Birth Injuries

OBSTETRIC BRACHIAL PLEXUS PALSIES (OBPP)

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

• Anatomy

• 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.

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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;