types of injury.

Erb's palsy involving C5, C6 and sometimes C7 causes the affected arm to be adducted and internally rotated, with extension at the elbow, pronation of the forearm, and flexion of the wrist ('waiter's tip' position). Paralysis of the upper arm is more common than paralysis of the lower arm or of the entire arm. The grasp reflex remains intact, but the Moro reflex is absent on the affected side.

Complete brachial plexus palsy presents with a limp, dangling appendage, without any trace of movement.

Klumpke's palsy, involving C7-8 and T1, is purely a lower brachial plexus palsy that presents as a clawed hand with function at the shoulder and elbow. There is also an associated dilation of the pupil on the side of the injury (the nerves which dilate the pupil leave the spinal cord on the C8 and T1 nerves and then travel with the artery to the brain and eye).

Management of Brachial Plexus Palsy

X-ray of the clavicle and upper arm on the affected side, and a chest X-ray to exclude ipsilateral diaphragmatic paralysis
where the nerve roots are not disrupted, most resolve spontaneously
babies without evidence of recovery by 1 month should be referred to the Erb's palsy and Brachial Plexus Injury Clinic at The Royal Children's Hospital (9345 5391). With the advent of new reconstructive techniques, useful function can be obtained by children who have failed conservative therapy, provided that timely treatment is given

Lower Extremities

Developmental dysplasia of the Hip (DDH)

Metatarsus Adductus

The most common congenital foot anomaly, metatarsus adductus is caused by intrauterine positioning. It may be a positional (flexible) deformity with no bony abnormality involved or a structural deformity. In a structural deformity, the forefoot usually cannot be abducted beyond the midline (neutral position) and the heel (hindfoot) is in a valgus position. In a positional deformity, the forefoot is very mobile and can be easily abducted. A positional deformity will correct without treatment. In a rigid foot, an orthopaedic consultation is necessary for early treatment.

Clubfoot ( Talipes Equinovarus)

Clubfoot is one of the most common congenital anomalies with an incidence of approximately 1 per 1000 live births. In Caucasians, males are affected twice as often as females. The involvement is bilateral in 50% of cases. A thorough examination should be made for other anomalies, especially the effects of fetal hypokinesia There are variations in the severity of clubfoot. Some are relatively flexible and correctable with serial exercises and casting. Treatment of fixed deformities should be started in the nursery; an orthopaedic consultation should be initiated as soon as possible after birth.

Syndactyly

This is frequently a familial tendency. The severity varies from minimal 'bridging' between adjacent fingers/toes to complete webbing of the hand/foot. Syndactyly of the toes does not interfere with function but may be unacceptable cosmetically. Treatment for syndactyly of the fingers depends on the severity and the presence of bony abnormalities. An early orthopaedic consultation is needed.

Polydactyly

Extra digits are common abnormalities affecting both the hands and the feet, with a familial tendency. The most common type is a floppy digit or skin tag on the lateral side of the hand. It may involve the duplication of a normal looking digit. All digital remnants should be surgically removed.

References

Tappero EP. 1996. Musculoskeletal system assessment. In Physical Assessment of the newborn, 2nd ed., Tappero EP, and Honeyfield ME, eds. Petaluma, California: NICU Ink, 117-136.

Rennie JM, Roberton NRC, eds. 1999. Textbook of Neonatology , 3rd ed., Edinburgh: Churchill, 275-280.

Shenaq et al. 1998. Brachial plexus birth injuries and current management. Clinics in Plastic Surgery;25(4):527-535

Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. 2000. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics;105(4 Pt1):896-905.

Web Links

http://www.ubpn.org The home page of the United Brachial Plexus Network. Very interesting

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