Minggu, 07 Oktober 2007

Birth Injuries

OBSTETRIC BRACHIAL PLEXUS PALSIES (OBPP)

from: McGuinness & Kay. Current Orthopaedics. 13:20-26. 1999.

  • Incidence is approx 2/1,000 births

  • Risk Factors:

    • Child

      • weight > 4000g / large for gestational age

    • Maternal

      • multiparity

      • diabetes

      • sibling with shoulder dystocia or OBPP

    • At Birth

      • shoulder dystocia

      • breech

      • long labour

      • forceps delivery.

  • Investigations:

    • EMG - doesn't correlate with prognosis & can be misleading.

    • MRI - fast spin echo MRI may demonstrate root avulsions.

  • Classification Table:

TYPE (Adler & Patterson)

TYPE (Narakas)

ROOTS

DEFICIT

PROGNOSIS

Erb-Duchenne

Group 1

C5,6

Deltoid, cuff, elbow flexors, wrist & hand dorsiflexors - 'waiters tip'

Best


Group 2

C5-7

Above except with sightly flexed elbow

Poor

Klumpke


C8-T1

Wrist flexors, intrinsics, Horners

Poor

Total Plexus

Group 3

C5-T1

Sensory & motor, flaccid arm

Worse

(Total Plexus + Horners)

Group 4

C5-T1

Sensory & motor, flaccid arm, Horner

Worst

  • Natural History:

    • C8-T1 injury with a Horners syndrome has the worst prognosis.

    • Isolated lower root lesions have a poor prognosis, since they are usually avulsion injuries.

    • The rate of recovery and the time of beginning of recovery affect the outcome.

    • Toronto scoring system (Clarke) assesses the child at 3 months of age

    • No biceps function at 3m indicates a poor prognosis.

    • Patients who show evidence of biceps function before 6 months of age have near-normal to excellent function.

    • In borderline cases exploration of the Brachial Plexus is performed.

    • Early repair has the best prognosis.

    • Recovery continues until 1 year old, then little further recovery thereafter.

  • Management:

    • Early Referral to a specialist unit.

    • Physiotherapy - passive range of motion exercises.

    • Splinting - not popular.

    • Surgery

  • Indications for Surgery:

    • C8-T1 injury with a Horners syndrome

    • C5/6 lesions with no muscle activity & breech baby.

    • Toronto score <>

    • Failure to progress adequately between 12-24 weeks

    • EMG criteria of Smith where doubt exists.

  • Surgical Technique:

    • Transverse incision

    • Neurolysis

    • Nerve grafting (Sural nerve)

    • Nerve transfers (accesory to suprascapular, intercostal to musculocutaneous)

  • Late Deformities:

    • Internal rotation & adduction contraction of the shoulder

      • modified L'Episcopo procedure - involves lengthening of pectoralis major & subscapularis tendons with transfer of teres major & insertions into posterior surface of the humerus to act as external rotators

      • osteotomy - for older children with fixed bony adaptive changes, proximal humeral external rotation osteotomy can be considered; - these patients will most often complain of internal rotation contracture

    • Posterior glenohumeral subluxation: - limitation of external rotation; - in late cases, with a deficient posterior glenoid consider humeral derotational osteotomy.


TORTICOLLIS

  • from fibrosis of sternal head of sternocleidomastoid

  • can result from unilateral shortening of sternocleidomastoid, commonly associated with fibrosis of the muscle; (may also involve the platysma and scalene muscles)

  • Aetiology & Natural History

    • birth trauma, occlusion of venous flow, or haematoma results in fibrosis of muscle & palpable mass noted within first 4 weeks of life

    • mass usually resolves within the first year of life (90% resolve)

    • non-tender enlargement may be palpated in body of sternocleidomastoid

  • Grisel's Syndrome:

    • Atlantoaxial Rotary Subluxation in association with pharyngeal infection, occurs predominantly in children

    • it results in severe torticollis, resistant to manual therapy

    • > 5 mm of anterior displacement of arch of C-1 (Fielding type III) indicates disruption of both facet capsules as well as transverse ligament

    • reduction w/ skeletal traction, followed by atlantoaxial fusion, is recommended


  • Rigid Torticollis:

    • may also present as rigid deformity, & sternocleidomastoid is not contracted or in spasm

    • torticollis most often follows an injury to the C1-C2 articulation; - frx of the odontoid in young child may not be apparent on initial x-rays

  • Associated Anomalies:

    • congenital atlanto-occipital abnormalities

    • bony anomalies of the Cervical Spine, esp involving C1 & C2

    • congenital webs of skin along the side of the neck, pteygium colli

    • DDH: (20%

    • plagiocephaly: - w/ persistent contracture of sternocleidomastoid, deformities of face and skull result and are apparent within first year of life; - flattening of face is noted on side of contracted sternocleidomastoid and is probably caused by child's sleeping position

    • metatarsus adductus

    • opthalmic disorders causing the child to tilt the head.

  • Non Operative Treatment:

    • 90% will respond to passive stretching within the first year of life

    • in first yr of life, rx consists of stretching sternocleidomastoid muscle by trying to rotate the head to opposite position. - stretching exercises should include not only lateral rotation, but also side bending to the opposite shoulder

  • Indications for Surgery:

    • failure of non operative treatment after 12 to 24 months of age, surgical intervention is needed to prevent further facial deformity

  • Operative Treatment:

    • involves resection of portion of distal sternocleidomastoid muscle from its sternal and clavicular attachments through transverse incision in the normal skin fold of the neck

    • skin incisions immediately adjacent to clavicle may result in unsightly hypertrophic scars. - transverse skin incisions in skin folds 1.5 cm proximal to clavicle result in imperceptible scars

    • uncommonly, distal resection is insufficient and proximal release of sternocleidomastoid is needed;

1 komentar:

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