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    Brachial Plexus Asia in

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    Fajrin Gumilar
    Brachial plexus injuries in neonates can occur during birth when excessive lateral force causes the head to be pulled away from the shoulders, stretching or tearing the brachial plexus nerves. These injuries are more common with large babies, shoulder dystocia, and when the mother has diabetes. Clinical signs depend on which nerves are injured but may include weakness of arm muscles or Horner's syndrome. Most injuries heal on their own with rest and physical therapy but some require surgery. With treatment, over two-thirds of infants recover full function, though permanent impairment can occur.

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    Brachial Plexus Asia in

    Uploaded by

    Fajrin Gumilar
    17 views19 pages
    Brachial plexus injuries in neonates can occur during birth when excessive lateral force causes the head to be pulled away from the shoulders, stretching or tearing the brachial plexus nerves. These injuries are more common with large babies, shoulder dystocia, and when the mother has diabetes. Clinical signs depend on which nerves are injured but may include weakness of arm muscles or Horner's syndrome. Most injuries heal on their own with rest and physical therapy but some require surgery. With treatment, over two-thirds of infants recover full function, though permanent impairment can occur.

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    Brachial Plexus Asia In

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    Brachial plexus injuries in neonates can occur during birth when excessive lateral force causes the head to be pulled away from the shoulders, stretching or tearing the brachial plexus nerves. These injuries are more common with large babies, shoulder dystocia, and when the mother has diabetes. Clinical signs depend on which nerves are injured but may include weakness of arm muscles or Horner's syndrome. Most injuries heal on their own with rest and physical therapy but some require surgery. With treatment, over two-thirds of infants recover full function, though permanent impairment can occur.

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    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    17 views19 pages

    Brachial Plexus Asia in

    Uploaded by

    Fajrin Gumilar
    Brachial plexus injuries in neonates can occur during birth when excessive lateral force causes the head to be pulled away from the shoulders, stretching or tearing the brachial plexus nerves. These injuries are more common with large babies, shoulder dystocia, and when the mother has diabetes. Clinical signs depend on which nerves are injured but may include weakness of arm muscles or Horner's syndrome. Most injuries heal on their own with rest and physical therapy but some require surgery. With treatment, over two-thirds of infants recover full function, though permanent impairment can occur.

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    BRACHIAL PLEXUS INJURY IN

    NEONATES

    LOURDES ASIAIN
    February 2005
    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.
    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
    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.
    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.
    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 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

    Ptosis
    Miosis and
    anhydrosis
    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
    PATHOGENESIS (uterine contractions).
    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
    Clinical Manifestations

    If phrenic nerve is involved, as mentioned earlier


    respiratory 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


    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
    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
    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
     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
    THANK YOU

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