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ORTHOPEDIC DISORDERS IN infa nts a re relatively common, with many presenting at or soon after birth. Early recognition is critica l as conditions, such as developmenta l dysplasia of the hip a nd brachia l plex us pa lsy, have the best outcomes when treated ea rly. Developmenta l dyspla sia of the hip (DDH) occurs more of ten in fema les with a n incidence rate between 1 in 1,000 or 1 in 50 bir ths, depending on cla ssif ication, culture a nd screening exa m. In newborns, DDH is of ten found as a " hip click," but it ca n have a wide spectrum of presentations. The acetabulum may be too sha llow or surrounding ligaments and other sof t tissues a round the joint may be loose, causing the femora l head to move more tha n norma l in the hip socket. Other cases may have subluxation of the femora l head, or it may dislocate. Risk factors include f irst-born babies, breech presentation, a nd fa mily histor y. If suspected, consider a lso metata rsus adductus a nd tor ticollis, as these deformities tend to cluster. Diagnosis is primarily based on a physica l exam, such as the Or tola ni a nd Ba rlow ma neuvers. Asymmetric thigh or labia l folds may a lso be sig ns. DDH may not be detected right away, so screenings should occur regularly through the toddler stage. A f ter 3 months of age, a positive Or tola ni or Ba rlow exa m is unlikely due to muscula r contracture. Other sig ns include positive Ga lea zzi test indicating leg-leng t h discrepa ncy, limited hip abduction, hy perlordosis, a nd waddling ga it. Older patients often present with hip pain, pain exacerbated by extension and externa l rotation, and limitations in wa lking or other activities. If physica l exa ms a re inconclusive, a n ultrasound a round 6 to 8 weeks of age shows positioning of the femora l head, if it dislocates from the acetabulum during the Barlow maneuver, a nd prog ress of the developing acetabulum. Interpretation of X-rays is ha rder a nd should be delayed until 3 to 6 months when ossif ication of the femora l head has occurred. Treatment varies based on extent. The majority of Barlow- positive cases stabilize without treatment. In newborns, a Pavlik harness, with a 95 percent success rate, may be used to hold the legs in abduction and flexion to correct the dislocation. If this fails, a hip abduction brace is an option. In children 6 months to 2 years, closed reduction and casting may be used. After age 2, open reduction and casting are usu- ally needed, but surgical results may be less satisfactory than early treatment. Brachial plexus birth palsy occurs when the nerve roots of the brachial plexus are injured, such as during a diµcult delivery. Although these injuries may be minimized by good obstetric care, early induction of large babies and Caesarian delivery of breech babies, it is estimated that 0.3 to 2.5 per 1,000 newborns are ažected annually. Risk factors include: + Large birth weight greater than 4,000 grams + Breech presentation + Prior delivery of a child with brachial plexus birth injury + Shoulder dystocia + Prolonged second stage of labor + Use of extraction techniques + Maternal diabetes/obesity Signs include ažected arm in the "waiter's tip" position, symmetrical Moro or tonic neck reflex, presence of Horner's syndrome, and winged scapula. Fortunately, 80 percent of injuries recover spontaneously, and mild cases benefit from gentle positioning, arm massage and range-of-motion exercises. More significant injuries require additional treatments including surgery to repair the injured nerves or the transfer of tendons to assist with shoulder function. Bicep function at 6 months is the critical determinant of recovery. Limited externa l rotation of the shoulder is a lso an important consideration for an imaging evaluation and possible surgery. Dr. Mark Adamczyk is a board-certified, fellowship-trained pediatric orthopedic surgeon. He is co-director of the Akron Children's Hospital Brachial Plexus Treatment Center. ■ RECOGNIZING Orthopedic Disorders in Infants BY MARK ADAMCZYK, MD 1 9 M D N E W S . C O M /// M D N E W S C L E V E L A N D /A K R O N / C A N T O N ■ J A N U A R Y/ F E B R U A R Y 2 017