birth palsy

8/14/2019 Birth Palsy

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BIRTH PALSY

PRESENTED BY:

DR.MANISH BAVISKAR


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INTRODUCTION

First described clinically in 1779 by Smellie who cited a case ofbilateral arm paralysis following a face presentation, whichresolved in a few days

Danyau carried out an autopsy on a neonate who died shortlyafter traumatic forceps delivery

Duchenne in 1872 attributed the injury to traction on the arm

and introduced the term obstetric paralysis Erb in 1874 discovered that the characteristic paralysis of the

deltoid, biceps, coracobrachialis and brachioradialis could becaused by disruption of C5 and C6 roots at the point where theyemerge just between the scalene muscles, [which has therefore

been named after him] Klumpke in 1885 described the paralysis of the lower roots ofthe brachial plexus and highlighted the involvement of thesympathetic fibres in this paralysis.


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AETIOPATHOGENESIS

Postulates ranging frompoliomyelitis,congenital lesion,sequelae ofsubclinical systemic toxemia,posturla in-uteroischemia

Risk factors-shoulder dystocia,maternal

diabetes,Large foetus,Cephalo-pelvicDisproportion,Difficult labour:breech, face topubis,transverse presentations

Bentzons thesis-Erb - Duchenne paralysis alwaysdevelops as a sequel to over-stretching of the plexusby simultaneous lateral flexion of the neck andcontralateral depression of the opposite shoulder.

more common in multiparous than in primiparouswomen.


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CLASSIFICATION Classified into

Upper plexus palsy (Erbs)-C5,C6,C7

Lower plexus palsy (Klumpkes)-C8,T1

Total plexus palsy

INCIDENCE:0.38-1.86/1000 live birthsRisk factors-macrosomia,shoulder dystocia,assisted

delivery,breech delivery,prolonged labour,excessive maternal

weight gain,previous similar family historyAssoc. injuries-# clavicle,physeal # of humerus,#s about

shoulder girdle,torticollis,facial nerve palsy,Horners

syndrome,phrenic nerve palsy


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Traction forces to fetus in utero onnervestemporary conductiondeficits,nerve root avulsions from spinalcord

Lateral torsion to neck,direct traction toisolated upper limb

Compression injuries to umbilical cordsor amniotic bands

In-utero trauma in bicornuate/fibroiduterus

Ceaserian deliveries

Most common-macrosomic

baby,delivery complicated by shoulder

ETIOLOGY


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PATHOPHYSIOLOGY Depending on i.severity of injury

ii.anatomical locationUpper-most common (73%-86%)

-muscles involved-externalrotators,abductors of shoulder,elbowflexors,supinators,wrist extensors(WAITERS TIP ie.IR,Ad.,Pron.,Palmarflexion)

Lower-least common (0.6%)musclesinvolved-wrist and fingerflexors,intrinsic hand muscles (CLAWHAND)

Total-20%

-flail,insensate arm


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Associated other nerve injuries Phrenic nerve(C3-C5)-hemidiaphragmatic

paralysis Sympathetic communicating branch to stellate

ganglion-Horners syndrome(ptosis,anhydrosis,myosis,enophthalmos

Grave prognostic sign-Horners syndrome,flail

extremity,multiparous mother,weight>4500gms

Glenoid deformities-glenoid hypoplasia,humeral head

flattening,acromial beaking,hooking of coracoidprocess,posterior subluxation/dislocation of shoulder joint


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Waters et al classification of glenohumeraldeformity by radiographic type

I-50 difference in retroversion (no posteriorsubluxation

III-posterior subluxation of humeral head IV-severe deformity

V-flattening & dislocation of humeral head &glenoid

VI-dislocation of humerus head in infancy

VII-growth arrest of proximal humeralepiphysis


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Clinical presentation Perinatal history

Assoc. h/o Horners syndrome,ipsilateralphrenic n. palsy,facial n. palsy

R/o cervical spine patho.,cerebral

palsy,septic shoulder Range of motion-all affected joints

(active/passive)

Sensory examination

torticollis-

Loss of sympathetic tone


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INVESTIGATIONS X-RAYS-cervical

spine,shoulder,clavicle,elbow,hand CT SCAN-presence of

pseudomeningocoele assoc. with nerveroot avulsions from spinal cord

MRI SCAN-Brachial plexus visualiseddirectly;neuroma detected much morereadily

EMG-NCV-limited role

-specific root damage cannotbe detected

-used as baseline invx for post-

op. f/u


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MANAGEMENT

Repeated Clinical Evaluation-Reaction onpinching, nail and hair growth, trophic

changes give an approximate indication about

sensations in the infant

Clinical examination is repeated at 3 weeks

splints used for maintaining external rotation

and abduction at shoulder are not particularly

helpful


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ROLE OF ELECTROPHYSIOLOGY

Electromyography (EMG) Nerve conduction (NC) including CMAP and

SNAP

Spinal evoked potentials (SEP)

Somato sensory evoked potentials (SSEP)

Progressively improving EMG with clinicalcorrelationconservative

Denervation persists unchanged and SNAPand SSEPpreganglionic injuryearlyoperative intervention


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SURGICAL MANAGEMENT Initial reports of improvement in function following

surgical exploration of the plexus published in theearly 1900s

Sever reported in 1925 and Jepson reported in 1930disappointing results of surgeryconservativeapproachsecondary reconstruction viz.muscle

transfers,corrective osteotomies,or joint fusion INDICATIONS-

Total palsy at birth with a positive Horners syndrome

Upper root palsies with no sign of recovery at the

third month Upper root palsies with no sign of recovery of deltoid

or biceps at third month especially in those caseswhere some recovery is present but not complete.


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SURGICAL TECHNIQUES

Exploration of brachial plexus-clear ruptures,avulsions of the entire plexus, avulsions of isolated

roots,neuroma

Microsurgical repair-neurolysis, resection and

anastomosis;nerve grafting using sural nerves as

interposition grafts Common donor nerves-Spinal accessory (XIth)

nerve,Intercostal nerves (commonly 3rd to 6th),C4

motor root,Ansa hypoglossi, Opposite C7

Common recipient nerves-Suprascapular,Musculocutaneous,Axillary,Median nerves


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Actions to be restored in order of priority:-Elbow flexion-Shoulder stability (rotator cuff via suprascapular nerve)-Shoulder abduction-Hand prehension

Results--Periodically evaluated post-op at three monthly intervals,

-signs of nerve regeneration like Tinels sign-disappearance of trophic changes

-maintenance of muscle mass

-ultimate contraction and return of movement

-improvement in periodic EMG-NCV giving documentary proof

of nerve regenerationEvaluation of results should be done using the Mallet scale of I-IV grades or MRC grades for muscle power


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LATE OBSTETRIC PALSY Features unique to Cross-innervation (caused by

misdirection of regenerated axons), muscularimbalance and shoulder deformity due to growth,mainly rotational or subluxatory.

secondary operations to restore a more functionalmuscle balance

Episcopo procedure-transferring the Teres major andLatissimus dorsi on the posterior side to theinfraspinatus and then on to the Humerus anteriorly

Chuang procedure-transferring Teres major to the

Infraspinatus and the clavicular head of the Pectoralismajor to the area lateral to the long head of bicepsanteriorly

Rotational osteotomy and capsulorraphy mainly forinternal rotation deformity and gross subluxation.


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THANK YOU

birth palsy

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