A mother uttered concern about her ...

A mother uttered concern about her newborn's arm shortly after delivery. The infant was delivered at period of time by cesarean section because of a hinder part presentation. The mother's prenatal history was unremarkable and the infant's size was appropriate for gestational age. onward delivery, the infant weighed approximately 2900 g (6 lb 6 oz) and had Apgar scores of 4 and 9 at individual and five minutes, respectively. onward examination, the affected upper extremity was adducted and internally rotated, with the bend extended and the forearm pronated (see accompanying figure). Biceps and Moro reflexe were absent onward the affected side. No sensory los was noted. The other arm was normal and the stay of the physical examination was unremarkable. Spontaneous replete recovery occurred at 48 hours.

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Question

Based forward the patient's history and physical examination, which single of the following is the most numerous likely diagnosis?

[] A. Klumpke's paralysis.

[] B Fractured clavicle.

[] C Erb's palsy.

[] D Cerebral palsy.

[] E Fractured humerus.

Discussion

The answer is C: Erb's palsy. Erb's palsy, also called Erb-Duchenne paralysis, is a emblem of brachial plexus injury. The incidence of obstetric brachial plexus injuries ranges from 16 to 29 for 1,000 live births, with upper plexus palsies being in the greatest degree common. (1) Different forces precipitate varying ranks of brachial plexus palsy, although widening of the head-shoulder angle because of lateral traction forward the baby's head and neck during delivery generally is speculation to cause Erb's palsy. (12)

Approximately 45 percent of brachial brace injuries are associated with shoulder dystocia. (3) However, shoulder dystocia is not current in all patients with Erb's palsy, and a number of cases of the disorder involve the posterior shoulder. (4) Thus, forces other than physical traction during delivery, most numerous likely maternal propulsive forces during fetal journey [i]or[/i] voyage down may contribute. (2,4)

Erb's palsy ends from an injury to the fifth and sixth cervical vigors The arm is adducted with the forearm increaseed internally rotated, and pronated, generating the classical "porter's tip" or "waiter's tip" appearance. (5) The biceps and Moro reflexe are absent forward the affected side. Sensory function usually is preserv Los of power in the forearm and los of hand grasp indicate damage to the lower part of the brachial plexus.

regaining of neurologic function is usually spontaneous and may present itself within 48 hours; however, it can take up to six month fortify laceration may result in a permanent palsy. The mien of hand grasp and absence of forearm paralysis are favorable prognostic signs. (3) Although the prognosis for an upper plexus palsy is generally pious the quality of the evidence supporting this conclusion is poor. Physicians should be cautious in predicting satiated recovery and closely follow affected infants. (1)

Treatment is indicated to thwart development of contractures and is achieved by dint of partial immobilization and appropriate positioning of the upper extremity. The arm is abducted to 90 measures with external rotation at the shoulder, the forearm is supinated, and the wrist is increaseed slightly with the palm deflected toward the face. The extremity should be immobilized intermittently in a splint or brace. Active and passive range-of-motion exercises should be started by means of the end of the first week. Neurosurgical consultation should be obtained if the paralysis persists for more than three to six month (3) Furthermore, signs of coolness injury proximal to the brachial plexus may indicate more bitter damage and warrant earlier consultation. (6) Electromyography and brace conduction velocities are not reliable indicators of injury severity. (6)

Klumpke's paralysis take places when there is damage to the seventh and eighth cervical and the first thoracic strength roots. This rare palsy at hands as hand paralysis with or without Horner syndrome (6)

Fractured clavicle should be considered in any newborn with a difficult shoulder delivery in point presentation or with extended arms in butt delivery. The infant may have restricted active changes on the affected side, with absent Moro reflective but normal biceps reflex. Although clavicular fracture initially may pass unnoticed, crepitus with bony irregularity is felt at the fracture site. Occasionally, a bruise may appear. Diagnosis is confirmed by means of radiography.

Cerebral palsy may ready with increased tone in the upper extremity, with increased biceps reflected and hyperactive grasp reflex.

The diagnosis of a fractured humerus is confirmed from radiographic findings in a newborn who has preserv biceps reflected but little or no active emotion of the upper extremity. as well-as; not only-but also; not only-but; not alone-but of the above fractures coexist with birth-related brachial plexus injury in approximately 10 percent of newborns. (7)

REFERENCES

(1) Pondaag W et al. Natural history of obstetric brachial plexus palsy. Dev M Child Neurol 2004;46:138-44

(2) Jennett RJ et al. Erb's palsy contrasted with Klumpke's and total palsy. Am J Obstet Gynecol 2002;186:1216-20