|Year : 2016 | Volume
| Issue : 1 | Page : 16-18
Bilateral brachial plexus palsy with unilateral phrenic nerve paresis: An uncommon birth injury
Shyam Sundar Mina1, Deepika Mina2
1 Department of Pediatric Medicine, Safdarjung Hospital, Vardhman Mahavir Medical College, New Delhi, India
2 Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India
|Date of Web Publication||8-Dec-2016|
Dr. Shyam Sundar Mina
Department of Pediatric Medicine, Safdarjung Hospital, Vardhman Mahavir Medical College, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Events during delivery of an infant can result in substantial harm to the infant or mother. Common birth injuries consist of traumatic brain injury, seizures, and mental retardation. Brachial plexus palsy, although rare, may result in substantial and chronic impairment. Phrenic nerve palsy is a peripheral nerve disorder caused by excessive cervical extension due to birth trauma. In this report, we describe the case of a newborn with bilateral brachial plexus palsy along with unilateral phrenic nerve paresis.
Keywords: Birth injuries, brachial plexus palsy, phrenic nerve paresis
|How to cite this article:|
Mina SS, Mina D. Bilateral brachial plexus palsy with unilateral phrenic nerve paresis: An uncommon birth injury. Afr J Trauma 2016;5:16-8
| Introduction|| |
Neonatal nerve injuries including brachial plexus injury and phrenic nerve injury may result from a stretch injury due to lateral hyperextension of the neck at birth. Risk factors include breech and difficult forceps deliveries. Phrenic nerve injury (3rd, 4th, 5th cervical nerves) with diaphragmatic paralysis must be considered when cyanosis and irregular and labored respirations develop. This uncommon cause of respiratory distress of newborn may be missed easily among multiple common etiologies of respiratory distress of newborn if this entity is not kept in mind and thorough examination is not done.
| Case Report|| |
A single term 2.1 kg (small-for-gestational-age; PI - 2.032) male baby with breech presentation was delivered via vaginal through a difficult extraction. The baby did not cry immediately at birth, gave no spontaneous respiratory efforts, and was resuscitated with bag and mask ventilation for 30 s, followed by ambu bag and endotrachial tube ventilation for 5 min. The patient was extubated after establishment of spontaneous respiratory. Apgar score was 2, 5 and 7 at 0, 1, and 5 min, respectively. Cord pH was 7.1. There were no risk factors for sepsis and maternal morbidity or obvious congenital anomalies. Baby was lethargic with poor general condition. Systemic examination revealed respiratory distress score of 4/10. There was normal cardiovascular finding and the abdomen was soft and scaphoid in appearance. On central nervous system examination, baby was lethargic and floppy with decreased spontaneous movements, normotensive anterior fontanelles, pupils dilated with sluggish reaction, generalized hypotonia (scarf sign - crosses midline), reflexes not elicited. Initial diagnosis was birth asphyxia with hypoxic ischemic encephalopathy. On the 3rd day of life, the baby was in shock with acute kidney injury that was successfully managed. The pupils become normal in size and shape, and it was reactive to light; there were no cranial nerve deficits. Tone movements and tendon reflexes were reduced in the upper limb but normal in the lower limbs. The baby was maintaining saturation (SpO2 - 95%) on supplemental oxygen from an initial saturation of 86% without oxygen and started on orogastric feeds. Upper limbs abnormality was noted on the day 7. Upper limbs were extended bilaterally, adducted, and internally rotated [Figure 1]. Orthopedic surgeon referral was taken and neck stabilization was advised because of suspicion of cervical cord injury. Physiotherapist advised 60° abduction of both upper limbs in view of suspected bilateral brachial plexus injury. Feeding of the infant was gradually improved from orogastric to spoon feeds. On the 9th day, diaphragmatic movements on the right side were observed to be decreased as compared to the left. X-ray of the chest revealed higher position of the right hemidiaphragm [Figure 2] and ultrasound of the chest also showed decreased diaphragmatic movements on right, suggestive of phrenic nerve paresis. On the 16th day, baby aspirated feed, had an apneic episode, and required bag and mask ventilation for 1 min. Sepsis screen was negative; X-ray of the chest showed pneumonic patch over right upper lobe and right hemidiaphragm elevated. Baby was managed conservatively. Magnetic resonance imaging (MRI) of the brain/cranium revealed a small extradural bleed in the temporal region. Final diagnosis was birth asphyxia with hypoxic ischemic encephalopathy with birth injury - extradural hematoma, bilateral brachial plexus palsy with unilateral phrenic nerve paresis. A test of nerve conduction velocity (NCV) was not possible at this age. On the 30th day of life, he was accepting breastfeeds well, consistently gained weight, and demonstrated good respiratory efforts. However, in view of persistence of the bilateral upper limb deformity, physiotherapy was continued at 60° abduction. Baby was discharged for regular follow-up. Repeat MRI was planned after 4-6 weeks (sprouting of nerve endings in brachial plexus). NCV was planned at 3 months if palsy persists, and brainstem evoked response audiometry was also planned.
|Figure 2: Chest X-ray showing elevated right side of the diaphragm with dextrocardia|
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| Discussion|| |
Historical reports of perinatal brachial plexus palsy describe incidences ranging from 0.42 to 1.5 per 1000 live births.,, Significant disability may persist in the affected limb in about 10-20% of individuals after 2 years. Generally, there is a less favorable prognosis for those with bilateral brachial plexus palsy than for those afflicted in just one limb.
Phrenic nerve injury (3rd , 4th , 5th cervical nerves) with diaphragmatic paralysis must be considered when cyanosis and irregular and labored respirations develop. Such injuries are usually unilateral and are associated with ipsilateral upper brachial plexus palsy. The diagnosis is established by X-ray of the chest showing elevation of the right hemidiaphragm [Figure 2] and abdomen ultrasound revealing sluggish movements of the right dome of the diaphragm with respiration. The movement of the left dome of the diaphragm is usually normal.
In brachial plexus injury, partial immobilization and appropriate positioning of limb are main components of treatment. If the paralysis persists without improvement for 3-6 months, then neuroplasty, neurolysis, end-to-end anastomosis, or nerve grafting offers hope for partial recovery. The three most common treatments from Erb's palsy are nerve transfers (usually from the opposite leg), subscapularis releases, and latissimus dorsi tendon transfers.
In phrenic nerve injury, no specific treatment is required and infants should be placed on the involved side and given oxygen if necessary. Recovery usually occurs spontaneously by 1-3 months; rarely, surgical plication of the diaphragm may be indicated. In our case, baby improve over 2 months.
Most of the birth injuries are preventable by skilled and competent obstetric care. Early diagnosis and intervention are associated with better outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]