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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;

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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:

1 CASE CONFERENCE Suying Lam, MD PGY1

2 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

3 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

4 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 +

5 Neonatal Brachial Plexus Palsies  Smellie 1779  Duchenne and Erb 1870’s  Klumpke 1885

6 Brachial Plexus Anatomy

7 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

8 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)

9 Differential Diagnosis  Pyramidal Tract Lesions  Pre-brachial plexus lesions  Cervical Spinal Cord Injury  Amyoplasia Congenita (arthrogryposis)  Pseudoparalysis secondary to pain (humeral fracture)  Anterior horn cell injury (congenital varicella or congenital cervical spinal atrophy

10 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

11 Complete Brachial Plexus Palsy

12 Duchenne-Erb Palsy  C5-C6  Position: internally rotated, adducted, elbow extended, forearm is pronated, wrist is flexed and adducted, and fingers are flexed.

13 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)

14 Klumpke Palsy  C8-T1  Floppy hand: wrist is flexed, fingers extended following the forces of gravity  Horner’s syndrome

15 Fascicular brachial plexus palsy  One muscle or a group of muscles in the arm  Due to injury of a small group of motor fibers

16 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

17  Other treatments: Neuromuscular electrical stimulation Botulinum toxin A therapy  Surgical Intervention

18 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.


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