Staying Ahead of Musculoskeletal Deformities in Children

It was Samantha Ackerman's tiny footprint, taken only minutes after birth, that alerted an observant nurse that something was amiss. At one day old, Samantha was diagnosed with clubfoot, a congenital deformity that occurs in about one in every thousand births in the United States. The affected foot tends to be smaller than normal, with the toes pointing downward and the forefoot turning inward. The heel cord is also tight, causing the heel to be drawn up to the leg, making it impossible to put the foot flat on the ground.

Evaluating Newborns for Musculoskeletal Concerns

According to Roger F. Widmann, MD, Chief of Pediatric Orthopedic Surgery, it is critical to evaluate newborns and infants for any kind of musculoskeletal deformity and begin them on a course of treatment as soon as possible. "The general and normal progression of mobility for a child includes sitting at six months, standing by nine or 10 months, and independently standing and taking steps at about a year," says Dr. Widmann, adding that there is a large range of what is considered normal in between. "If left untreated, a condition like clubfoot can prevent children from walking effectively."

The Ackermans' pediatrician steered them to David M. Scher, MD, a pediatric orthopedic surgeon who specializes in clubfeet and hip dysplasia. "Very often, clubfeet can be detected during routine prenatal ultrasounds," says Dr. Scher. "Knowing ahead of time gives the parents the opportunity to research clubfoot and the different treatment options available, and then to plan a course of action soon after birth."

Clubfoot can range from very mild to very severe. "Two main factors determine its severity - the degree of deformity and stiffness," says Dr. Scher, who began treating Samantha at five days old using the Ponseti technique, named for the physician who developed it in the 1940s. This technique involves a series of manipulations during which the bones are gently rotated and the soft tissues are stretched, followed by casting the leg weekly to hold the foot in place.

"The optimal time to treat a child is shortly after birth," says Dr. Scher. Following five or six casts, the child is fitted for special shoes with a bar between them to be worn for three months and then only during the nighttime. About 80 percent of cases also require a small operation called a tenotomy in which the surgeon cuts the Achilles tendon to lengthen it, allowing the ankle to bend up. This procedure is generally done in the physician's office under local anesthesia.

Dr. David Scher, a pediatric orthopedic surgeon specializing in clubfoot and celebral palsy, examines the progress of Desmond Teague, age three, who has been treated for clubfoot.

Developmental dysplasia of the hip (DDH), also known as dislocation of the hip, is another deformity that can be present at birth, or develop shortly after as the baby starts to grow. The condition occurs when the head of the child's femur, the long thigh bone, does not fit correctly into the hip socket.

"The femoral epiphysis - the small part of the hip - is made of cartilage and there is not enough calcium in it to show up on X-ray until the child is six months of age," says Daniel W. Green, MD, a pediatric orthopedic surgeon at HSS. "In addition to our physical exam, we use ultrasound to image the hips, and if we diagnose DDH, we treat them right away with a soft harness to hold the hips in the correct position. By initiating treatment in the first week or two of life, there is more than a 90 percent success rate in achieving normal mobility."

"In certain cases, infants may be born with hips that are either dislocated or partially out of the socket, and that may have something to do with the position of the fetus," says Ronald S. Adler, MD, PhD, Chief, Division of Ultrasound and Body CT. "During pregnancy, for instance, if the child is turned around in a breech position, they are more susceptible to having their hips partially dislocated."

Through ultrasound, Dr. Adler uses high frequency sound waves to produce images of soft tissues and assess developmental abnormalities in the hips of newborns. "Because ultrasound does not employ ionizing radiation, the procedure is extremely safe," explains Dr. Adler.

Adapting advanced imaging techniques to the pediatric population is familiar territory for HSS radiologists. Hollis Potter, MD, Chief of Magnetic Resonance Imaging (MRI), who has performed MRIs on babies just a few months old to patients over 100, notes, "When a child needs an MRI, it's done with the greatest of care and with the greatest of expertise from our pediatric anesthesiologists, if sedation is indicated.

"We engage the child and parents early on and introduce the child to the environment of the MR in a very positive way," Dr. Potter continues. "Our technicians have a real sense of how to put the child at ease…lots of smiling, lots of telling them 'we're going to take some fun pictures, and you're going to get to see them.'"

"Through early screening, pediatricians recognize many of the musculoskeletal problems," adds Dr. Scher. But, just as importantly, he says, are parents' observations of their child's manners and behaviors. "Parents are usually the first to recognize something isn't quite right, either by how the child is feeding or not feeding, or how they hold their head. The earlier they detect something is wrong, the sooner we can begin to treat the child."

"Mobility clearly begins with pediatrics," says HSS internist C. Ronald MacKenzie, MD. "These are not only the growing years, but the years in which motor skills are developed. Conditions that have a great impact on musculoskeletal functions could produce impairments that have immense implications for future quality of life. HSS physicians put strategies in place right from the start that will carry their patients through a lifetime."

posted 8/29/2005

Written by Linda Errante