|Year : 2015 | Volume
| Issue : 2 | Page : 104-108
Prevalence of musculoskeletal abnormalities in newborn: A 10 years retrospective analysis of 10,674 neonates in Indian population at a tertiary care hospital
Nilesh Ghorpade1, Navendu Goyal1, Jewel John2
1 Department of Orthopaedics, Christian Medical College, Ludhiana, Punjab, India
2 Department of Pediatrics, Christian Medical College, Ludhiana, Punjab, India
|Date of Web Publication||6-Apr-2015|
Dr. Navendu Goyal
House Number 1039, Sector 4, Panchkula, Haryana
Source of Support: None, Conflict of Interest: None
Purpose: There are multiple orthopedic conditions that plague a newborn. However, identification of many conditions is difficult and requires strict vigilance. Keeping the idea in mind, a retrospective analysis of various orthopedic problems was done in a tertiary care setting in India. Materials and Methods: A 10 years retrospective analysis done at a tertiary care setting to identify various orthopedic conditions in a newborn. Results: The overall prevalence of musculoskeletal abnormalities in the study group was 2.03% (20/1000). Foot abnormalities composed the highest group with 43.3% (8.8/1000), followed by hand abnormalities 23.50% (4.78/1000), spinal abnormalities 15.20% (3.09/1000), trauma 5.5% (1.12/1000) and paralytic conditions 5.06% (1.03/1000). The rest of the conditions had a combined prevalence of 1.5/1000 (7.37%). Low birth weight, nonvaginal delivery, maternal age more than 30 years and multiparity were significantly associated with an increased incidence of congenital malformations. Conclusion: Musculoskeletal abnormalities are commonly seen in newborns and early identification, and prompt intervention can lead to a bright future for the child.
Keywords: Birth injury, congenital anomalies, neonate, pediatric orthopedics
|How to cite this article:|
Ghorpade N, Goyal N, John J. Prevalence of musculoskeletal abnormalities in newborn: A 10 years retrospective analysis of 10,674 neonates in Indian population at a tertiary care hospital. J Clin Neonatol 2015;4:104-8
|How to cite this URL:|
Ghorpade N, Goyal N, John J. Prevalence of musculoskeletal abnormalities in newborn: A 10 years retrospective analysis of 10,674 neonates in Indian population at a tertiary care hospital. J Clin Neonatol [serial online] 2015 [cited 2020 Apr 5];4:104-8. Available from: http://www.jcnonweb.com/text.asp?2015/4/2/104/154104
| Introduction|| |
It is not rare for an orthopedic surgeon to be conferred for a neonatal examination to identify a possible orthopedic abnormality. Nevertheless, interrogation of a newborn is a very hard job as compared to an adult as all the features are not easily identifiable. For, e.g. a newborn foot is less defined, has a greater range of motion, has soft endpoints and has greater amounts of subcutaneous fat as compared to an adult foot. Congenital anomalies account for 8-15% of perinatal deaths and 13-16% of neonatal deaths in India. 
Various orthopedic conditions are recognized at birth. Some of these include metatarsus adductus, congenital talipes equino cavo varus (CTEV/club foot), polydactyly, syndactyly, congenital pseudarthrosis of the tibia and fibula, a constriction band of the legs and limb length discrepancies. Newborn trauma is also not uncommon. Fractures of the clavicle, humerus and femur have been widely reported during childbirth. 
A flail upper extremity secondary to brachial plexus injury during childbirth or a lower limb weakness secondary to myelodysplasia is one of the most commonly reported conditions in a newborn.
Developmental dysplasia of the hip (DDH) is also a commonly seen pathology in the newborn. Flexion contracture is common in the newborn, but they usually resolve with time. Other conditions such as congenital knee dislocation and congenital muscular torticollis, though less common, have been reported widely.
Recognizing and identifying these conditions are of utmost importance both for a pediatrician and an orthopedic surgeon. Timely diagnosis and intervention can not only prevent a further complication but can ensure a healthy future for a newborn.
The aim of this work was to assess the prevalence of orthopedic congenital abnormalities in the newborn in our setting and to appraise the risk factors associated for these abnormalities and to compare our results with former surveys. By analyzing these risk factors, we wanted to clarify the steps that can be considered at an appropriate time to prevent and care for these abnormalities and therefore secure a safer future. With the advent of interventions like ultrasonography and amniotic fluid analysis, it has become exceedingly easier to study and detect various congenital abnormalities and thus intervene and take necessary action.
| Materials and Methods|| |
This retrospective study was conducted in a pediatric, neonatal unit at a tertiary care hospital in India after due ethical clearance by the Hospital Research Committee. Ten years data from 2001 to 2011 were obtained from the hospital records and analyzed for various abnormalities. The data were scrutinized for multiple risk factors known to cause abnormalities at birth and the prevalence of these abnormalities in our hospital setting.
During this study, a total of 10,674 neonates was reviewed over the 10 years period for the presence of congenital musculoskeletal abnormalities. Of these, 217 (2.03%) neonates with musculoskeletal abnormalities were identified and further examined. Only the neonatal unit admissions were included, and the entire outpatient department (OPD) based data were excluded.
Maternal data analyzed included maternal age at delivery, obstetric history of the mother, complications during pregnancy, labor, and type of delivery. Fetal parameters studied were gender distribution of the newborn, birth weight, presence or absence of congenital abnormality and the dispersion of these abnormalities amongst different organ systems of the physical structure.
The diagnosis of each condition was made after a thorough examination and investigations, by a senior pediatrician in consultation with an orthopedic consultant. The identified abnormalities were categorized into different regions of the body. The results were analyzed using Statistical package for the social sciences (IBM Corporation) version 21 for Windows. Chi-square test and independent t-tests were used for statistical analysis. P < 0.05 was taken as significant.
| Results|| |
One hundred and eighteen (11.05%) males and 99 (9.27%) females were found to have congenital malformations. This difference, however, was insignificant. There was a great variation in the birth weight amongst the newborns with the lowest weight recorded at 0.86 kg and the highest weight recorded at 3.90 kg with a mean of 2.38 kg. One hundred and twenty (55.30%) neonates weighed <2.5 kg, and 97 (44.70%) weighed more than 2.5 kg.
There were 6 (2.76%) breech deliveries, 21 (9.68%) deliveries by forceps, 97 (44.70%) by cesarean section and 93 (42.86%) normal vaginal deliveries in the study group. Maternal age range was quite variable with 18 years as the lowest to 40 years as the highest with a mean of 26.1 years.
One hundred and twenty (55.30%) deliveries were of primigravida mothers, 49 (22.58%) deliveries where the newborn was second child, 33 (15.21%) newborns were the 3 rd child and in 15 (6.91%) deliveries, the child born was 4 th or more.
Demographic data for the study are summarized in [Table 1].
All the mothers were screened for complications during their pregnancy. One hundred and sixty-four (75.58%) mothers were placed with an associated prenatal complication. The dispersion of various prenatal maternal complications is depicted in [Table 2].
A total of 33 different types of abnormalities was detected in the study group and involved almost all areas of the body. Ninety-four of all the identified abnormalities involved the foot with CTEV as the most common which was seen in 60 neonates. Other identified abnormalities in the foot included polydactyly, malaligned toes, pes cavus, calcaneovalgus, and metatarsus adductus.
Hand deformities were the second most common abnormalities seen in the study group with 51 neonates with some form of the hand abnormality. Polydactyly and syndactyly formed the major group with 43 neonates having this abnormality. Four neonates had hand contractures, 3 had clinodactyly and 2 neonates had a radial club hand.
Spinal deformities formed the 3 rd major group with 33 spinal abnormalities identified, including spinal dysraphism in 30 newborns and thoracolumbar dysplasia in 3. Sixteen neonates had spina bifida occulta, 10 had myelocele, and 4 had meningomyelocele.
Twelve neonates had some sort of trauma. Three fractures each of femur and humerus were seen and 1 each of clavicle and ribs was seen amongst this group. One neonate also had a dislocated knee in the trauma group.
A total of 11 neonates was noted to have paralysis. Erb's palsy occurred in 10 neonates and paraplegia in 1. Several other abnormalities which were identified in the study group included limb hypoplasia and aplasia, genu recurvatum, joint and limb infections, DDH and divided pubic rami.
All the abnormalities found are summarized in [Table 3].
Upon statistical analysis of the results obtained, a significant correlation of congenital abnormalities was found with birth weight <2.5 kg, nonvaginal delivery, maternal age more than 30 years and multiparity. [Figure 1] shows distribution of anomalies detected in neonates
| Discussion|| |
Orthopedic conditions in a newborn can be of a wide variety. Diagnosis of these can be a herculean task as compared to a grown up adult because of tremendous differences in the body structure. Timely diagnosis and treatment can, however, gain a vast divergence in the future growth.
The incidence of congenital disorders at birth varies from one territory to another. European Surveillance of Congenital Anomalies has reported a prevalence of 3.8 limb defects per 1000 births.  A recent European study reported a prevalence of congenital limb defects as 21.1/10,000.  Other studies have reported different incidence of congenital malformations, Perveen and Tyyab reported a prevalence of 11.4/1000 births. 
In our study, the overall prevalence found was 2.03/1000 live births. This is comparable to other studies from India, which have found almost similar prevalence of congenital malformations, who have reported an incidence of 1.9%, 2.72%, and 2.22%. ,, As we included only the live births, the prevalence in our study may be less than it would be by including all the live and still births.
Musculoskeletal abnormalities have been reported to be the major congenital abnormality in many studies. ,, However, some studies have reported other systemic abnormalities. Central nervous system abnormalities have been reported by some , while others have reported genitourinary  and gastrointestinal abnormalities as the most prevalent type.  There was a slight deviation towards male prevalence of malformations as compared to females in our study. This corroborates with the pattern seen in some other studies as well. ,
The higher incidence of malformations with birth weight <2.5 kg in our study is similar to some other studies ,, while some studies have reported no relation to low birth weight. 
Higher incidence of malformations in the primipara group as compared to multipara is similar to that reported by Parmar et al.  On the other hand, several studies have reported a higher incidence in multipara, Naoom et al. reported 76.7% in multipara  while Jehangir et al. reported 88.89%,  whereas Anand et al. found no significant relation. 
We found a significant correlation to congenital abnormalities with increase in maternal age. Similar results were reported by Taksande et al.  No relation between maternal age and congenital defects was seen in other studies. ,
Foot deformities formed a very high number (43%) of all the deformities with CTEV prevalence of 5.62/1000 being the highest. Chotigavanichaya et al. reported CTEV as 4/1000, polydactyly as 2.6/1000, calcaneovalgus as 60/1000 live births, which is in sharp contrast to 0.66/1000 calcaneovalgus in our study. They also reported metatarsus adductus in 7.6/1000 live births. Widhe reported adductus as the most common deformity at 3.1% followed by calcaneovalgus at 0.5% in their study. 
The overall prevalence of hand deformities was 4.78/1000 with poly and syndactyly being the major group. Radial club hand was seen in 0.19/1000. Giele et al. reported incidence of 1 in 506 for upper limb anomalies and Ekblom et al. reported 21.5/10,000 births. ,
Malaysian registry has reported an incidence of 0.42/1000 live births with the most common type of neural tube defects (NTDs) is anencephaly (0.19/1000 live births), followed by spina bifida (0.11/1000 live births) and encephalocoele (0.07/1000 live births), which are far less than that in our study.  However, our findings closely resembled that of a systemic review by Bhide et al., who found an overall birth prevalence of 4.1/1000 with a live birth prevalence of NTDs at 1.3/1000 births. 
Trauma during childbirth is not uncommon. Use of forceps or cesarean section can lead to increase in the incidence. Although the clavicle has been reported as the commonest bone to fracture during birth, others, such as the femur, humerus and ribs have been reported as well.  Ozdener et al. identified 73 cases of clavicular fracture with a prevalence of 0.75% (73/9700).  Husain et al. have reported a series of diaphyseal fractures of the humerus, while Jacobsen et al. reported six distal humeral epiphysis separations in neonates. , We found three cases each of the humerus and femur fractures and one clavicle fracture with a combined prevalence of 1.12/1000.
Incidence of Erb's palsy in our study is exactly similar to that of Jaggat et al.  Ouzounian et al. reported an incidence of 3/1000 in their study.  The reported incidence of DDH varies from 1.5 to 2.5/1000 live births. , We found, however, much fewer numbers of DDH in our study.
The main limitation of our study is the fact it is a hospital-based study, and the results may not be applicable to the larger population. Also, the study group was mainly from the neonatal unit patients, which may be a bias as OPD patients were excluded from the study. Awareness of both parents and doctors is the quintessential measure to reduce the incidence of these malformations that constitutes an important cause of morbidity and mortality in the newborn. Preventive measures should include genetic counseling of the parents and prenatal screening as a routine for all the patients.
| Conclusion|| |
A large number of congenital musculoskeletal abnormalities can occur and lead to significant morbidity and mortality. To provide a healthy and safe future for a newborn child, it is very important that appropriate steps are taken at the right time to minimize the physical and psychological burden to the neonates and their families.
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[Table 1], [Table 2], [Table 3]