Transcript CASE CONFERENCE

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:
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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
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Lungs: clear, equal breath sounds
Heart: RRR, no murmurs
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Abdomen: soft, NT, ND, BS+
Extremities: FROM R UE and both LE
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Reflexes: asymmetric moro reflex, sucking +, grasp +
 L UE: (+)abduction, (+)flexion but not against gravity.
Position: adducted, internally rotated, elbow extended, forearm
pronated, wrist and fingers flexed.
Neonatal Brachial Plexus Palsies
Smellie 1779
Duchenne and Erb 1870’s
Klumpke 1885
Brachial Plexus Anatomy
Risk Factors
 Large birth weight
 Average vertex: 3.8-5 Kg
 Average breech: 1.8-3.7 Kg
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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:
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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)
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
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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.