Presentation on theme: "CASE CONFERENCE Suying Lam, MD PGY1. Presentation: FT male with L upper extremity weakness Born via NSVD Nuchal cord x 1 not tight Apgar: 9 at 1 minute;"— Presentation transcript:
CASE CONFERENCE Suying Lam, MD PGY1
Presentation: FT male with L upper extremity weakness Born via NSVD Nuchal cord x 1 not tight Apgar: 9 at 1 minute; 9 at 5 minutes
Physical Exam VS: T: F HR: x’ RR: x’ BP: UE: LE: Weight: 4kg Length: 53 cm Head circumference: 36 cm Chest circumference: 35 cm Abdominal circumference: 33.5
Physical Exam General: alert, NAD, macrosomic Skin: pink HEENT: AFOF, + molding, + swelling Patent nares, no cleft, no pits Thorax: symmetric expansion Lungs: clear, equal breath sounds Heart: RRR, no murmurs Abdomen: soft, NT, ND, BS+ Extremities: FROM R UE and both LE L UE: (+)abduction, (+)flexion but not against gravity. Position: adducted, internally rotated, elbow extended, forearm pronated, wrist and fingers flexed. Reflexes: asymmetric moro reflex, sucking +, grasp +
Risk Factors Large birth weight Average vertex: Kg Average breech: Kg Breech presentation Maternal diabetes Multiparity Second stage of labor that lasts more than 60 minutes Assisted delivery (mid/low forceps, vacuum extraction) Forceful downward traction on the head during delivery Previous child with OBPP Intrauterine torticollis Shoulder dystocia
Causes Obstetric trauma: Clavicular fracture Humeral fracture Shoulder dislocation or subluxation Intrauterine compressive brachial plexus palsy Humeral osteomyelitis Neonatal Hemangiomatosis Exostosis of the first rib Neoplasm's (neuromas, rhabdoid tumors)
Diagnosis Laboratory: generally not necessary Imaging studies: Chest X-ray CT myelography High-resolution MRI Other tests: Electrodiagnostic studies (2-3 weeks after injury) Nerve conduction Studies
Complete Brachial Plexus Palsy
Duchenne-Erb Palsy C5-C6 Position: internally rotated, adducted, elbow extended, forearm is pronated, wrist is flexed and adducted, and fingers are flexed.
Upper middle trunk brachial plexus palsy C5-C6-C7 Difference with Erb’s palsy: wrist is in neutral position (wrist flexor and extensors are equally weak)
Klumpke Palsy C8-T1 Floppy hand: wrist is flexed, fingers extended following the forces of gravity Horner’s syndrome
Fascicular brachial plexus palsy One muscle or a group of muscles in the arm Due to injury of a small group of motor fibers
Management Rest period of 7 days pin the sleeve of neonate’s shirt to hold the elbow in a flexed position Physical Therapy Goals: minimizing bony deformities and joint contractures, while optimizing functional outcomes Passive and Active ROM exercise Bimanual activities Strengthening Promotion of sensory awareness Weight-bearing activities: propioceptive input + skeletal growth Static and dynamic splints Instructing parents and family: home exercise program
Other treatments: Neuromuscular electrical stimulation Botulinum toxin A therapy Surgical Intervention
Prognosis Degree of future improvement cannot be determined during a single evaluation, especially if performed immediately after birth. Improvement during the first few weeks is a relatively good indicator of final outcome. Incidence of permanent sequelae: 3-25% Findings consistent with severe initial injury (Horner’s syndrome) portend a less favorable prognosis Peripheral nerves re-myelinate at a rate of 1mm/day. If nerve is not transected, recovery can be expected by: 4-5 months in Erb’s palsy 6-7 months in upper-middle trunk palsy 14 months for a total BPP.