BRACHIAL PLEXUS INJURY IN
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BRACHIAL PLEXUS INJURY IN NEONATES LOURDES ASIAIN February 2005. BACKGROUND. 1764 Obstetrical brachial palsy described by Smellie.

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BRACHIAL PLEXUS INJURY IN NEONATES LOURDES ASIAIN February 2005

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Brachial plexus injury in neonates lourdes asiain february 2005

BRACHIAL PLEXUS INJURY IN

NEONATES

LOURDES ASIAIN

February 2005


Brachial plexus injury in neonates lourdes asiain february 2005

BACKGROUND

  • 1764 Obstetrical brachial palsy described by Smellie.

  • 1874 Wilhelm H. Erb described brachial plexus paralysis in adults which involved the upper roots and described certain types of “delivery paralysis”. He credited Duchenne for describing the brachial palsy following delivery in affected newborns.

  • 1885 Augusta Klumpke first described the clinical picture resulting from injury to lower roots.


  • Brachial plexus injury in neonates lourdes asiain february 2005

    EPIDEMIOLOGY

    Incidence of brachial plexus palsy is reported to affect

    0.5 to 1.9 per 1000 live births (Bar et al 2001)

    90% Erb palsy

    Most common on the right side because the most common

    delivery presentation is left occiput anterior vertex.

    Associated with:pre and gestational diabetes

    older maternal age

    increased BW, LGA

    Newborns with BP injuries have a higher incidence of low

    Apgar scores of less than 7 at 1 and 5 mins and of asphyxia

    than matched controls


    Brachial plexus injury in neonates lourdes asiain february 2005

    EPIDEMIOLOGY

    Brachial plexus palsy occurs in 26% of cases of shoulder

    Dystocia

    Both Shoulder dystocia and brachial plexus palsy are more

    common in LGA babies and Infants of diabetic mothers

    Infants of diabetic mothers have a higher incidence of permanent impairment

    In infants of diabetic mothers, the macrosomic process affects the trunk but not the head (large biacromial diameter)

    The head shoulder disproportion is difficult to predict in

    Utero.


    Brachial plexus injury in neonates lourdes asiain february 2005

    EPIDEMIOLOGY

    Clavicular fractures are often associated with shoulder

    dystocia , but the incidence of brachial palsy in these

    Cases is only 11%.

    Clavicular fracture =more mobility of shoulder

    Not always associated with difficult delivery (Intrauterine

    Maladaption palsy). Cases of in utero origin supported by

    EMG findings if denervation at birth.


    Brachial plexus injury in neonates lourdes asiain february 2005

    ANATOMY


    Anatomy

    ANATOMY


    Brachial plexus injury in neonates lourdes asiain february 2005

    Brachial plexus is comprised of a group of nerves

    arising form the nerve roots C5-T1.

    The uppper (C5-C6) roots innervate the deltoid, spinati,biceps,

    brachioradialis, biceps supinator and flexor muscles of

    the forearm.

    The lower roots (C7-T1) innervate the intrinsic muscles

    of the hand.

    The phrenic nerve, arising from C3-C5 can be involved

    resulting in ipsilateral diaphragmatic paralysis causing a

    decrease in thoracic space, tidal volume and vital capacity.

    Involvement of the sympathetic nerves from T1 that give rise

    to the sup cervical symp ganglion can result in Horner Synd.


    Horner syndrome

    HORNER SYNDROME

    Ptosis

    Miosis and anhydrosis


    Brachial plexus injury in neonates lourdes asiain february 2005

    Stretch, tear, compression or avulsion of the nerves

    usually after forceful lateral deviation of the head from

    the shoulders during delivery. Recent studies

    suggest intrinsic forces

    (uterine contractions).

    PATHOGENESIS


    Brachial plexus injury in neonates lourdes asiain february 2005

    Clinical Manifestations:

    Asymmetric Moro reflex

    Erb palsy caused by the disruption of the upper brachial plexus. Posture of adduction and inward rotation at the shoulder with extension and pronation

    at the elbow and flexion of the

    fingers = WAITER’S TIP

    Klumpke= absent grasp reflex

    of the hand


    Brachial plexus injury in neonates lourdes asiain february 2005

    Clinical Manifestations

    If phrenic nerve is involved, as mentioned earlier

    respiratory distress may be present.


    Brachial plexus injury in neonates lourdes asiain february 2005

    DIFFERENTIAL DIAGNOSIS

    Cervical Injury

    Cervical Spine injury

    Dislocation of upper extremity/fractures of upper

    extremity

    Intrauterine maladaptation palsy

    The physical findings of BP palsy are so unique so it is

    difficult to mistaken if for other diagnosis.


    Brachial plexus injury in neonates lourdes asiain february 2005

    DIAGNOSTIC WORKUP

    Evaluation can be undertaken by multiple modes of

    Imaging.

    EMG

    MRI

    Chest X ray

    Real time UltraSonography


    Brachial plexus injury in neonates lourdes asiain february 2005

    MANAGEMENT

    The majority of patients with brachial plexus palsy

    Dx at birth will recover from neurologic deficit.

    Those who do not recover during 3-6month period will

    Require surgical intervention.

    1-2 week rest of affected limb

    Early referral to upper extremity clinic and PT

    Caregivers should be instructed on how to handle baby:

    No traction of affected arm, no pressure under axila.

    Baby to be carried in football hold


    Brachial plexus injury in neonates lourdes asiain february 2005

    MANAGEMENT

    Surgical

    • Exploration

    • Neurolysis

    • Excision of scar tissue

    • Nerve grafting (local end to end anastomosis or remote

    • nerve transplant)

    • Surgical plication in case of diaphragmatic involvement

    • Special considerations in post surgical care:

    • Edema of neck and compromise of airway

    • Injury to vagal and laryngeal nerves

    • Risk for meningitis


    Brachial plexus injury in neonates lourdes asiain february 2005

    PROGNOSIS

    Study by Noetzel et al (2001) followed 80 patients with BP injury who did not recover by 2 weeks of age.

    Used the BMRC scales for evaluating muscle strength and found:

    Complete recovery in 66%

    Mild impairment in 11%

    Moderate weakness was seen in 9%

    Severe weakness in 14%

    When associated with phrenic nerve palsy and diaphragmatic paralysis, there is more likelihood of need for surgery for recovery.


    References

    REFERENCES

    • Brachial plexus palsy in neonates

      John B Cahil, Medlink

      Brachial plexus injury and obstetrical risk factors. Int J Gynecol Obst 2001;73 (1) 21-5

      Brachial plexus injuries, emedicine Aug 2004


    Thank you

    THANK YOU


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