Pediatric Orthopedic Physical Examination of the Infant: A 5-Minute Assessment

Abraham Ganel, MD, Israel Dudkiewicz, MD, Dennis P. Grogan, MD


J Pediatr Health Care. 2003;17(1) 

In This Article

Knees, Legs and Feet

Knees and Legs

The appearance, symmetry, and range of knee motion should be examined. Congenital dislocation of the knee manifests as hyperextension of the knee with limited flexion. Infants with this affliction are often born with their feet contiguous to the face. Congenital dislocation of the patella is manifested by lateral displacement of the patella and limited knee motion. The tibia is usually in a varus alignment due to the infant's normal intrauterine position. Anterior bowing of the tibia could be a sign of neurofibromatosis, or even congenital pseudoarthrosis of the tibia. Posteromedial bowing of the tibia presents with a significant angular deformity of the distal tibia with the foot positioned against the lower leg. Dysplasia of the fibula could be associated with bowing of the tibia, as well as valgus alignment of the ankle. The presence of a dimple on the anterior leg usually suggests a congenital anomaly. Alignment of the legs from the hips to the toes should be assessed for rotational malalignment.


Assessment of the feet should include evaluation of the range of motion of the ankle and subtalar joints. Snapping peroneal tendons manifest by anterior subluxation of these tendons over the lateral malleolus in dorsiflexion and relocation on plantar flexion. Limited dorsiflexion, or a fixed equinus position, are characteristic of congenital anomalies, such as clubfoot, or a vertical talus. Position and alignment of the heels should be noted as being varus, neutral, or valgus. A varus heel is characteristic of clubfoot deformity. The alignment of the forefoot should also be examined. Forefoot adduction may be a sign of clubfoot deformity, or metatarsus adductus. Assessment of the longitudinal arch of the feet is important. Normally the arch is decreased to absent in the infant, but a high arch could indicate a neurological problem. The number and appearance of the toes should be examined noting polydactyly (extra toes), syndactyly (webbing), overlapping of the fifth toe, or abnormal alignment of the great toe into either varus or valgus. Congenital halux valgus is rare. Constricting (amniotic) bands are often associated with foot abnormalities, such as congenital amputations of the toes or tips of the toes, and rigid clubfoot deformities.

Hemihypertrophy of the leg may present with limb length discrepancy, enlargement of the circumference of the thigh and/or calf, and asymmetry in foot sizes. Hemangiomata on the skin may represent a developmental syndrome such as Klippel-Trenaunay.

The baby should be turned onto its stomach to examine the back including the skin of the lower back and buttocks. A low hairline could be indicative of Klippel-Feil syndrome, Turner syndrome, or a web neck.


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