BRACHIAL PLEXUS INJURY IN NEONATES
Dr. Maher Shoblaq
Dr. Zuhair ALDajani
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.
BACKGROUND
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 commondelivery presentation is left occiput anterior vertex.
Associated with: pre and gestational diabetesolder maternal ageincreased 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 asphyxiathan matched controls
Brachial plexus palsy occurs in 26% of cases of shoulderDystocia
Both Shoulder dystocia and brachial plexus palsy are morecommon 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 inUtero.
EPIDEMIOLOGY
Clavicular fractures are often associated with shoulderdystocia , but the incidence of brachial palsy in theseCases is only 11%.
Clavicular fracture =more mobility of shoulder
Not always associated with difficult delivery (IntrauterineMaladaption palsy). Cases of in utero origin supported by EMG findings if denervation at birth.
EPIDEMIOLOGY
ANATOMY
ANATOMY
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 ofthe forearm.
The lower roots (C7-T1) innervate the intrinsic musclesof the hand.
The phrenic nerve, arising from C3-C5 can be involved resulting in ipsilateral diaphragmatic paralysis causing adecrease in thoracic space, tidal volume and vital capacity.
Involvement of the sympathetic nerves from T1 that give riseto the sup cervical symp ganglion can result in Horner Synd.
HORNER SYNDROME
PtosisMiosis and anhydrosis
Stretch, tear, compression or avulsion of the nervesusually after forceful lateral deviation of the head from the shoulders during delivery. Recent studiessuggest intrinsic forces(uterine contractions).PATHOGENESIS
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 reflexof the hand
Clinical Manifestations
If phrenic nerve is involved, as mentioned earlierrespiratory distress may be present.
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.
DIAGNOSTIC WORKUP
Evaluation can be undertaken by multiple modes of Imaging.
EMG
MRI
Chest X ray
Real time UltraSonography
MANAGEMENTThe majority of patients with brachial plexus palsy Dx at birth will recover from neurologic deficit.Those who do not recover during 3-6month period willRequire 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
Resting position
MANAGEMENTSurgical •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 airwayInjury to vagal and laryngeal nervesRisk for meningitis
PROGNOSISStudy 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
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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