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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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slide1

BRACHIAL PLEXUS INJURY IN

NEONATES

LOURDES ASIAIN

February 2005

slide2

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.
slide3

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

slide4

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.

slide5

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.

slide8

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

slide10

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

slide11

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

slide12

Clinical Manifestations

If phrenic nerve is involved, as mentioned earlier

respiratory distress may be present.

slide13

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.

slide14

DIAGNOSTIC WORKUP

Evaluation can be undertaken by multiple modes of

Imaging.

EMG

MRI

Chest X ray

Real time UltraSonography

slide15

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

slide16

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
slide17

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

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