Purpose and Goal: CNEP # 2031

  • Understand the effects of birth trauma in the neonate.
  • Learn about the effects of brachial plexus injury in the neonate.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for successful completion:

  • Successfully complete the post-test
  • Complete the evaluation form

Date

  • January 2016 – January 2018

Learning Objectives

  • Describe the risk factors for birth trauma in the neonate.
  • Describe the signs of brachial plexus injury in the neonate.
  • Identify 2 approaches for the treatment of brachial plexus injuries.

Introduction

  • Injury during birth is an adverse effect
  • It should be suspected following difficult delivery
  • Birth injuries increase morbidity and mortality
  • Brachial plexus injuries occur in up to 5% of deliveries

Risk Factors for Injury

  • Birth trauma is any injury sustained during birth
  • Some birth trauma is avoidable
  • Some birth trauma is not avoidable
    • Injuries occur despite skilled providers
    • Injury typically occurs from manipulation
    • Manipulation occurs due to difficult delivery
  • Risk factors for injury may be related to:
    • The fetus
    • The mother
    • The type of delivery
  • Fetal risk factors
    • Macrosomia
    • Shoulder dystocia
    • Post-term gestation
    • Perinatal depression
    • Abnormal presentation
    • Prolonged second stage
  • Maternal risk factors
    • Obesity
    • Diabetes
    • Small stature
    • Large weight gain
    • Pelvic abnormalities
  • Delivery risk factors
    • Instrumented delivery
    • Operative vaginal delivery

Peripheral Nerve Injuries

  • Peripheral nerve injuries are common
  • The peripheral nerves involved include:
    • Facial nerves
    • Phrenic nerves
    • Brachial plexus nerves
  • Nerve injuries result from:
    • Overstretching
    • Compression

Brachial Plexus Injury

  • Brachial plexus injury was identified in 1760
  • The brachial plexus is a network of nerves
    • Nerve fusions and divisions
    • Originate in cervical and thoracic regions
    • Terminate in nerves that innervate
      • Skin of the arm and shoulder
      • Muscles of the arm and shoulder
  • Brachial plexus injury results from trauma
    • First thoracic nerve (T1)
    • Lower cervical nerves (C5 - C8)
  • Injury occurs from lateral traction on the neck
    • Stretching
    • Compression
  • Damage to nerve roots may cause:
    • Hemorrhage
    • Simple edema
    • Complete tearing
  • There are distinct patterns to injuries
    • Erb’s Palsy
      • aka Duchenne palsy
      • aka Erb-Duchenne palsy
    • Klumpe’s Palsy
  • Erb’s palsy is injury to C5 and C6
    • Seen in 50% of nerve injuries
    • Results in upper trunk injury
      • Results arm paralysis
      • Results in shoulder paralysis
    • No wrist or hand involvement
  • Klumpe’s palsy is injury to C6 to T1
    • Results in lower trunk injury
      • Results in wrist paralysis
      • Results in hand paralysis
    • No arm or shoulder involvement
  • Injury to the entire brachial plexus
    • Is least common type of injury
    • Results in upper extremity paralysis
    • Often associated with sensory loss
    • May be associated with phrenic nerve palsy

Presentation of Brachial Plexus Injuries

  • Arm presentation depends on nerves involved
    • C5 and C6 injury
      • Prone
      • Adducted
      • Internally rotated
      • Extended forearm
      • Deltoid muscle affected
      • Biceps muscle affected
      • Normal wrist movement
      • Normal hand movement
    • C5 to C7 injury
      • Adducted
      • Internally rotated
      • Extended forearm
      • Pronated forearm
      • Flexed wrists and fingers
        • “Waiter’s tip” position
    • C5 to T1 injury
      • Arm paralysis
      • Flexed fingers
    • Severe damage to C5 to T1
      • Flaccid arm
    • C8 and T1 injury
      • Isolated hand paralysis

Diagnosis and Treatment of Injuries

  • Diagnosis is made by arm weakness at birth
  • Electrodiagnostic studies
    • Electromyography
    • Nerve conduction studies
    • Neuroimaging studies (MRI)
    • Ultrasound may also be useful
  • Most injuries resolve over 3 - 4 months
    • 80% – 90% recover within 3 months
    • 10% – 20% do not ever fully recover
  • Nerve regeneration occurs 1 inch/month
  • The treatment of injuries is controversial
    • No clear guidelines for treatment
  • Conservative treatment
    • Observation
    • Range of motion
    • Physical therapy
  • Surgical repair or reconstruction
    • For nerve avulsion
    • For delayed recovery
    • Prognosis depends on damage
  • Timing of surgical intervention
    • May be required in first year of life
    • Rarely considered before 3 months
    • Post surgery recovery
      • Improvement in 2 weeks
        • Full recovery
      • Improvement in 4-6 weeks
        • Partial recovery
      • No improvement in 3 months
        • No recovery
  • Botulinum toxin injections
    • Botox has been used
    • Limited data is available
    • Further study is needed
  • Referral to a Neurologist should be considered

Summary

  • Traumatic nerve injury may be seen in neonates
  • Brachial plexus damage is the most common injury
  • Infants present with a paralyzed arm
    • Paralysis depends on the amount of damage
  • The early recognition of nerve damage is important
    • To decrease parental fear and anxiety
    • To improve nerve recovery and outcomes

References

  1. Parker, L.A. 2006. Part 2: Birth Trauma: Injuries to the Intraabdominal Organs, Peripheral Nerves, and Skeletal System. Advances in Neonatal Care, 6 (1), p. 7-14.
  2. Benjamin, K. 2005. Part 1: Injuries to the Brachial Plexus: Mechanisms of Injury and Identification of Risk Factors. Advances in Neonatal Care, 5 (4), p. 181-189.
  3. Benjamin, K. 2005. Part 2: Distinguishing Physical Characteristics and Management of Brachial Plexus Injuries. Advances in Neonatal Care, 5 (5), p. 240-251.
  4. McKee-Garrett, T.M. 2015. Neonatal Birth Injuries. Up-To-Date.
  5. Russman, B. 2015. Neonatal Brachial Plexus Palsy. Up-To-Date.

Evaluation

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