Birth Injuries-Excluding Scalp and Intracranial Injuries

Dr.Abdulmahdi.A. Hasan
PhD. Child Psychiatry

Birth Injuries-Excluding Scalp and Intracranial Injuries


Skull fractures
Bones of the skull are less mineralized at birth and thus more compressible.
Follow repeated forceful contact of the fetal skull against the maternal pelvis
Linear fractures of the skull are accompanied by soft tissue changes and cephalhematoma
Depressed fractures are visible palpable indentations in the smooth contour of the skull( ping-pong) ball
Prognosis
Simple fractures heal without sequelae
Leptomeningeal cyst may develop, if detected early, cyst can be excised successfully and brain atrophy prevented
Repeat radiographs within 2-3 months to detect early widening of the fracture line
Facial nerve palsy
Prolonged 2nd stage and midforceps delivery
Central paralysis- limited to lower 1/2 or 2/3 of the contralateral side
Peripheral-entire side of the face
Persistently open eye on the affected side
Vocal cord paralysis
Uncommon injury, unilateral- symptom free or hoarseness with mild inspiratory stridor or bilateral-stridor, left more common than right
Unilateral- gentle handling and frequent small feedings, usually resolves within 6 wks
Bilateral is caused by hypoxia or hemorrhage into the brain stem
Bilateral-immediate intubation, tracheostomy required in most patients.

Fracture of the clavicle
Complete and some greenstick fractures may be apparent shortly after birth. Obvious callus at 7-10 days of age
Movement of the arm may be affected
Pain subsides in 7-10 days
Brachial palsy
Erb-Duchenne- C5+ C6 –upper arm paralysis,Moro, biceps and radial reflexes are absent, grasp reflex is intact, ipsilateral phrenic nerve injury with respiratory distress
Klumpke-lower arm paralysis-C8+T1-rare-intrinsic muscles of the hand and the long flexors of the wrist and fingers affected, grasp reflex is absent and tendon reflexes are present, ipsilateral Horner, delayed pigmentation of the iris- sensory deficit-ulnar
Paralysis of the entire arm- all reflexes absent,flaccid, sensory deficit up to shoulder
Eval and Therapy
Thorough physical-palpate sternomastoid, fractures of clavicle, humerus or ribs
Abdominal asymmetry- indicate paralysis of hemidiaphragm, ocular asymmetry- Horner syndrome
CT, MRI or myelography for avulsions
Electromyography is unreliable in predicting extent of damage
Exercises involving shoulder rotation,elbow flexion and extension, wrist flexion, thumb abduction,adduction and opposition
Treatment
Infant evaluated every month and if no improvement in deltoid, biceps and triceps function occurs by 3rd month, good outcome without surgery is not likely
Primary brachial plexus exploration during the fourth month
Exploration,evaluation and repair of the injury has resulted in 90% of patients having useful function above the elbow
Function below the elbow has resulted in 50% to 70% recovery
Phrenic nerve paralysis
Difficult breech delivery
Recurrent episodes of cyanosis, irregular and labored respirations
Breathing is almost completely thoracic, no bulging of the abdomen, excursions on the involved side are ineffectual
Areas of atelectasis appear bilaterally
US shows abnormal motion of the diaphragm
Fluoroscopy only for the equivocal case
Treatment
O2 for cyanosis or hypoxemia, IV fluids, gavage feedings, antibiotics are indicated if pneumonia occurs
If bilateral, assisted ventilation shortly after delivery
Infants who did not recover diaphragmatic function within 30 days did not demonstrate recovery-disruption of the phrenic nerve
Candidates for plication of the diaphragm early in the 2nd month of life
Injuries to spine and spinal cord
Result from breech deliveries, brow and face presentations
High cervical-Stillborn, respiratory depression, shock, hypothermia
Upper or mid-cervical region-flaccidity and immobility of the lower limbs, cardiac function is strong, urinary retention may be the first symptom, paralysis of the abdominal wall, intercostal muscles may be affected , sensation is absent over the lower half of the body, absent DTR, constipation, brachial plexus involved in 20%

Spinal cord injuries
3rd group-C7-T1- survive for long periods, transient paraplegia, skin is dry and scaly, muscle atrophy, contractures and bony deformities, bladder distention and constant dribbling followed by paraplegia in flexion, spontaneous micturition, mass reflex and profuse sweating over the involved part of the body
4th group- partial spinal cord injury and CVA. subtle neurologic signs of spasticity- cerebral palsy

Treatment
Infants affected at birth require basic resuscitative measures
In case of vertebral fracture-immediate neurosurgical consultation for reduction and relief of cord compression, followed by appropriate immobilization
Position of paralyzed parts should be changed every 2 hrs, indwelling urinary catheter should be inserted
Urology consult
Injuries to intra-abdominal organs
Rupture of the liver- large infants, IDM,breech
May appear normal from 1-3 days of life, any infant with shock, abdominal distension, pallor, anemia, and irritability with no evidence of blood loss
Crit and hgb stable initially, then sudden circulatory collapse, with rupture of the hematoma through the capsule
Abdomen is rigid, bluish discoloration of the overlying skin. CT scan may help in diagnosing subcapsular hematoma
Treatment
Prompt transfusion of prbcs and correction of coagulation disorder
Laparotomy with evacuation of the hematoma and repair of any lacerations
Any fragmented, devitalized liver tissue should be removed
Blood transfusion and the tamponade of intra-abdominal pressure might be adequate therapy in some infants
Rupture of the spleen
Large infants in breech position, erythroblastosis, congenital syphilis
Underlying clotting defect
Clinical signs of hemoperitoneum and blood loss
Left upper quadrant mass and medial displacement of the gastric bubble
Packed rbc’s and exploratory laparotomy
Attempt to repair and preserve the spleen
Adrenal hemorrhage
Increased size and vascularity at birth
Macrosomic, IDM, cong syphilis, neuroblastoma, hemorrhagic disease
Fever, tachypnea, cyanosis, mass in flank and purpura
Adrenal insufficiency, poor feeding, vomiting, uremia, convulsions and shock
US- initially solid appearance then cystic
Blood , IVF and corticosteroids
Laparotomy, evacuation of clots if extends to peritoneal cavity