A 1-month-old infant attended the Child Health Program.
Personal history: fetal third trimester ultrasound showed bilateral localised foot dilatation (right: 4.5 mm; left: 4.1 mm).
Cesarean section was performed at 41+4 weeks of gestation due to induction failure.
His Apgar score was 5/9 and required type III resuscitation; progressed in transition less than 24 hours.
Family history of interest: paternal sister cousin with congenital scoliosis.
Body weight: 3.960 kg (percentile 25); height: 53 cm (percentile 50); perimeter: 37 cm (percentile 25).
A good general condition, congenital skull fracture with anterior 1 x 1 cm, slight plagiocephalia, short neck with lateral deviation of the head to the left side and slight limitation of mobility, as well as scoliosis were observed
In the inspection a cutaneous hook is observed in this scapulae, which is smaller than the contralateral one.
The rest of the physical and neurological examination was normal.
Associated findings of elevated scapula, scoliosis, torticollis and plagiocephalia were decided to refer the patient to the traumatology service of the reference hospital.
Due to a history of foot-and-mouth dilation, a control ultrasound was requested.
In the revision of the fourth passage, although the dysactive arm is more pronounced, there is a greater discrepancy between the size of both scapulas (the right arm measures 7 cm, compared to the 4.5 cm of the left shoulder) and the height.
The plagiocephalia is now moderate, so it is decided to refer to the neurosurgical service to assess cranial orthosis.
In order to confirm the diagnosis and rule out other associated alterations, the following complementary tests were performed:
A grade II/IV bilateral foot dilatation, a 9 mm right renal pelvis and a 1 cm left renal pelvis were observed.
- a hip dysplasia (going in 2009) due to suspected hip dysplasia: no significant findings
- Radiography of the complete column and scapular fixation in 2009: alterations in the fusion of the vertebral bodies of the upper back and lower cervical spine are observed.
First left side quadrant.
Left 2nd to 5th ribs with decreased intercostal space.
Elevation of left scapula (alloyed scapula).
- Radiography of the lateral spine (June 2009): abnormalities in segmentation of the vertebral bodies of the upper dorsal and lower cervical spine, as well as elevation of the left scapula, are observed.
- Echocardiogram and electrocardiogram: normal.
