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The Newborn Examination
Karen Montgomery-Reagan, D.O.
OUCOM
Department of Pediatrics
Overview
• Review birth Hx and VS
• Listen to heart while infant quiet:
Cardiovascular- inspection, palpation, and
auscultation
• Start from top: Head and Neck – head, face,
ears, eyes, nose, mouth, and neck
• Chest and Lungs
• Abdomen – inspection, palpation, and
auscultation
• Genitourinary – kidneys and genitalia
• Orthopedic – spine, upper and lower extremities
Vital Signs
– Heart Rate (rates/min)
• Awake 85-205
• Sleeping 80-160
– Respiratory Rate (breaths/min)
• 30-60
– Systolic Blood Pressure (SBP)
•
•
•
•
Infant SBP: 80
Age 12 hours: 50-70 / 25-45
Age 96 hours: 60-90 / 20-60
Hypotension defined in neonate to 28 days <60
APGAR Score
Score
Heart Rate
Respiratory effort
Muscle tone
Reflex irritability (nose
suction)
Color
0
1
2
Absent
<100bpm
>100bpm
Absent, irregular
Slow, crying
Good
Limp
Some flexion of
extremities
Active motion
No response
Grimace
Cough or sneeze
Blue, pale
Acrocyanosis
Completely pink
Dubowitz/Ballard Score
• External Characteristics
– To be done within few hrs
of birth
– Edema
– Skin texture, color,
and opacity
– Lanugo
– Plantar creases
– Nipples and breasts
– Ear form and firmness
– Genitals
• Neuromuscular Score
– To be done within 24 hrs
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–
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Posture
Square Window
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
Small for Gestational Age
• Symmetric
– HC, length, weight all <10 percentile
– 33% of SGA infants
– Cause: Infection, chromosomal abnormalities, inborn errors of
metabolism, smoking, drugs
• Asymmetric
– Weight <10 percentile, HC and length normal
– 55% of SGA infants
– Cause: Uteroplacental insufficiency, Chronic hypertension or
disease, Preeclampsia, Hemoglobinopathies, altitude, Placental
infarcts or chronic abruption
• Combined
– Symmetric or asymmetric
– 12% of SGA infants
– Cause: Smoking, drugs, Placental infarcts or chronic abruption,
velamentous insertion, circumvallate placenta, multiple gestation
Large for Gestational Age
• Etiologies
– Infants of diabetic mothers
– Beckwith-Wiedemann Syndrome
• characterized by macroglossia, visceromegaly,
macrosomia, umbilical hernia or omphalocele, and
neonatal hypoglycemia
– Hydrops fetalis
– Large mother
Skin
• Color
–
–
–
–
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Pallor: associated with low hemoglobin
Cyanosis: associated with hypoxemia
Plethora: associated with polycythemia
Jaundice: elevated bilirubin
Slate grey color: associated with
methemoglobinemia
Skin
• Jaundice
– Total and direct bilirubin levels should
be measured in newborns with
jaundice.
– Causes can be related to increased
unconjugated hyperbilirubinemia
(physiologic, breastfeeding,
increased production, decreased
hepatic uptake/conjugation) or
conjugated (hepatobiliary disorders,
ductal disturbances)
– The AAP has published guidelines on
the management of
hyperbilirubinemia in the newborn.
Skin
• Lanugo
– Fine hair on shoulders
and back
– More common in
preemies
– Usually disappears in
2-4 weeks
• Vernix Caseosa
– Cheesy white covering
Skin Lesions
• Petechiae
– On scalp and face after vertex delivery
• Sucking blister
– Develops from infant sucking on skin
in utero.
– Disappears as infant progress with
feeding.
• Hemangiomas
– Usually enlarges in 1st year of life.
– Large facial hemangiomas may be
associated with posterior fossa
malformations.
– MC benign tumor of infancy
– Most require no intervention
Skin Lesions
• Telangiectatic Nevi
– Also called salmon patches
or stork bite nevi
– Flat, pink lesion found on
upper eyelids, forehead,
nape of neck
– Fade by 1-2 years old
except those on nape of
neck which may persist
• Cutis Marmorata
– Transient mottling of the
skin
– Occurs when baby is
exposed to the cold
Skin Lesions
• Milia
– Pinpoint white papules
of keratogenous
material.
– Usually on nose,
cheeks and forehead.
– Can last for several
weeks.
Skin Lesions
• Miliaria
– Obstructed eccrine
sweat ducts.
– Pinpoint vesicles on
forehead, scalp, and
skinfolds.
– Usually clears within
one week.
Skin Lesions
• Transient Neonatal
Pustular Melanosis
– Small vesicopustules,
generally present at birth.
– Contain WBCs and no
organisms.
– Intact vesicle ruptures to
reveal a pigmented macule
surrounded by a thin skin
ring.
Skin Lesions
• Erythema Toxicum
Neonatorum
– Most common newborn
rash.
– Lesions are firm, yellow or
white pustules on a red and
swollen base.
– Lesions may be found in
face, trunk and limbs.
– Lasts about 5-7 days.
– Wright Stain shows
eosinophil sheets.
Skin Lesions
• Café au lait spots
– Suspect
nuerofibromatosis if
there are many large
spots
Skin Lesions
• Mongolian spots
– Well demarcated
symmetric bluish gray to
deep brown to black skin
markings
– Common among people of
Asian, East Indian, African,
and Latino heritage.
– Often on the base of the
spine, on the buttocks and
back
– Generally fade in a few
years and disappear by
puberty.
Neurological Exam
• Posture
– Term infants normal posture is hips abducted
and partially flexed, with knees flexed.
– Arms are abducted and flexed at the elbow.
– Fists are often clenched, with the fingers
covering the thumb
• Tone
– To test, support the infant with one hand under
the chest. Neck extensors should be able to
hold head in line for 3 seconds
– There should be no more than 10% head lag
when moving from supine to sitting positions.
Neurological Reflexes
• Ensure symmetrical
• Biceps jerk C5-C6, knee jerk L2-L4, ankle jerk S1-S2, anal wink S4S5, truncal incurvation reflex T2-S1.
• Primitive reflexes are present: Babinski, Moro, Galant, palmer and
plantar grasps, sucking, rooting, placing/stepping, and asymmetric
tonic neck reflex (Fencer’s pose).
Neurological Exam
• Cranial Nerve Exam
– CN II: Pupillary reflex
– Oculocephalic Reflex (doll’s eyes)
• CN III, IV, and VI
• If Brainstem intact:
– Eyes deviate contralaterally
– Look away from direction of rotation
– CNV and VII: Corneal, sucking, and rooting reflexes
– CN VIII: Response to Noise
– CN IX and X : Gag reflex
Macrocephaly
• Causes
– Familial with autosomal dominant inheritance
– Hydrocephalus
– Other conditions
•
•
•
•
•
•
•
Achondroplasia (skeletal dysplasia)
Sotos' Syndrome (Cerebral Gigantism)
Alexander's Disease
Canavan's Disease
Gangliosidoses
Glutaric aciduria Type I
Neurofibromatosis Type I
Microcephaly
• Causes
– Familial
– Trisomy 13, 18, 21
– Cornelia de Lange, Rubinstein-Taybi, Smith-Lemli-Opitz,
Prader-Willi
– Teratogen Exposure
• Fetal Alcohol Syndrome
• Radiation exposure in utero (<15 weeks gestation)
• Fetal Hydantoin
– TORCH Virus congenital infection
• Cytomegalovirus, Rubella, Toxoplasmosis
– Other causes
•
•
•
•
Meningitis/Encephalitis
Gestational Diabetes
Maternal hyperphenylalaninemia
Hypoxic-ischemic encephalopathy
Head Examination
• Head
– Check overriding sutures, number and size of
fontanelles
• Molding
• Over-riding of cranial bones
• Normal finding at delivery
• Resolves spontaneously over first 5 days of life
Head Trauma
• Cephalohematoma
– Not as common, but can occur
after prolonged labor and
instrumentation use.
– Rupture of blood vessels that
traverse skull to the periosteum
– Fluctuant swelling, does not
cross suture lines
– No overlying discoloration, but
possible fracture
– Uncomplicated resolves in 2
weeks to 3 months, if fracture,
Xray in 4-6 weeks to ensure
closure, depressed fractures
require neurosurgical consult.
Head Trauma
• Caput seccedaneum
– Common after prolonged labor.
– Accumulation of blood above
periosteum.
– Soft tissue swelling that crosses
suture lines with overlying
petechiae, purpura or bruising.
– Usually resolves spontaneously
over several days.
Fontanelles
• Anterior
– Junction of coronal suture
and sagittal suture
– Mean newborn size: 2.1 cm
(larger in black infants)
– Often enlarges in first few
months of life
– Closes between 4 to 26
months (median 13.8
months)
– Closes by 3 months in 1%
of infants
– Closes by 24 months in
96% of infants
• Posterior
– Junction of lambdoidal
suture and sagittal suture
– Mean newborn size: 0.5 to
0.7 cm
– Closes by 2 months
Fontanelles
• Exam of anterior fontanelle
– Palpate fontanelle with infant sitting upright
quietly
– Auscultate for bruit (suggests AV
malformation)
– Macewen's Sign (percussion of fontanelle)
• Dull cracked-pot sound suggests increased ICP
Fontanelles
• Bulging fontanelle
• Crying, coughing or vomiting
• Increased intracranial pressure: Hydrocephalus,
Meningitis/encephalitis, Hypoxic-ischemic injury,
Intracranial hemorrhage, Dermoid tumors of the
scalp
• Sunken fontanelle
• Decreasedintracranial pressure (dehydration)
• Large fontanelle or delayed closure
• Congenital hypothyroidism,Trisomy 21, Rickets,
Achondroplasia, Increased Intracranial Pressure
Head Examination
• Craniosynostosis
– Premature closing of
cranial sutures
– Results in growth
restriction perpendicular to
affected suture and
compensatory overgrowth
in unrestricted regions.
– If accompanied by
restricted brain growth or
hydrocephalus,
neurosurgical intervention
is needed.
Facial Examination
• Facial Nerve Paralysis
– Usually caused by
compression of the facial nerve
against the sacral promontory
or by trauma of a forceps
delivery.
– The nasolabial fold on the
affected side is not present, the
corner of the mouth droops and
the affected eye is unable to
close.
– Infant will have difficulty with
feeding, drooling from the
paralyzed side.
– Most palsies resolved
spontaneously within days.
Ear Examination
Assess for asymmetry or
irregular shape
– Note presence of auricular or
pre-auricular pits, fleshy
appendages, lipomas, or skin
tags.
– Low set ears
• Below lateral canthus of eye
• Associated with genitourinary
anomalies, because these
areas develop at similar times.
– Malformed ears
• Can be associated with
Downs or Turners Syndromes
Eye Examination
• Normal Eye findings following delivery
– Red reflex
• Hold opthalmoscope 6-8” from eye.
• Should transmit a clear red color back.
– Equal pupil size and reactivity to light
– Retinal or Subconjunctival Hemorrhages
• Common after vaginal delivery
• Clears spontaneously in 1-2 weeks
– Lid edema
• Force applied to open the eye often results in lid eversion
• Examination should be postponed until the edema resolves
– Eye Color
• Permanent eye color usually not attained until age 6 months.
Eye Examination
• Conjunctivitis
– Relatively common in newborns.
– Chemical
• Silver nitrate prophylaxis given at delivery
• Requires no treatment,
• resolves within 48 hours
– Gonorrheal
• 24-48 hours old
• Profound edema, purulent exudate
• Tx – Penicillin G, Rocephin, or Claforan
– Chlamydial
• Occurs within 7-10 days
• Watery discharge changes to
copious/purulent
• Tx – Erythromycin
– HSV
• Occurs within 2 weeks
• Keratitis, cataracts, chorioretinitis
• Tx – Topical and systemic antivirals
Eye Examination
• Abnormal Funduscopic Exam
– Lens opacity
• Indicates congenital cataract
• Associated with TORCH Virus
infection
• If monocular or dense cataract,
newborn is at risk for developing
amblyopia.
– Leukocoria (White reflex or Cat’s eye
reflex)
• Suggests lens, vitreous or fundus
abnormality
• Evaluate for Retinoblastoma
• Requires Opthalmologic Referral
Eye Examination
• Coloboma (ocular tissue defect)
– Eyelid margin defect: Treacher
Collins Syndrome
– Aniridia (absent iris)
• Usually occurs bilaterally
• Associated with poor visual acuity and
nystagmus
– Iris and retina defect: CHARGE
association
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•
•
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Coloboma
Heart disease
Choanal Atresia
Postnatal growth retardation
Genital hypoplasia
Ear Abnormality
• Requires Opthalmologic Referral
Nose Examination
• Babies are obligate nose breathers until 4
months old.
• Check patency with stethoscope (listen over
nares).
• Look for nasal flaring as a sign of increased
respiratory effort.
• Choanal Atresia
– Small NG tube unable to pass through nares.
– Normally should meet no resistance.
– Bilateral atresia
• Cyanosis that is relieved with crying.
• Is an emergency in the newborn.
• Requires an oral airway and surgical repair
Mouth Examination
• Observe the size and shape of the mouth
– Microstomia – seen in Trisomy 18 and 21
– Macrostomia – seen in
mucopolysaccharidoses
– Fish mouth – seen in Fetal Alcohol Syndrome
– Macroglossia – associated with
hypothyroidism and mucopolysaccharidoses
– Small Chin – associated with Pierre Robin
Mouth Examination
Epstein pearls
Natal Teeth
• small white cysts which
contain keratin
• frequently found on either side
of the median raphe of the
palate.
• Resolves in 1-2 months
• Occurs 1 in 2,000 births
• Location is most often the
lower incisors.
• Risk of aspiration if loosely
attached, most require
removal.
• More often present in
newborns with cleft palate.
Mouth
• Ranulas
– small bluish-white
swellings of variable
size on the floor of the
mouth representing
benign mucous gland
retention cysts
Mouth
•
Cleft Lip
–
–
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–
•
Incidence 1 in 750 (Caucasian)
Can be seen with or without cleft
palate
Common in Trisomy 13
Repair is usually at 3 months of
age
Cleft Palate
–
–
–
–
Incidence 1 in 2500 (Caucasian)
Midline defect starts at uvula
May involve soft and hard palate
and incisive foramen
Repair is usually before age 1 for
normal speech
Neck Examination
• Palpation
– Palpate all neck muscles
– Webbed neck
• Associated with Turner’s and Noonan’s Syndromes
– Lymph Nodes
• Unusual at birth, presence usually indicates congenital
infection
– Torticollis
• Sternocleidomastoid muscle injury from birth trauma.
• Hematoma and fibrosis results in muscle shortening.
• Muscle adaptation from abnormal intrauterine position.
Neck Examination
• Most common neck masses:
– vascular malformations, abnormal lymphatic
tissue, teratomas, and dermoid cysts
• Cystic hygromas
– Most common neck mass
• Thyroglossal duct cysts
– Typically midline and inferior to hyoid bone
– Surgical consultation is required
Chest/Lung Examination
• Inspection
– Supernumerary breast or nipple is common
(10%)
– Breast enlargement secondary to maternal
hormones
– Unilateral absence or hypoplasia of
pectoralis major
• Poland's Syndrome (Poland's Sequence)
– Widely spaced nipples
• Turner's Syndrome
• Noonan Syndrome
Chest/Lung Examination
• Inspection
– Chest Deformity
• Pectus Carinatum
– Much less common than Pectus Excavatum
– More common in males by ratio of 4:1
– Narrow thorax with increased anteroposterior diameter
• Pectus Excavatum
– Gender predominance: Boys (3:1 ratio)
– Mild: Oval pit near infrasternal notch
– Severe: Sinking of entire lower sternum
Chest/Lungs
• Observe
– Respiratory pattern
• Brief periods apnea are normal in transition,
called “periodic breathing”
– Chest movement
• Symmetry
• Retractions and Tracheal tugging
• Ascultation
– Audible stridor, grunting
– Wheeze, rales, rhonchi
Cardiovascular
• Inspection
– Check for pallor, cyanosis, or plethora
• Palpation
– Check capillary refill
• Should be less than 3 seconds
– Precordium
• Feel for increased activity and thrill
– Pulses
• Ipsilateral femoral (postductal) and brachial (preductal)
pulses should be equal in timing and intensity
• Decreased femoral = coarctation of aorta
• Bounding pulses often indicated PDA
Cardiovascular
• Auscultation
– Rhythm
• Gallup Rhythms
• Split S2 is Normal
• Split S2 absent
– Aortic or pulmonic valvular atresia or stenosis
– Results in high pulmonary vascular resistance
– Rate
• Regular, irregular
– Murmur
• Quality, radiation, location of intensity
Abdominal Inspection
• Abdominal Shape
– Flat: Seen with decreased tone, Diaphragmatic
hernia - abdominal contents in chest, Abnormal
abdominal musculature
– Distended: Consider obstruction, Excess air
inside or outside the bowel, Fluid in the
peritoneal cavity (ascites), Enlarged viscus
Abdominal Examination
• Abdominal wall defects
– Usually diagnosed prenatally.
• Omphalocoele
– Covered with membrane unless it has ruptured.
– Cord attachment at apex of defect.
– 67% have an associated abnormality.
• Gastroschisis
– Not covered with a membrane.
– Defect is to right of umbilicus.
– Cord attachment to abdominal wall.
– Management – immediate surgical consultation
• Abdominal Auscultation
– Normoactive bowel sounds all four quadrants
Abdominal Palpation
•
Abdominal Localized Mass
–
•
Gastrointestinal Duplications, Meconium ileus, Mesenteric or
omental cyst, Pyloric stenosis, Volvulus, Wilms tumor,
Neuroblastoma, Renal vein thrombosis
Liver
–
–
Usually palpable 2 cm below costal margin
Hepatomegaly
–
•
Many causes depending on presence or absence of
hyperbilirubinemia (direct or indirect) and associated splenomegaly
Spleen
–
–
Not usually palpable
Splenomegally
•
•
Etiology can be infectious or extramedullary hematopoeisis
Kidneys
–
Length vertically should be 4.5-5.0 cm in full term infant.
Umbilicus
• Umbilical Cord
– Count number of vessels
• 3 vessel cord is normal (1 vein and 2 arteries)
– A single umbilical artery is present in up to 1%, which
may be associated with asymptomatic renal anomalies
• Umbilicus
– Check for signs of bleeding, infection,
granuloma, or abnormal communication with
the intra-abdominal organs
• Examine for umbilical hernias
Male Genitourinary Examination
• Inspection
– Check glans, urethral opening, prepuce and shaft
• Term normal length is 3.5 +/- 0.7 cm
• Term normal diameter is 1.1 +/- 0.2 cm
• Abnormally small penis
– Reduced androgen effect or reduced growth hormone in 2nd
and 3rd semester
– Normally it is difficult to completely retract the
foreskin.
– Circumcised infants should be checked for edema,
bleeding or complications at the incision site.
– Full term infants should have brownish pigmentation
and fully rugated scrotums
Male Genitourinary Examination
• Hypospadias
• A proximally displaced urethral
meatus.
• Wide variation from mild glanular
to severe perineal.
• Chordee
• Ventral curvature of the penis.
• May accompany hypospadias.
• Can be due to skin tethering or a
short urethra.
• Circumcision should be delayed in these
infants.
Male Genitourinary Examination
• Communicating Hydrocele
•
•
•
•
Incomplete obliteration of processus vaginalis
Painless, tense, fluctuant scrotal mass that transilluminates.
Withold surgery until after first year of life
Most will resolve spontaneously
• Inguinal Hernia
• Soft, nontender, reducible bulge in inguinal canal, especially
at time of increased intra-abdominal pressure.
• Becomes tender and tense with discoloration of overlying
skin if incarcerated.
• Requires elective surgical repair as soon as possible.
Male Genitourinary Examination
• Palpation of Testes
– If not palpable must determine if it is retractile,
ectopic or cryptorchid.
– Unilateral retracted testicle
• Testicle may be brought down into scrotum.
• Follow-up examinations in the clinic.
– Unilateral palpable ectopic or undescended testicle
• Observe for descent.
• Surgical correction at 6 month to 1 year.
– Unilateral nonpalpable testicle (15% of cases)
• Laparoscopy at 6 months to 1 year for evaluation.
• Testicle found on laparoscopy in 50% of cases.
• Orchiopexy brings testis into scrotum (98% efficacy).
Female Genitourinary Examination
• Inspection
– Check labia, clitoris, urethral opening and external
vaginal vault
– Common normal findings
• Prominent labia minora and clitoris
– Clitoris can have a relatively prominent appearance,
especially if the labia are underdeveloped or the infant is
premature.
– Clitoromegaly may be a sigh of masculinization or a virilizing
tumor.
– Can also be caused by increased androgen production or
drug use.
• Vaginal/hymenal skin tag
• Mucoid/whitish discharge
• Small amount of vaginal bleeding
– Secondary to withdrawal of maternal hormones.
Ambiguous Genitalia
• Newborns with ambigious
genitalia: require rapid
diagnosis and treatment!
• Potential clinical
manifestations: hypoglycemia,
hyperpigmentation, apneic
episodes, seizures,
hyperkalemia, dehydration,
hypotension, vascular
collapse, shock
• Also social emergency: Refer
to the infant as “your baby” or
“your child,” delay naming the
child/birth certificate until sex is
determined
Rectum and Anus
• Anus patent and not ectopic
– Assess with probe or small finger
• No fistulas present
• Pilonidal dimple/cyst
– pit or sinus in the sacral area
– pilonidal dimple may also be a deep tract, rather than a
shallow depression, leading to a sinus that may contain
hair.
– During adolescence the pilonidal dimple or tract may
become infected forming a cyst-like structure called a
pilonidal cyst. These pilonidal cysts may require surgical
drainage or total excision to prevent reinfection
• Meconium passed within 48 hours of birth
Spinal Dysraphism
•
Spina Bifida Occulta
–
•
No abnormality of meninges, spinal cord or nerve
roots
Spinal Meningocele
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–
–
–
Meninges herniate through posterior vertebral
arches
Spinal cord and nerve roots are not involved.
Most often occurs in low back
Anterior herniation at sacrum may also occur
•
–
May result in constipation or bladder abnormality
Usually asymptomatic and covered by full layer
skin
Spinal Dysraphism
•
Myelomeningocele
–
–
–
–
Meninges, spinal cord and nerve roots are
involved
Lumbosacral region in 75% of cases
Associated with dysfunction of multiple organ
systems
Signs
•
•
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Flaccid paralysis of lower extremities
Deep Tendon Reflexes absent
Associated Conditions
•
•
•
•
Hydrocephalus and Chiari II Malformation (80% of cases)
Neurogenic bladder
Urinary Incontinence
Stool Incontinence
Spinal Dysraphism
•
Spinal Dysraphism
–
–
–
Dermatologic signs seen in 50-90% of cases
Skin findings may be only signs of occult lesion
Findings
•
Hypertrichosis
–
•
•
•
Increased vellus Hair
» Non-pigmented fine "peach fuzz" hair covering body
Lipoma
Midline Hemangioma
Large midline dimple above gluteal crease
–
–
–
Do not probe dimple
Small sacral dimple within gluteal crease is normal
Not worrisome if bottom of dimple can be visualized
UE Orthopedic Examination
Clavicle
• May Fracture from Birth Trauma
• Most common newborn orthopedic injury,
especially large infants
• Pain with movement and Moro reflex
• Pseudoparalysis of extremity on fracture side
• Sternocleidomastoid muscle spasm on affected
side
• Deformity or discoloration may be possible
• Crepitus at fracture site
• Palpable bony irregularity at fracture site
UE Orthopedic Examination
•
Digits (Fingers and Toes)
–
Supernumerary Digit
•
•
•
•
•
–
Occur more often in black infants.
Tends to be hereditary
Frequently lateral to the 5th digit of
hand or foot.
Extra digit may have a nail, attached
by small pedicle.
Ligature around the digit allows it to
fall off in several days.
Polydactyly
•
•
•
•
Extra-digit is located more often on
the foot.
Bone is palpable within the extra-digit.
The digit may have voluntary
movement.
Amputation of digit when child is > 1
year old.
UE Orthopedic Examination
• Digits
– Syndactyly
• Simple – involves soft tissue
attachment only
• Complex – involves fusion of bone
or nail
• Partial - web extends from base
partially
• Complete - web from base to tip of
finger
• Radiographs needed to determine
degree of fusion.
• Should refer to orthopedics.
UE Orthopedic Examination
• Upper Extremities
– Single Palmar Crease
• Seen in Down's
Syndrome
• Seen in 4% of normal
babies
– Ulnar or radial bone
absence
UE Orthopedic Examination
• Upper Extremity
– Brachial Plexus Injuries
• Results from excessive traction of C5-T3 spinal
nerve roots.
• Erb-Duchenne palsy
– Most common injury, involves C5-C7
– Arm adducted, internally rotated, elbow extended, arm
pronated, wrist flexed, “waiter’s tip if C7 involved.
• Klumpke’s palsy
– Incidence is rare, involves C8-T1.
– Hand is paralyzed, no voluntary motion.
LE Orthopedic Examination
• Lower Extremities
– Bowing of legs is normal
variation
– Positional deformities of foot
• Foot should be easily
replaced to normal position
– Talipes Equinovarus
(Clubfoot)
• Heel inversion (varus) with
internal rotation
• Forefoot inverted and
adducted (soles face each
other)
• Plantar flexion with inability to
dorsiflex
• Leg internal rotation
• Refer immediately for serial
casts
• Severe clubfoot requires
surgery
LE Orthopedic Examination
• Metatarsus Adductus (InToeing)
– Forefoot rotated inwardly
– Banana shaped or C-shaped
foot
– Lateral border of foot convex
– Medial border of foot concave
– Base of fifth metatarsal
(styloid) prominent
– Both feet are inverted (face
each other)
– Mild or flexible improves
during first 3 months of life
– Full resolution spontaneously
in 85% of cases
– Rigid deformity requires
treatment
LE Orthopedic Examination
• Calcaneovalgus
Deformity
– Foot has up and out
appearance
– Foot dorsiflexes easily (long
heel cord, ligaments lax)
– Limited plantar flexion (less
than 90 degrees)
– Lateral Sole deviation (banana
shaped)
– Feet are everted (facing away
from each other)
– Heel position is valgus (medial
malleoli are closer)
LE Orthopedic Examination
• Congenital hip dislocation
– Ortolani test
• Attempts to dislocate hip
• Hip clunk felt on exam
• Must distinguish from a hip click which is benignl
– Galeazzi's Sign
• Compare the 2 femur lengths
– Barlow's Test
• Attempts to sublux unstable hip
– Perform with caution
Resources
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http://dermatlas.med.jhmi.edu
http://www.fpnotebook.com
http://health.allrefer.com
http://health-pictures.com/index.htm
www.neonatolgy.org
Nelson’s Textbook of Pediatrics
American Family Physician, “The Newborn
Examination: Parts I and II” January 2002.