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Key messages

  • Common neonatal limb problems involve absent, extra/malformed parts or malfunctioning tissue.
  • Most cases of brachial plexus palsy resolve spontaneously.
  • Infants without signs of recovery at one month of age should be referred to a brachial plexus injury clinic.
  • Metatarsus adductus is the most common congenital foot anomaly, related to intrauterine positioning.
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    In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines with a view to completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.

    Anomalies of the musculoskeletal system in neonates may be evident as:

    • the absence of a part
    • extra parts
    • malformed parts
    • malfunctioning tissue.

    Anomalies may be congenital or acquired (for example, birth trauma) and usually affect the infant's movement, muscle tone or posture.

    Upper extremities

    Obstetric brachial plexus palsy

    Obstetric brachial plexus palsy is caused by injury to the brachial plexus during birth. Features include:

    • Occurs most often in large babies.
    • It is caused by stretching of components of the brachial plexus.

    Forms of brachial plexus injury:

    Erb's palsy

    Erb’s palsy is an injury to the upper brachial plexus nerve. Features include:

    • Involves C5, C6 and sometimes C7.
    • Causes the affected arm to be adducted and internally rotated.
    • Extension at the elbow.
    • Pronation of the forearm.
    • Flexion of the wrist ('waiter's tip' position).
    • Paralysis of the upper arm is more common than paralysis of the lower arm or the entire arm. The grasp reflex remains intact, but the Moro reflex is absent on the affected side.

      Figure 1: Erb's palsyFigure 1: Erb’s palsy

      Complete brachial plexus palsy

    Features include:

    • Presents with a limp, dangling appendage, without any trace of movement.

    Klumpke's palsy

    Features include:

    • It involves C7-8 and T1.
    • It is purely a lower brachial plexus palsy.
    • It presents as a clawed hand with function at the shoulder and elbow.
    • There is an associated dilation of the pupil on the side of the injury (the nerves which dilate the pupil leave the spinal cord on the C8 and T1 nerves and then travel with the artery to the brain and eye).

    Management of brachial plexus palsy

    Management involves:

    • Radiograph of the clavicle and upper arm on the affected side.
    • Chest radiograph to confirm or exclude ipsilateral diaphragmatic paralysis.
    • If the nerve roots are not ruptured, most resolve spontaneously.
    • Babies should be referred to the Obstetric brachial plexus palsy clinic at the Royal Children's Hospital. This clinic provides a multidisciplinary service to children and adolescents who have an Erb's or Obstetric Brachial Plexus injury.
    • On receipt of referral a physiotherapy review is made with the clinic's physiotherapist to review and gauge severity of the injury.  Based on this assessment a follow-up clinic appointment may be made in the next available clinic.  If the injury is deemed severe by the referring physician the child is normally booked into the next available clinic regardless of physiotherapy assessment.
    • Referral forms can be faxed to the Physiotherapy Department on (03) 9349 1546. For urgent referrals call the physiotherapy department on (03) 9345 5411.
    • A statewide referral form is available here.

    Lower extremities

    Developmental dysplasia of the hip (DDH)

    See developmental dysplasia of the hip.

    Metatarsus adductus

    Metatarsus adductus is the most common congenital foot anomaly, related to intrauterine positioning. It may be positional or structural.

    Figure 2: Metatarsus adductusFigure 2: Metatarsus adductus 


    Features of positional (flexible) deformity 

    • No bony abnormality involved.
    • The forefoot is very mobile and can be easily abducted.
    • Will correct without treatment.

    Feautures of structural (fixed) deformity

    • The forefoot usually cannot be abducted beyond the midline (neutral position).
    • The heel (hindfoot) is in a valgus position.
    • In a rigid foot, an orthopaedic consultation is necessary for early treatment.

    Clubfoot (talipes equinovarus)

    Figure 3: Talipes equinovarus, club footFigure 3: Talipes equinovarus 


    • Clubfoot is one of the most common congenital anomalies with an incidence of approximately one per 1,000 live births.
    • In Caucasians, males are affected twice as often as females.
    • The involvement is bilateral in 50 per cent of cases.
    • A thorough examination should be made for other anomalies, especially the effects of fetal hypokinesia.
    • There are variations in the severity of talipes.
    • Some are relatively flexible and correctable with serial exercises and casting.
    • An orthopaedic consultation should be initiated as soon as possible after birth and treatment of fixed deformities should be started preferably before discharge. Treatment in babies born prematurely will commence when medical condition allows. 



    • This is frequently a familial tendency.
    • The severity varies from minimal 'bridging' between adjacent fingers/toes to complete webbing of the hand/foot.
    • Syndactyly of the toes does not interfere with function but may be unacceptable cosmetically. Treatment for syndactyly of the fingers depends on the severity and the presence of bony abnormalities.
    • An early orthopaedic or plastic surgery consultation is needed, but will usually be arranged after discharge. 
    Figure 4a: Syndactyly left handFigure 4a: Syndactyly left handFigure 4b: Syndactyly left handFigure 4b: Syndactyly left hand Source:



    • Extra digits are common abnormalities affecting both the hands and the feet, with a familial tendency.
    • The most common type is a floppy digit or skin tag on the lateral side of the hand.
    • It may involve the duplication of a normal looking digit.
    • It is advisable that all digital remnants be surgically removed.
    Figure 5: Polydactyly left handFigure 5: Polydactyly left hand Source:


    More information



    • Tappero EP. 1996. Musculoskeletal system assessment. In Physical Assessment of the newborn, 2nd ed., Tappero EP, and Honeyfield ME, eds. Petaluma, California: NICU Ink, 117-136.
    • Rennie JM, Roberton NRC, eds. 1999. Textbook of Neonatology , 3rd ed., Edinburgh: Churchill, 275-280.
    • Shenaq et al. 1998. Brachial plexus birth injuries and current management. Clinics in Plastic Surgery;25(4):527-535
    • Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. 2000. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics;105(4 Pt1):896-905.
    • Google images

    Further reading

    • Ponseti IV, 1996. Congenital clubfoot. Fundamentals of treatment. Oxford University Press, Oxford, New York.
    • Levene M, Tudehope D. 1993. Essentials of neonatal medicine. 2nd ed., Oxford: Blackwell, 315-324.

    Get in touch

    Clinical Guidance Team
    Safer Care Victoria

    Version history

    First published: August 2014
    Review by: August 2017

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