1
|
Shah V, Coroneos CJ, Ng E. The evaluation and management of neonatal brachial plexus palsy. Paediatr Child Health 2021; 26:493-497. [PMID: 34992702 PMCID: PMC8711584 DOI: 10.1093/pch/pxab083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/10/2021] [Indexed: 12/30/2022] Open
Abstract
Neonatal brachial plexus palsy presents at birth and can be a debilitating condition with long-term consequences. Presentation at birth depends on the extent of nerve injury, and can vary from transient weakness to global paresis, with active range of motion affected. Serial clinical examination after birth and during the neonatal period (first month of life) is crucial to assess recovery and predicts long-term outcomes. This position statement guides the evaluation of neonates for risk factors at birth, early referral to a multidisciplinary specialized team, and ongoing communication between community providers and specialists to optimize childhood outcomes.
Collapse
Affiliation(s)
- Vibhuti Shah
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario, Canada
| | | | - Eugene Ng
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario, Canada
| |
Collapse
|
2
|
Shah V, Coroneos CJ, Ng E. L'évaluation et la prise en charge de la paralysie néonatale du plexus brachial. Paediatr Child Health 2021; 26:498-503. [PMID: 34992703 PMCID: PMC8711581 DOI: 10.1093/pch/pxab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/11/2021] [Indexed: 12/30/2022] Open
Abstract
La paralysie néonatale du plexus brachial, qui se manifeste à la naissance, peut être débilitante et avoir des conséquences prolongées. La présentation à la naissance dépend de l'importance de la lésion nerveuse et peut varier entre une faiblesse transitoire et une parésie globale qui touche l'amplitude active des mouvements. Il est essentiel de procéder à des examens cliniques sériels après la naissance et pendant la période néonatale (jusqu'à l'âge d'un mois) pour évaluer le rétablissement et prédire le pronostic à long terme. Le présent document de principes décrit l'évaluation des facteurs de risque des nouveau-nés à la naissance, l'orientation précoce vers une équipe multidisciplinaire spécialisée et les communications entre les intervenants communautaires et les spécialistes pour optimiser le pronostic pendant l'enfance.
Collapse
Affiliation(s)
- Vibhuti Shah
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)Canada
| | - Christopher J Coroneos
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)Canada
| | - Eugene Ng
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)Canada
| |
Collapse
|
3
|
Transient congenital Horner syndrome and multiple peripheral nerve injury: a scarcely reported combination in birth trauma. CASE REPORTS IN PERINATAL MEDICINE 2021. [DOI: 10.1515/crpm-2021-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
To describe an infrequent association of multiple injuries in relation to perinatal trauma and the challenge of clinical examination for proper diagnosis.
Case presentation
A male newborn was born at 41 weeks gestational age to a multipara diabetic mother, by forceps. Apgar 8/9. Upon admission, he exhibited axial hypotonia, right brachial paresis, a large left parietal cephalohematoma, but no skull fractures or orbital injuries. He also showed ocular misalignment with marked esotropia of the right eye, ptosis and mild anisocoria, suggesting right Horner syndrome, and left facial palsy. During the oculo-cephalic reflex examination he exhibited a normal adduction and impaired abduction of the right eye. The cranial MRI showed an extensive left parietal cephalohematoma, with internal foci of recent bleeding, and supra and infratentorial laminar subdural hematomas. No lesions were evidenced in the cavernous sinuses. The recovery of extra and intraocular motility at one month of life in our patient highlighted the transitory nature of the lesions and was reassuring for the parents.
Conclusions
This case highlights the importance of a detailed clinical examination in the initial evaluation of a newborn at neurological risk after birth trauma. The association of sixth cranial nerve palsy, Horner syndrome, facial palsy, and brachial plexus injury have been scarcely referred in this context and, if not adequately interpreted, might suggest erroneous diagnoses with very different prognoses.
Collapse
|
4
|
Rehabilitation of Neonatal Brachial Plexus Palsy: Integrative Literature Review. J Clin Med 2019; 8:jcm8070980. [PMID: 31284431 PMCID: PMC6679188 DOI: 10.3390/jcm8070980] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 11/24/2022] Open
Abstract
This integrative literature review has been carried out with the aim of analyzing the scientific literature aimed at identifying and describing existing rehabilitation treatments/therapies for neonatal brachial plexus palsy (NBPP). NBPP is a frequent consequence of difficult birthing, and it impairs the function of the brachial plexus in newborns. This is why knowledge on rehabilitation strategies deserves special attention. The data collection was carried out in January 2019, in the EBSCOhost and BVS (Biblioteca Virtual em Saúde) platforms, in the CINAHL Complete, MEDLINE Complete, LILACS and PubMed databases. Thirteen articles were included in this integrative literature review, based on a literature search spanning title, abstract and full text, and considering the inclusion criteria. Two main treatments/therapies for NBPP rehabilitation were identified: conservative treatment and surgical treatment. Conservative treatment includes teamwork done by physiatrists, physiotherapists and occupational therapists. These professionals use rehabilitation techniques and resources in a complementary way, such as electrostimulation, botulinum toxin injection, immobilizing splints, and constraint induced movement therapy of the non-injured limb. Professionals and family members work jointly. Surgical treatment includes primary surgeries, indicated for children who do not present any type of spontaneous rehabilitation in the first three months of life; and secondary surgeries, recommended in children who after primary surgery have some limitation of injured limb function, or in children who have had some spontaneous recovery, yet still have significant functional deficits. Treatment options for NBPP are defined by clinical evaluation/type of injury, but regardless of the type of injury, it is unanimous that conservative treatment is always started as early as possible. It should be noted that there was no evidence in the literature of other types of rehabilitation and techniques used in clinical practice, such as preventive positioning of contractures and deformities, hydrotherapy/aquatic therapy, among others, so we consider there is a need for further studies at this level in this area.
Collapse
|
5
|
Chinchalkar SJ, Larocerie-Salgado J, Cepek J, Grenier ML. The Use of Dynamic Assist Orthosis for Muscle Reeducation following Brachial Plexus Injury and Reconstruction. J Hand Microsurg 2018; 10:172-177. [PMID: 30483028 DOI: 10.1055/s-0038-1642068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 03/07/2018] [Indexed: 10/17/2022] Open
Abstract
Therapeutic management of brachial plexus injuries remains complex. The impact of brachial plexus injuries on everyday human functioning should not be underestimated. Early active-assisted range of motion following such injuries may prevent myostatic contractures, minimize muscle atrophy, facilitate muscle fiber recruitment, and enable a faster return to baseline strength levels. The dynamic assist elbow flexion orthosis proposed is designed to provide patients with a graded system for muscle reeducation and function. No clinical data are currently available on the use of this orthosis design; however, this article presents a treatment option based on sound clinical reasoning to facilitate rehabilitation following this devastating injury.
Collapse
Affiliation(s)
- Shrikant J Chinchalkar
- Roth-McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada
| | | | - Jeremy Cepek
- Schullic School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | | |
Collapse
|
6
|
Yilmaz V, Umay E, Tezel N, Gundogdu I. Timing of rehabilitation in children with obstetric upper trunk brachial plexus palsy. Childs Nerv Syst 2018; 34:1153-1160. [PMID: 29623411 DOI: 10.1007/s00381-018-3790-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/28/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The initiation timing of rehabilitation in children with obstetric brachial plexus palsy is controversial. The aim of the present study is to evaluate the effectiveness of rehabilitation timing to the functional outcomes of patients with obstetric upper trunk brachial plexus palsy. MATERIAL AND METHODS Twenty-nine patients, who did not previously received any rehabilitation programme but attended our outpatient clinic, were included for the study. The electrophysiological findings, obstetric characteristics, and demographic features of the patients were recorded. The range of motion (ROM) of shoulders, elbows, and wrists and the strength of the muscles associated with these joints were evaluated. Modified Mallet Scale (MMS) was used for functional evaluation. A 4-week rehabilitation programme was performed twice at 2-month intervals. Patients were divided into three groups according to their ages as follows: 1-3 years old (group 1), 3-5 years old (group 2), and 5-7 years old (group 3). The ROMs, muscle strengths, and MMS scores of the patients were all evaluated. RESULTS Two out of 29 patients were female (6.9%) and 27 were male (93.1%). All 29 patients had right upper extremity palsy (100%). The MMS scores, ROMs, and muscle strength of the upper extremities had improved in all the groups following the standardized rehabilitation programme. CONCLUSIONS A rehabilitation programme is the best choice of treatment before surgical procedures in patients with mild to moderate obstetric upper trunk brachial plexus palsy regardless of age and the initiation time.
Collapse
Affiliation(s)
- Volkan Yilmaz
- Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Physical Rehabilitation Medicine Clinic, Irfan Bastug Street, Altindag, Ankara, Turkey.
| | - Ebru Umay
- Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Physical Rehabilitation Medicine Clinic, Irfan Bastug Street, Altindag, Ankara, Turkey
| | - Nihal Tezel
- Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Physical Rehabilitation Medicine Clinic, Irfan Bastug Street, Altindag, Ankara, Turkey
| | - Ibrahim Gundogdu
- Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Physical Rehabilitation Medicine Clinic, Irfan Bastug Street, Altindag, Ankara, Turkey
| |
Collapse
|
7
|
Heise CO, Martins R, Siqueira M. Neonatal brachial plexus palsy: a permanent challenge. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:803-8. [DOI: 10.1590/0004-282x20150105] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Neonatal brachial plexus palsy (NBPP) has an incidence of 1.5 cases per 1000 live births and it has not declined despite recent advances in obstetrics. Most patients will recover spontaneously, but some will remain severely handicapped. Rehabilitation is important in most cases and brachial plexus surgery can improve the functional outcome of selected patients. This review highlights the current management of infants with NBPP, including conservative and operative approaches.
Collapse
|
8
|
Hall JG. Amyoplasia involving only the upper limbs or only involving the lower limbs with review of the relevant differential diagnoses. Am J Med Genet A 2014; 164A:859-73. [PMID: 24459095 DOI: 10.1002/ajmg.a.36397] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 11/21/2013] [Indexed: 12/27/2022]
Abstract
Of individuals with Amyoplasia, 16.8% (94/560) involve only the upper limbs (Upper Limb Amyoplasia-ULA) and 15.2% (85/560) involve only the lower limbs (Lower Limb Amyoplasia-LLA). The accompanying paper deals with other forms of Amyoplasia [Hall et al., 2013] and discusses etiology. An excess of one of monozygotic (MZ) twins is seen in both groups (ULA 4/94 (4.3%), LLA 5/85 (5.9%)), gastrointestinal (GI) abnormalities thought to be of vascular origin (bowel atresia and gastroschisis) (ULA 16/94 (17%), LLA 4/85 (4.7%)), small or partial absence of digits (ULA 6/94 (6.2%), LLA 8/85 (9.4%)), and umbilical cord wrapping around the limbs at birth (ULA 3/94 (3.2%), LLA 7/85 (8.2%)) (severe enough to leave a permanent groove). Pregnancy complications occurred in 42/60 (70%) of ULA and 36/54 (67%) of LLA. Prenatal diagnosis, after ultrasound usage became routine, occurred in only 7/25 (28%) of ULA and 5/12 (12%) of LLA. This series may represent an over estimate of the complications and associations occurring in ULA and LLA. Differential diagnoses separating LLA from the genetic forms of "lower limb only" arthrogryposis and ULA from "upper limb only" genetic forms of arthrogryposis and Erb's palsy is provided.
Collapse
Affiliation(s)
- Judith G Hall
- Departments of Medical Genetics and Pediatrics, University of British Columbia, BC Children's Hospital Vancouver, British Columbia, Canada
| |
Collapse
|
9
|
Hall JG, Aldinger KA, Tanaka KI. Amyoplasia revisited. Am J Med Genet A 2014; 164A:700-30. [DOI: 10.1002/ajmg.a.36395] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 11/14/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Judith G. Hall
- Departments of Medical Genetics and Pediatrics; University of British Columbia and BC Children's Hospital; Vancouver Canada
| | - Kimberly A. Aldinger
- Center for Integrative Brain Research; Seattle Children's Research Institute; Seattle Washington
| | - Kimi I. Tanaka
- Departments of Medical Genetics and Pediatrics; University of British Columbia and BC Children's Hospital; Vancouver Canada
| |
Collapse
|
10
|
Gurewitsch ED, Allen RH. Reducing the risk of shoulder dystocia and associated brachial plexus injury. Obstet Gynecol Clin North Am 2011; 38:247-69, x. [PMID: 21575800 DOI: 10.1016/j.ogc.2011.02.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Despite persisting controversy over shoulder dystocia prediction, prevention, and injury causation, the authors find considerable evidence in recent research in the field to recommend additional guidelines beyond the current American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines to improve clinical practice in managing patients at risk for experiencing shoulder dystocia. In this article, the authors offer health care providers information, practical direction, and advice on how to limit shoulder dystocia risk and, more importantly, to reduce adverse outcome risk.
Collapse
Affiliation(s)
- Edith D Gurewitsch
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | | |
Collapse
|
11
|
Lagerkvist AL, Johansson U, Johansson A, Bager B, Uvebrant P. Obstetric brachial plexus palsy: a prospective, population-based study of incidence, recovery, and residual impairment at 18 months of age. Dev Med Child Neurol 2010; 52:529-34. [PMID: 20041937 DOI: 10.1111/j.1469-8749.2009.03479.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM The aim of this investigation was to study the incidence of obstetric brachial plexus palsy (OBPP), to prospectively follow the recovery process, to assess the functional outcome at 18 months of age, and to find early prognostic indicators. METHOD Of the 38 749 children born between 1999 and 2001 in western Sweden, 114 (70 males, 44 females) had an OBPP. Ninety-eight children were examined on six occasions at up to 18 months of age. Muscle strength, range of motion, hand preference, and functional abilities were noted, and the severity of the OBPP was classified. RESULTS The incidence of OBPP was 2.9 per 1000 live births, and the incidence of persisting OBPP was 0.46 per 1000. At 3 months of age, the predictive value of regained elbow flexion for complete recovery was 100%, 99% of shoulder external rotation, and 96% of forearm supination. Most of the 18 children with persisting OBPP could perform functional activities but asymmetries were noted. Five children had a mild, 11 had a moderate, and two had a severe impairment. Three had undergone nerve surgery, one with a mild and two with a severe persisting impairment. INTERPRETATION Most children with an OBPP recover completely. Muscle strength at 3 months of age can be used to predict outcome.
Collapse
Affiliation(s)
- Anna-Lena Lagerkvist
- Department of Paediatrics, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
| | | | | | | | | |
Collapse
|
12
|
Tierney TS, Tierney BJ, Rosenberg AE, Krishnamoorthy KS, Butler WE. Infantile myofibromatosis: a nontraumatic cause of neonatal brachial plexus palsy. Pediatr Neurol 2008; 39:276-8. [PMID: 18805367 DOI: 10.1016/j.pediatrneurol.2008.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 01/24/2008] [Accepted: 06/10/2008] [Indexed: 11/28/2022]
Abstract
Most injuries to the neonatal brachial plexus occur acutely at birth, and are iatrogenic in origin. However, when weakness is accompanied by atrophy, nontraumatic etiologies should be considered. The differential diagnosis of chronic congenital brachial plexopathy includes cervical bone malformations, humeral osteomyelitis, varicella, and compression from various types of infantile tumors. An illustrative male infant delivered at 37 weeks of gestation with wasted musculature of the left upper arm, ipsilateral Horner's syndrome, and a hemidiaphragm is presented. On further examination, this patient manifested an underlying cervical tumor compressing the brachial plexus. Diagnostic steps leading to the pathologic identification of a solitary cervical myofibroma included physical examination, electromyography, radiographic imaging, and open biopsy. This report emphasizes the importance of differentiating acute from chronic congenital plexus palsy and of recognizing the possibility that infection or neoplasm may underlie the latter.
Collapse
Affiliation(s)
- Travis S Tierney
- Neurosurgery Service, Massachusetts General Hospital, 55 Fruit Street, White 502, Boston, MA 02114, USA.
| | | | | | | | | |
Collapse
|
13
|
Chen YC, Lui CC, Liao JJ, Huang SC, Chang YC. Spinal cord tumor mimicking obstetric brachial plexus palsy. Int J Gynaecol Obstet 2007; 100:179-80. [PMID: 18061191 DOI: 10.1016/j.ijgo.2007.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Revised: 07/28/2007] [Accepted: 07/30/2007] [Indexed: 11/29/2022]
Affiliation(s)
- Yu-Chieh Chen
- Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | | | | | | |
Collapse
|
14
|
Abstract
A practical clinical review of those aspects of shoulder dystocia management that are directly relevant to birth injury is presented. In contrast to more popular viewpoints, the tenets of this paper are that, with few exceptions, clinically relevant, permanent brachial plexus injury is nearly universally associated with shoulder dystocia, injury is causally related to mechanical stresses induced during shoulder dystocia delivery, and management algorithms can be optimized to reduce the incidence of mechanical birth injury from shoulder dystocia. Advantages of direct rotational manipulation of the fetus within the birth canal are emphasized, supported by critical analysis of maneuver-related outcomes research. The competing issue of potential asphyxial insult with prolonged shoulder dystocia is addressed in light of evidence for differential time-dependency between central and peripheral nerve injury as head-to-body interval increases. The importance of proper execution of shoulder dystocia maneuvers for maximizing favorable outcome of shoulder dystocia is iterated, as is coordination of teamed response by multiple healthcare providers. To avoid permanent neurologic sequelae from shoulder dystocia, clinicians are encouraged to be ever mindful of traction applied to the fetal head and neck, to become adept at performance of alternative maneuvers that instead concentrate on finesse rather than force, and to be more favorably disposed to the use of such maneuvers early and often in shoulder dystocia management algorithms.
Collapse
Affiliation(s)
- Edith Diament Gurewitsch
- Department of Gynecology/Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| |
Collapse
|
15
|
Abstract
Using an evidence-based, medical approach, the strengths and pitfalls of the causation- and standard-of-care-based arguments proffered by plaintiff and defense counsel in shoulder dystocia- associated birth injury litigation are reviewed based on medical plausibility. The role of the expert witness as arbiter of the relationship between medical care rendered and the untoward outcome of such care is distinguished from that of other court members. Proposed solutions to the medical malpractice litigation crisis are also examined in light of relevant differences in the pathogenetic bases for birth injuries of various types.
Collapse
Affiliation(s)
- Edith D Gurewitsch
- Department of Gynecology/Obstetrics, Division of Maternal Fetal Medicine, The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA.
| | | |
Collapse
|
16
|
Heise CO, Gherpelli JLD. Prognostic relevance of risk factors for obstetrical brachial plexopathy. ARQUIVOS DE NEURO-PSIQUIATRIA 2006; 64:30-4. [PMID: 16622549 DOI: 10.1590/s0004-282x2006000100007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We did a case-control study to verify if the birthweight, forceps delivery or perinatal asphyxia have any significant effect on the prognosis of obstetrical brachial plexopathy. Group A was composed of 25 infants who completely recovered at the age of 6 months. Group B was composed of 21 infants who were still not able to remove a blindfold from the face with the affected limb in the sitting position at the age of 12 months. There was no statistical difference of the median birthweight or median first minute Apgar score between the groups. There was also no relation between birthweight higher than 4000g, first minute Apgar score lower than 6 or forceps delivery with a poor prognosis.
Collapse
Affiliation(s)
- Carlos O Heise
- Ambulatório de Neurologia do Desenvolvimento, Clínica Neurológica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | | |
Collapse
|
17
|
Gurewitsch ED, Johnson E, Hamzehzadeh S, Allen RH. Risk factors for brachial plexus injury with and without shoulder dystocia. Am J Obstet Gynecol 2006; 194:486-92. [PMID: 16458651 DOI: 10.1016/j.ajog.2005.07.071] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2005] [Revised: 06/06/2005] [Accepted: 07/19/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To ascertain whether brachial plexus palsy (BPP) that occurs without shoulder dystocia (SD) represents a traction injury during unrecognized SD or a natural phenomenon with a different mechanism of injury, we compared risk factors and outcomes between SD-associated and non-SD-associated BPP. STUDY DESIGN Neonates with BPP after cephalic vaginal delivery were pooled from all deliveries at Johns Hopkins (June, 1993-December, 2004) and a dataset of litigated permanent BPP from multiple institutions (1986-2003), grouped by SD association based on clinician documentation and compared by using Fisher exact and t tests. RESULTS Thirty percent of 49 non-SD-BPP and 11% of 280 SD-BPP lacked all risk factors for SD (P = .002). Compared with SD-BPP infants, non-SD-BPP infants were average weight (P < .001) and had cord pH less than 7.10 (P = .01) more commonly and exhibited a trend toward posterior shoulder involvement (P = .06). Nearly all non-SD-BPP were temporary, whereas more than 90% of permanent BPP were associated with SD (odds ratio 17, 7.3-39.6). CONCLUSION Non-SD-BPP is uncommon and likely mechanistically distinct from SD-BPP. Risk factors, birth weight, fetal acidosis, posterior arm involvement, and injury severity distinguish between shoulder dystocia-related brachial plexus injuries and those not recorded as such.
Collapse
Affiliation(s)
- Edith D Gurewitsch
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | |
Collapse
|
18
|
Benjamin K. Part 2. Distinguishing physical characteristics and management of brachial plexus injuries. Adv Neonatal Care 2005; 5:240-51. [PMID: 16202966 DOI: 10.1016/j.adnc.2005.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Brachial plexus injuries (BPI) are usually readily apparent at or shortly after birth. Failure of caregivers to recognize and appropriately treat BPI may contribute to the risk of life-long neuromuscular dysfunction for the infant and represents a serious medical-legal liability for the delivery provider. This article is the second in a series on BPI and provides a standard classification and a systematic guide to physical examination of the infant with suspected BPI. Conditions that mimic BPI are discussed along with diagnostic studies used to confirm this disorder. The natural history and predictors of outcome are presented along with a sample treatment protocol. Pictures and video clips are provided to enhance the reader's understanding of the consequences of this injury and the potential for improvement with surgical treatment. Useful Internet resources for parents, focused discharge planning, and guidelines for appropriate monitoring and follow-up are provided. Advantages of early referral and management by a multidisciplinary team at a brachial plexus specialty center are discussed.
Collapse
Affiliation(s)
- Kathleen Benjamin
- Department of Neonatology, The Children's Hospital, Denver, CO 80218, USA.
| |
Collapse
|
19
|
Benjamin K. Part 1. Injuries to the brachial plexus: mechanisms of injury and identification of risk factors. Adv Neonatal Care 2005; 5:181-9. [PMID: 16084476 DOI: 10.1016/j.adnc.2005.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Upper-arm weakness (paresis) or paralysis indicates peripheral-nerve damage to the brachial plexus, a network of lower cervical and upper thoracic spinal nerves supplying the arm, forearm, and hand. Physical findings reflect muscle paralysis from spinal nerve roots. The mechanism of injury includes maternal, obstetric, and infant factors that apply traction on or compression to the anatomically vulnerable brachial plexus. Nerve regeneration can occur if nerve tissue components are preserved. Recovery is affected by multiple factors, including the type and site of injury, intervention timing, and developmental factors. The majority of injuries recover in days or months; however, residual deficits can persist. Part 1 of 2 of this article provides an overview of the neurophysiology of peripheral-nerve damage and nerve regeneration. The multifactorial etiology of brachial plexus injuries will be reviewed. Photographs and on-line video clips will enhance the description of the brachial plexus injury classifications and illustrate mechanisms of shoulder dystocia and obstetric relief maneuvers. A systematic approach to the physical examination will be explored in Part 2. Serial evaluation of motor function recovery is essential and is accomplished by appropriate referrals and follow-up. Part 2 will also describe treatment options and discuss anticipatory parent guidance.
Collapse
|
20
|
Allen RH, Gurewitsch ED. Temporary Erb-Duchenne Palsy Without Shoulder Dystocia or Traction to the Fetal Head. Obstet Gynecol 2005; 105:1210-2. [PMID: 15863585 DOI: 10.1097/01.aog.0000141635.94905.21] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although many retrospective studies report that brachial plexus palsies occur after vaginal delivery in the absence of recorded shoulder dystocia, there are no known prospective reports by a treating clinician (PubMed, English language only, 1952-June 2004, search terms: shoulder dystocia, nonshoulder dystocia, obstetric brachial plexus injury, Erb's palsy, Erb-Duchenne palsy, spontaneous vaginal delivery). CASE A multiparous patient presented with a birth plan requesting that the baby be allowed to deliver on its own, without traction on the head and without suctioning. Although induced at term for elevated blood pressure, the otherwise healthy patient experienced a normal labor with a 30-minute second stage. At delivery, which was videotaped by the father, the fetal head presented over an intact perineum in a right-occiput-anterior position. Without traction, the anterior shoulder delivered spontaneously with the next contraction and Valsalva, followed by the posterior shoulder. The trunk followed routinely. The average-weight for gestational age neonate exhibited an Erb-Duchenne palsy of the right (posterior) arm that resolved on the fourth day of life. CONCLUSION Temporary Erb-Duchenne palsy can occur in the posterior arm after normal labor and spontaneous delivery without shoulder dystocia or traction on the fetal head.
Collapse
Affiliation(s)
- Robert H Allen
- Department of Biomedical Engineering and Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland 21218, USA.
| | | |
Collapse
|
21
|
Ochiai H, Ikeda T, Mishima K, Aoo N, Iwasaki K, Fujiwara M, Nakano S, Ikenoue T, Wakisaka S. Local administration of glial cell line-derived neurotrophic factor improves behavioral and histological deficit of neonatal Erb's palsy in rats. Neurosurgery 2003; 53:973-7; discussion 977-8. [PMID: 14519229 DOI: 10.1227/01.neu.0000083029.91562.7f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2002] [Accepted: 06/04/2003] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We sought to evaluate from a behavioral and histological viewpoint the effect of local administration of glial cell line-derived neurotrophic factor (GDNF) on neonatal preganglionic Erb's palsy in rats. METHODS The Erb's palsy model was produced by transecting the anterior and posterior roots of the left C5-C7 nerves of 7-day-old rats. The rats were divided into GDNF-treated (n = 10) and vehicle-treated groups (n = 11). After we transected the roots, contact in the proximal and distal stumps of the transected nerves was maintained, and the transected point and the entire intraspinal portion of the transected roots were enclosed by Gelfoam soaked with 10 micro g GDNF or saline. The behavioral evaluation consisted of a foot-fault test and a forepaw muscle strength test, all of which were performed from the third to the seventh weeks after the operation. Seven weeks after the operation, all rats were killed, the number of anterior horn cells was counted at C5-C7, and the differences on each side were compared. RESULTS In the vehicle-treated group, the foot-fault test indicated an abnormality in forelimb function on the root transection side. In the GDNF-treated group, however, significant improvement in forelimb function was observed on the basis of the foot-fault test results obtained in the third to sixth weeks after the operation. In the histological evaluation, the number of anterior horn cells from the side in which the operation took place in the vehicle-treated group was significantly less than that taken from the contralateral side at each segment. In the GDNF-treated group, however, there was no difference in any of the segments, regardless of the side from which they were taken. CONCLUSION Local administration of GDNF in a neonatal preganglionic Erb's palsy model resulted in significant improvement in deficits on the basis of behavioral and histological evaluations.
Collapse
Affiliation(s)
- Hidenobu Ochiai
- Department of Neurosurgery, Miyazaki Medical College, Miyazaki, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Ochiai H, Ikeda T, Mishima K, Yoshikawa T, Aoo N, Iwasaki K, Fujiwara M, Ikenoue T, Nakano S, Wakisaka S. Development of a novel experimental rat model for neonatal pre-ganglionic upper brachial plexus injury. J Neurosci Methods 2002; 119:51-7. [PMID: 12234635 DOI: 10.1016/s0165-0270(02)00167-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A neonatal upper brachial plexus injury, referred to as Erb's palsy, is a serious obstetric problem. Some surgical methods are used to treat this injury, but they are inadequate. To seek new treatments for Erb's palsy, we used a model for cervical preganglionic root transection in neonate rats and evaluated the behavioral and histological compatibility of this model with Erb's palsy. Two groups were used in this study. In the group, receiving the Erb operation, the left anterior and posterior roots of spinal vertebra C5-C7 were transected at the preganglionic level, and the results were compared with those of a group that received a sham operation. In the group, receiving the Erb operation, walking difficulties and behavioral abnormalities were observed. These observations were noted on the side where the transection took place, and the problems were attributed to proximal muscle weakness in the forelimb. Additionally, the forepaw grip was not impaired. Furthermore, in this group, the number of anterior horn cells in the cervical cord on the transected side was significantly lower than that on the contralateral side (P < 0.001). The results of this study indicate that the model fulfills the criteria for the clinical symptoms of Erb's palsy and that it may also serve as a new method for enabling treatment of the condition.
Collapse
Affiliation(s)
- Hidenobu Ochiai
- Department of Neurosurgery, Miyazaki Medical College, 5200, Kihara, Kiyotake, Miyazaki 889-1692, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Smida M, Jalel C, Soohun T, Djebbi Y, Nessib MN, Ben Ghachem M. [Brachial plexus paralysis of infectious origin: report of four cases]. Arch Pediatr 2002; 9:814-7. [PMID: 12205792 DOI: 10.1016/s0929-693x(01)00994-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Brachial plexus palsy (BPP) may occur after septic osteoarthritis of the shoulder. BPP is a rare, well recognized complication. The pathophysiology is thought to be either ischemic nerve damage secondary to occlusion of vasa nervorum or extrinsic compression. Early diagnosis and treatment of the infection are needed. CASE REPORTS We report the cases of three infants aged less than three months and one six-day-old newborn infant who presented with an authentic BPP due to an osteoarthritis of the shoulder. The diagnosis of osteoarthritis relied on clinical, biological and radiological signs. In one case, the causal germ (Enterobacter) was isolated. The diagnosis of the palsy was based on clinical signs. EMG performed on one patient, showed signs of abnormal motor pattern. Following intravenous antibiotics and percutaneous drainage, all infants completely recovered.
Collapse
Affiliation(s)
- M Smida
- Service d'orthopédie infantile, hôpital d'Enfants de Tunis Bab Saadoun, 1007 Tunis, Tunisie.
| | | | | | | | | | | |
Collapse
|
24
|
|
25
|
|