BIRTH PALSY

08/08/09

PRESENTED BY: DR.MANISH BAVISKAR

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INTRODUCTION
• First described clinically in 1779 by Smellie who cited a case of bilateral arm paralysis following a face presentation, which resolved in a few days • Danyau carried out an autopsy on a neonate who died shortly after 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 be caused by disruption of C5 and C6 roots at the point where they emerge just between the scalene muscles, [which has therefore been named after him] • Klumpke in 1885 described the paralysis of the lower roots of the brachial plexus and highlighted the involvement of the sympathetic fibres in this paralysis.
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AETIOPATHOGENESIS
• Postulates ranging from poliomyelitis,congenital lesion,sequelae of subclinical systemic toxemia,posturla in-utero ischemia • Risk factors-shoulder dystocia,maternal diabetes,Large foetus,Cephalo-pelvic Disproportion,Difficult labour:breech, face to pubis,transverse presentations • Bentzon’s thesis-Erb - Duchenne paralysis always develops as a sequel to over-stretching of the plexus by simultaneous lateral flexion of the neck and contralateral depression of the opposite shoulder. • more common in multiparous than in primiparous women.
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CLASSIFICATION

• Classified into  Upper plexus palsy (Erb’s)-C5,C6,C7  Lower plexus palsy (Klumpke’s)-C8,T1  Total plexus palsy

INCIDENCE: •0.38-1.86/1000 live births •Risk factors-macrosomia,shoulder dystocia,assisted delivery,breech delivery,prolonged labour,excessive maternal weight gain,previous similar family history •Assoc. injuries-# clavicle,physeal # of humerus,#s about shoulder girdle,torticollis,facial nerve palsy,Horner’s syndrome,phrenic nerve palsy
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ETIOLOGY
• Traction forces to fetus in utero on nervestemporary conduction deficits,nerve root avulsions from spinal cord • Lateral torsion to neck,direct traction to isolated upper limb • Compression injuries to umbilical cords or amniotic bands • In-utero trauma in bicornuate/fibroid uterus • Ceaserian deliveries • Most common-macrosomic 08/08/09 baby,delivery complicated by shoulder

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PATHOPHYSIOLOGY

• Depending on i.severity of injury ii.anatomical location  Upper-most common (73%-86%) -muscles involved-external rotators,abductors of shoulder,elbow flexors,supinators,wrist extensors (WAITER’S TIP ie.IR,Ad.,Pron.,Palmar flexion)  Lower-least common (0.6%)muscles involved-wrist and finger flexors,intrinsic hand muscles (CLAW HAND)  Total-20% 08/08/09 -flail,insensate arm

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Associated other nerve injuries
• Phrenic nerve(C3-C5)-hemidiaphragmatic paralysis • Sympathetic communicating branch to stellate ganglion-Horner’s syndrome (ptosis,anhydrosis,myosis,enophthalmos Grave prognostic sign-Horner’s syndrome,flail extremity,multiparous mother,weight>4500gms Glenoid deformities-glenoid hypoplasia,humeral head flattening,acromial beaking,hooking of coracoid process,posterior subluxation/dislocation of shoulder joint

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Waters et al classification of glenohumeral deformity by radiographic type
• I-<50 difference in retroversion • II->50 difference in retroversion (no posterior subluxation • 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 humeral epiphysis
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Clinical presentation
• Perinatal history • Assoc. h/o Horner’s syndrome,ipsilateral phrenic 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 nerve root avulsions from spinal cord • MRI SCAN-Brachial plexus visualised directly;neuroma detected much more readily • EMG-NCV-limited role -specific root damage cannot be detected -used as baseline invx for post08/08/09 op. f/u

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MANAGEMENT
• Repeated Clinical Evaluation-Reaction on pinching, 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 ELECTRO PHYSIOLOGY (EMG) • Electromyography
• Nerve conduction (NC) including CMAP and SNAP • Spinal evoked potentials (SEP) • Somato sensory evoked potentials (SSEP)  Progressively improving EMG with clinical correlationconservative  Denervation persists unchanged and SNAP and SSEPpreganglionic injuryearly operative intervention
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SURGICAL MANAGEMENT
• Initial reports of improvement in function following surgical exploration of the plexus published in the early 1900s • Sever reported in 1925 and Jepson reported in 1930 disappointing results of surgeryconservative approach secondary reconstruction viz.muscle transfers,corrective osteotomies,or joint fusion • INDICATIONS Total palsy at birth with a positive Horner’s 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 cases where 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 Tinel’s 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 regeneration Evaluation of results should be done using the Mallet scale of IIV 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), muscular imbalance and shoulder deformity due to growth, mainly rotational or subluxatory. • secondary operations to restore a more functional muscle balance  Episcopo procedure-transferring the Teres major and Latissimus dorsi on the posterior side to the infraspinatus and then on to the Humerus anteriorly  Chuang procedure-transferring Teres major to the Infraspinatus and the clavicular head of the Pectoralis major to the area lateral to the long head of biceps anteriorly  Rotational osteotomy and capsulorraphy mainly for internal rotation deformity and gross subluxation.

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THANK YOU

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