Intrauterine vascular deficiency of the upper limb

Congenital brachial artery occlusion causing neonatal forearm compartment syndrome

Congenital brachial artery occlusion is rare. We report four patients who presented at birth with absent wrist pulses. We propose management recommendations that include anti-coagulation, duplex ultrasound assessment and fasciotomy surgery as early as is safe and possible.

Microsurgical Salvage of Neonatal Upper Limb Ischaemia Following Intrauterine Brachial Vessel Constriction

Neonatal limb ischaemia is a rare disease entity with devastating morbidity, including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. 

We report a case of limb revascularisation and salvage due to intrauterine brachial artery thrombosis. Published literature is limited to case reports and case series, with various treatment modalities discussed. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life-long morbidity.

A male baby at (36+6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularization was achieved with a contralateral interposition reversed great saphenous vein graft. 

Though extremely rare and the clinical presentation varies with the location and timing after birth, the surgeon should maintain a low threshold for suspicion of in the presence of the characteristic sequelae of ischaemia. Doppler ultrasonography can aid the diagnosis where ambiguous, and therapy should be individualised based on the clinical presentation; this case emphasises the role of surgery in limb salvage.

Lower-Limb Ischemia at Birth Because of Spontaneous Arterial Thrombosis: A Case Report

CASE

A full-term neonate presented with right lower extremity ischemia at birth because of spontaneous thrombosis of the right common iliac artery. He was initially managed with supportive treatment, anticoagulation, and dressings; however, advanced gangrenous changes precluded salvage of the ischemic limb. A guillotine amputation was performed at day 15 of life, and the stump went on to heal well by secondary intention.

CONCLUSION

Thromboembolic events occurring in infancy are well-recognized phenomena; however, it is far rarer to encounter a neonate born with "congenital gangrene". We discuss the etiology, approach to diagnosis, and treatment of this rare but devastating condition.

Neonatal Compartment Syndrome and Compound Presentation at Birth

Neonatal compartment syndrome is a rare condition. Early diagnosis and timely surgical intervention are paramount to optimize outcome. Time to fasciotomy is the most important prognostic factor. The purposes of this study were to describe a case presentation of neonatal compartment syndrome associated with a compound birth presentation and to perform a literature review. In this case, the neonate’s fingers were noted to be present on maternal cervical examination 24 hours before delivery. The patient then was noted to have a sentinel skin lesion. A diagnosis of neonatal compartment syndrome was suspected, and she underwent urgent fasciotomy. Literature review identified a total of 60 patients from 26 studies. Most patients were managed operatively. All patients presented with a sentinel skin lesion, emphasizing the importance of this clinical sign in diagnosis. Manometry is not routinely performed and no standards are available for acceptable pressure gradients.

Physeal bar equivalent

Premature partial physeal arrest without the formation of an osseous bar - physeal bar equivalent (PBE) - is uncommon. Four children with a PBE had an infection near the distal femoral physis before the age of 11 months. Some growth was achieved after resection of the PBE in each case. Of two cases diagnosed and treated early, one required only contralateral physeal arrests to achieve limb-length equality at maturity. The other, currently 8 years and 4 months old, has a 1.1-cm limb-length discrepancy 6 years after PBE resection and will require observation until maturity. Of two cases diagnosed and treated late, one required ipsilateral femoral lengthening and contralateral femoral shortening and physeal arrests to treat the limb-length discrepancy and angular deformity. The other, currently 7 years and 1 month old, has a 4.8-cm discrepancy and will need future surgical limb-length equalization. Early recognition and treatment of PBE is required to avoid severe limb-length inequality and angular deformity.

Salvage of Necrotic-Appearing Limb after In Utero Endoscopic Lysis of Constriction Bands

We report a case of amniotic band syndrome complicated by constriction bands and marked distal swelling of both lower extremities. Color Doppler interrogation of the right lower extremity revealed complete lack of blood flow below the level of the constriction. Upon fetoscopic survey, the right lower extremity beyond the constriction band appeared dusky red and discolored with desquamation, consistent with a necrotic appearance. The constriction bands were cut in utero using endoshears, thereby allowing restoration of blood flow on postoperative day 1. The patient was counseled extensively regarding the possibility of limb dysfunction or amputation. However, the baby was born with functional lower extremities, and at 21 months of age, the child was cruising and jumping on his own. This case demonstrates that there is unique plasticity in fetal limb recovery after a severe ischemic injury that is not otherwise seen in postnatal life. Reperfusion of the necrotic-appearing limb resulted in restoration of appearance and function without apparent deleterious effects on the fetus. We believe the favorable outcome in this case was likely due to timeliness of the in utero lysis of amniotic bands and the plasticity of fetal healing.

Free myocutaneous flap transfer to treat congenital Volkmann's contracture of the forearm

The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.

Neonatal volkmann ischemic contracture: case report and review of literature

Background Neonatal Volkmann ischemic contracture in newborns is a devastating condition with lifelong consequences. Case Report We report a neonate born with necrotic skin lesions and bullae on right dorsal thenar aspect of hand, who subsequently developed compartment syndrome requiring fasciotomy. Review and Conclusion Necrotic skin lesions with/without swelling, bullae are invariably present at birth in these patients and should be recognized as a sentinel finding of underlying tissue ischemia/compartment syndrome. Early recognition and prompt surgical intervention can be limb saving. A range of radiologic abnormalities and contractures were noted in upto 84% of such patients followed long term. Hence, we recommend close follow-up until occurrence of epiphyseal fusion in these patients.

Intrauterine upper limb ischemia: an unusual presentation of fetal thrombophilia-a case report and review of the literature

Upper limb ischemia presenting in neonatal period is extremely rare. Moreover, presenting newborn with evidence of intrauterine upper limb vascular occlusion is even rarer. It needs prompt intervention to restore perfusion and avoid morbidity. We present a newborn with right upper limb brachial artery thrombosis causing ischemia that was noted at birth and appeared later to be homozygous for factor V Leiden and glycoprotein IIIa with no other identifiable risk factors. In this report, we present the case, its successful medical management, proper counseling, and review of the literature. We recommend investigating the neonates and their parents for thrombophilia mutations when they present with unusual vascular occlusion site as newborns.

In utero arterial thrombosis treated with recombinant tissue plasminogen activator in an infant of a diabetic mother: A case report and literature review

A 36+5 days' gestation infant of a diabetic mother suffered arterial thrombosis with severe vascular occlusions in multiple limbs, especially of the left upper extremity. Although the mechanism remains elusive, the association between venous and arterial thrombi in infants and diabetic mothers has previously been established. Cases typically result in the amputation of the dysvascular limbs. In the present case, the use of selective angiography to administer recombinant tissue plasminogen activator allowed the left upper extremity to be salvaged with amputation of only the left thumb.

Intrauterine extremity gangrene and cerebral infarction at term: a case report

Intrauterine extremity gangrene in combination with cerebral infarction is a serious and rare event. We present a case with a healthy mother who gave birth to a child with this condition. At term, the mother presented at the antenatal clinic with decreased fetal movements. Cardiotocography (CTG) showed signs of fetal distress and a caesarean section was performed. The left arm of the newborn was found gangrenous. Amputation of the arm was necessary and the child was subsequently treated with anticoagulant therapy due to thrombosis and cerebral infarction in the left hemisphere found by magnetic resonance imaging (MRI). At one year of age the boy was doing well and had prosthesis as a left arm. He had no signs of further complications. Despite thorough examination of the parents and the child, the reason for the thrombosis is still unknown.

[Neonatal Volkmann's syndrome]

BACKGROUND

Acute limb compartment syndrome or Volkmann's ischaemic contracture is an acquired ischaemia of nerve and muscle causes by raised pressure within a closed fascial space. Congenital Volkmann's ischaemic contracture (CVIC) is a rare entity.

PATIENTS AND METHODS

A 2-day-old girl was referred with a problem of the left forearm and arm, which exhibited cold oedema with decreased mobility. Lesions were present at birth and were rapidly complicated by skin necrosis. The mother was taking olazanpine, prazepam and valpromide throughout the entire pregnancy. Delivery was complicated by shoulder dystocia requiring obstetric procedures such as suprapubic pressure, Couder's maneuver and episiotomy. On physical examination her left hemi-thorax, left arm, forearm and hand exhibited marked oedema. A large and well-demarcated bullous, fibrous and ulcerated area of skin necrosis was observed on the elbow fold and on the inner anterior part of the arm. Digital flexion with cyanosis was present. MR angiography revealed extensive oedema of the soft tissue and muscle with fascial effusion, associated with compression of the arm arteries and reduced blood flow in the forearm. A fasciotomy was performed at Day 3 of life. The postsurgical arterial MRI was normal. At Day 10 of life, the patient developed opisthotonos involving spasms and tremors associated with numerous intercritical abnormalities evoking benzodiazepine weaning syndrome. The child's neurological status was stabilized by treatment with phenobarbital and clonazepam. She was subsequently lost to follow-up.

DISCUSSION

CVIC has been ascribed to multiples causes. Mechanical compression is the main recognized factor: amniotic band constriction, umbilical cord loops, compression in utero by a deceased co-twin, malposition of the hand, arm or forearm, local or general factors that can add to extraction problems: brachypelvic disproportion, extraction with forceps, oligo/polyhydramnios, pre-term delivery, pre-eclampsia, caesarean section, premature labour, excessive maternal weight gain or diabetes. Our case emphasized three main points. First, the diagnostic value of early MR angiography in the event of associated extensive tissue oedema, multiple arterial compression and decreased vascular perfusion. Second, the role of shoulder dystocia in triggering the traumatic factor reported for the first time. Third, the role of neuroleptic and anxiolytic treatments taken by the mother during pregnancy. Prazepam is a long-acting benzodiazepine that can cause impregnation and withdraw syndromes in neonates. Impregnation "floppy infant syndrome" is an early event characterized by hypotonia, hypoventilation and lethargy. Hypotonia and decreased foetal movements may favour prolonged pressures and malposition with secondary crush injury during delivery. Maternal medication has not been cited hitherto as an aetiological factor in neonatal compartment syndrome.

Combined intrauterine vascular insufficiency and brachial plexus palsy: A case report

A unique case of combined intrauterine vascular insufficiency and complete brachial plexus palsy is described in a newborn delivered by cesarean section. Intrauterine vascular insufficiency resulted in a right below elbow amputation at 3 weeks of age. Amputation length was preserved after a pedicled thoracoabdominal flap. Function of the C5, C6, and C7 nerve roots returned to normal by 3 months of age.

Intrauterine gangrene of the lower extremity in the newborn: a report of two cases

We describe 2 cases of intrauterine gangrene involving the lower extremity in 2 unrelated neonates. Both cases were complicated by prematurity, and 1 case was complicated by an intrauterine distal femur fracture and twin-twin transfusion syndrome. Both cases resulted in profound ischemic necrosis from the knee to the foot, requiring knee disarticulation. In both cases, a follow-up period of 7 years is now completed, and no further medical or surgical complications have arisen.

Forearm compartment syndrome in the newborn: report of 24 cases

PURPOSE

Isolated cases of ischemia, compartment syndrome, or Volkmann's ischemic contracture in the forearm of the newborn infant have been reported in the past. The purpose of this study is to review a large series of patients with neonatal forearm compartment syndrome and to report the important clinical features.

METHODS

A search of medical records from 1980 to 2000 identified 24 children with evidence of ischemia of the forearm at the time of birth. Records and images were reviewed for prenatal and birth history, maternal factors, medical conditions, pattern of involvement, treatment, and outcomes. Patients were grouped according to the extent of initial soft-tissue involvement.

RESULTS

All patients presented with a sentinel forearm skin lesion. Patterns of involvement ranged from mild skin and subcutaneous lesions to dorsal and volar compartment syndrome with or without distal tissue loss. Early treatment intervention was limited to a single case in which the diagnosis of compartment syndrome was made and an emergency fasciotomy was performed with a good outcome. In other cases tissue loss, compressive neuropathy, muscle loss, and late skeletal changes were responsible for impaired function. Distal bone growth abnormality was common.

CONCLUSIONS

Forearm compartment syndrome in the newborn is not as uncommon as previously thought. The skin lesion was the common, salient, initial diagnostic finding. Early diagnosis and appropriate referral led to the salvage of a functional limb in 1 of the patients in this series. The severity of the initial insult correlated with the degree of impairment in growth and function. The delayed diagnosis and treatment of an evolving compartment syndrome may compromise further final function.