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CASE CONFERENCE

CASE CONFERENCE . Suying Lam, MD PGY1. Presentation:. FT male with L upper extremity weakness Born via NSVD Nuchal cord x 1 not tight Apgar: 9 at 1 minute; 9 at 5 minutes. Physical Exam. VS: T: F HR: x’ RR: x’ BP: UE: LE: Weight: 4kg Length: 53 cm Head circumference: 36 cm

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CASE CONFERENCE

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  1. CASE CONFERENCE Suying Lam, MD PGY1

  2. Presentation: • FT male with L upper extremity weakness • Born via NSVD • Nuchal cord x 1 not tight • Apgar: 9 at 1 minute; 9 at 5 minutes

  3. Physical Exam • VS: • T: F • HR: x’ • RR: x’ • BP: UE: LE: • Weight: 4kg • Length: 53 cm • Head circumference: 36 cm • Chest circumference: 35 cm • Abdominal circumference: 33.5

  4. Physical Exam • General: alert, NAD, macrosomic • Skin: pink • HEENT: AFOF, + molding, + swelling Patent nares, no cleft, no pits • Thorax: symmetric expansion • Lungs: clear, equal breath sounds • Heart: RRR, no murmurs • Abdomen: soft, NT, ND, BS+ • Extremities: FROM R UE and both LE • L UE: (+)abduction, (+)flexion but not against gravity. Position: adducted, internally rotated, elbow extended, forearm pronated, wrist and fingers flexed. • Reflexes: asymmetric moro reflex, sucking +, grasp +

  5. Neonatal Brachial Plexus Palsies Smellie 1779 Duchenne and Erb 1870’s Klumpke 1885

  6. Brachial Plexus Anatomy

  7. Risk Factors • Large birth weight • Average vertex: 3.8-5 Kg • Average breech: 1.8-3.7 Kg • Breech presentation • Maternal diabetes • Multiparity • Second stage of labor that lasts more than 60 minutes • Assisted delivery (mid/low forceps, vacuum extraction) • Forceful downward traction on the head during delivery • Previous child with OBPP • Intrauterine torticollis • Shoulder dystocia

  8. Causes • Obstetric trauma: • Clavicular fracture • Humeral fracture • Shoulder dislocation or subluxation • Intrauterine compressive brachial plexus palsy • Humeral osteomyelitis • Neonatal Hemangiomatosis • Exostosis of the first rib • Neoplasm's (neuromas, rhabdoid tumors)

  9. Differential Diagnosis • Pyramidal Tract Lesions • Pre-brachial plexus lesions • Cervical Spinal Cord Injury • Amyoplasia Congenita (arthrogryposis) • Pseudoparalysis secondary to pain (humeral fracture) • Anterior horn cell injury (congenital varicella or congenital cervical spinal atrophy

  10. Diagnosis • Laboratory: generally not necessary • Imaging studies: • Chest X-ray • CT myelography • High-resolution MRI • Other tests: • Electrodiagnostic studies (2-3 weeks after injury) • Nerve conduction Studies

  11. Complete Brachial Plexus Palsy

  12. Duchenne-Erb Palsy • C5-C6 • Position: internally rotated, adducted, elbow extended, forearm is pronated, wrist is flexed and adducted, and fingers are flexed.

  13. Upper middle trunk brachial plexus palsy • C5-C6-C7 • Difference with Erb’s palsy: wrist is in neutral position (wrist flexor and extensors are equally weak)

  14. Klumpke Palsy • C8-T1 • Floppy hand: wrist is flexed, fingers extended following the forces of gravity • Horner’s syndrome

  15. Fascicular brachial plexus palsy • One muscle or a group of muscles in the arm • Due to injury of a small group of motor fibers

  16. Management • Rest period of 7 days  pin the sleeve of neonate’s shirt to hold the elbow in a flexed position • Physical Therapy Goals: minimizing bony deformities and joint contractures, while optimizing functional outcomes • Passive and Active ROM exercise • Bimanual activities • Strengthening • Promotion of sensory awareness • Weight-bearing activities: propioceptive input + skeletal growth • Static and dynamic splints • Instructing parents and family: home exercise program

  17. Other treatments: • Neuromuscular electrical stimulation • Botulinum toxin A therapy • Surgical Intervention

  18. Prognosis • Degree of future improvement cannot be determined during a single evaluation, especially if performed immediately after birth. • Improvement during the first few weeks is a relatively good indicator of final outcome. • Incidence of permanent sequelae: 3-25% • Findings consistent with severe initial injury (Horner’s syndrome) portend a less favorable prognosis • Peripheral nerves re-myelinate at a rate of 1mm/day. If nerve is not transected, recovery can be expected by: • 4-5 months in Erb’s palsy • 6-7 months in upper-middle trunk palsy • 14 months for a total BPP.

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