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LETTER TO THE EDITOR
Year : 2016  |  Volume : 9  |  Issue : 2  |  Page : 274-276  

Duchenne-Erb's palsy in newborn: Result of birth trauma


1 Department of Pediatrics, Pt. B. D. Sharma, PGIMS, Rohtak, Haryana, India
2 Department of Pediatrics, GMC, Jammu, Jammu and Kashmir, India
3 Department of Pathology, NKP Salve Medical College, Nagpur, Maharasthra, India
4 RNT Medical College, Udaipur, Rajasthan, India

Date of Web Publication1-Mar-2016

Correspondence Address:
Deepak Sharma
Department of Pediatrics, Pt. B. D. Sharma, PGIMS, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.167961

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How to cite this article:
Sharma D, Pandita A, Shastri S, Sharma PK. Duchenne-Erb's palsy in newborn: Result of birth trauma. Med J DY Patil Univ 2016;9:274-6

How to cite this URL:
Sharma D, Pandita A, Shastri S, Sharma PK. Duchenne-Erb's palsy in newborn: Result of birth trauma. Med J DY Patil Univ [serial online] 2016 [cited 2019 Dec 14];9:274-6. Available from: http://www.mjdrdypu.org/text.asp?2016/9/2/274/167961

Sir,

Brachial plexus injury in newborn is the result of birth trauma that takes place during delivery. The incidence of brachial plexus injury ranges from 0.1% to 0.2% of all births. [1],[2] Brachial plexus injury is of three types namely Erb's palsy, global plexus injury, and Klumpke's injury. The physical examination is the most reliable method for differentiation of three and guide for prognosis. [3]


  Case Top


A male newborn with weight of 3.8 kg was born to G2P0L1 mother through vaginal delivery. The mother had a male neonate in previous pregnancy with birth weight of 2.95 kg and was delivered by normal uneventful vaginal delivery. The index baby had shoulder dystocia and was delivered using McRoberts maneuver and required bag and mask resuscitation for 1 min, with Apgar score of 6/8/8 at 1, 5 and 10 min, respectively. The mother during labor was under regular monitoring with continuous cardiotocography (CTG) monitoring and CTG was not suggestive of any late or variable deceleration and fetal heart rate had good variability. Baby had paucity of movements of left upper limb with normal movements of right upper limbs. During examination, baby's left arm was adducted and internally rotated, extended, and pronated at the elbow joint [Figure 1]. Moro's, bicep, and radial reflexes were absent of left side but grasp reflex was present. X-ray was done to rule out fracture clavicle which was normal. Baby was diagnosed as case of Duchenne-Erb's palsy due to birth trauma. Baby weakness gradually improved, and physiotherapy was started after 7 days. On follow-up, there was no weakness and adequate movement was present of left limb.


  Comments Top


Erb's palsy involves the upper trunk (C5, C6, and occasionally C7) and is the most common type of brachial plexus injury, accounting of approximately 90% of cases. Total brachial plexus injury is very rare and results from trauma involving C5 to T1. The cause of Brachial plexus injury is excessive traction on the head, neck, and arm during birth. Risk factors usually responsible for it include macrosomia, shoulder dystocia, malpresentation, and instrumented deliveries. [4],[5] In the index case, the risk factors were macrosomic neonate and shoulder dystocia that lead to Erb's palsy. The different causes of Erb's palsy includes: [6]

  1. Obstetrical brachial plexus palsy.
  2. Kaiser Wilhelm syndrome.
  3. Uterine malformation.
  4. Familial congenital brachial plexus palsy.
  5. Congenital varicella syndrome.
  6. Humeral or vertebral osteomyelitis.
  7. Exostosis of the first rib.
  8. Tumors.
  9. Hemangioma.


Erb's palsy injury usually involves nerve roots, especially where the roots come together to form the nerve trunk of the plexus. There is typically adduction and internal rotation at the shoulder joint. At the elbow joint, there is extension and pronation with flexion of wrist and fingers. This deformity is typically causes "waiter tip deformity." The most commonly involved nerves include suprascapular nerve, musculocutaneous nerve, and the axillary nerve. The muscles which are affected include deltoid, infraspinatus, biceps, supinator, and brachioradialis muscles of the upper limb. [7] Neurological examination is characterized by the absence of Moro's, biceps, and triceps reflexes of the affected upper limb with the presence of grasp reflexes as interossei muscles are not affected. Sometimes diaphragmatic paralysis is also seen if associated paralysis involves C3 and C4. Erb's palsy should be differentiated from Klumpke's paralysis. [8]

Differential diagnosis includes:

  • Cerebral injury.
  • Clavicle fracture.
  • Humerus fracture.
  • Lower cervical injury.


Treatment involves conservative management. Physiotherapy and exercise are done to prevent contracture which are started 7-10 days of injury. It have excellent prognosis with good neurological outcome. It is essential to identify the Erb's palsy at birth with its characteristics clinical features so that parents can be counseled regarding this benign condition. [9]

Birth injury is defined by the National Vital Statistics Report as "an impairment of the infant's body function or structure due to adverse influences that occurred at birth." It may take place either antenatally, intrapartum, or during resuscitation and may be avoidable or unavoidable. A neonate who is at a risk for birth injury should be examined thoroughly and in detail by the neonatologist who attains the delivery including a detailed neurologic evaluation. Particular attention should be paid to symmetry of structure and function, cranial nerves, range of motion of individual joints, and integrity of the scalp and skin. The various types of birth trauma are: [10],[11]

A. Head and neck injury:

  1. Injuries because of intrapartum fetal monitoring such as scalp abrasion, lacerations, facial, or ocular trauma.


B. Extracranial hemorrhages:

  1. Caput succedaneum.
  2. Cephalhematoma.
  3. Subgaleal hematoma.


C. Intracranial hemorrhages:

  1. Subdural or epidural hemorrhages.
  2. Subarachnoid hemorrhages.
  3. Intraventricular hemorrhages.


D. Skull Fractures such as linear, depressed, or occipital osteodiastasis.

E. Facial or mandibular fractures.

F. Nasal injury.

G. Ocular injuries like retinal and subconjunctival injury.

H. Ear injuries such as lacerations, hematoma, abrasion, and cauliflower ears.

I. Sternocleidomastoid injury.

J. Pharyngeal injury.

K. Nerve injury:

a. Facial nerve injury which can be of central, peripheral, or nerve branch injury.

b. Recurrent laryngeal nerve injury.

c. Spinal cord injuries such as high or mid cervical cervical and brain stem injury.

d. Brachial plexus injury:

1. Erb's palsy.

2. Global plexus injury.

3. Klumpke's injury.

e. Phrenic nerve injury.

L. Bone injury:

a. Clavicular fracture.

b. Long bone injury includes Humerus, Femur.

M. Intra-abdominal injury of organs such as liver, spleen, adrenal hemorrhage.

N. Soft tissue injury such as lacerations, abrasions, petechiae, ecchymoses, and subcutaneous fat necrosis.

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.

 
  References Top

1.
Alfonso DT. Causes of neonatal brachial plexus palsy. Bull NYU Hosp Jt Dis 2011;69:11-6.  Back to cited text no. 1
    
2.
Chauhan SP, Blackwell SB, Ananth CV. Neonatal brachial plexus palsy: Incidence, prevalence, and temporal trends. Semin Perinatol 2014;38:210-8.  Back to cited text no. 2
    
3.
Gosk J, Rutowski R. Obstetrical brachial plexus palsy - Etiopathogenesis, risk factors, prevention, prognosis. Ginekol Pol 2004;75:814-20.  Back to cited text no. 3
    
4.
Hudic I, Fatusic Z, Sinanovic O, Skokic F. Etiological risk factors for brachial plexus palsy. J Matern Fetal Neonatal Med 2006;19:655-61.  Back to cited text no. 4
    
5.
Ouzounian JG. Risk factors for neonatal brachial plexus palsy. Semin Perinatol 2014;38:219-21.  Back to cited text no. 5
    
6.
Sandmire HF, DeMott RK. Erb′s palsy causation: A historical perspective. Birth 2002;29:52-4.  Back to cited text no. 6
    
7.
Jennett RJ, Tarby TJ, Krauss RL. Erb′s palsy contrasted with Klumpke′s and total palsy: Different mechanisms are involved. Am J Obstet Gynecol 2002;186:1216-9.  Back to cited text no. 7
    
8.
Jennett RJ, Tarby TJ, Kreinick CJ. Brachial plexus palsy: An old problem revisited. Am J Obstet Gynecol 1992;166:1673-6.  Back to cited text no. 8
    
9.
Chater M, Camfield P, Camfield C. Erb′s palsy - Who is to blame and what will happen? Paediatr Child Health 2004;9: 556-560.  Back to cited text no. 9
    
10.
Parker LA. Part 1: Early recognition and treatment of birth trauma: Injuries to the head and face. Adv Neonatal Care 2005;5:288-97.  Back to cited text no. 10
    
11.
Parker LA. Part 2: Birth trauma: Injuries to the intraabdominal organs, peripheral nerves, and skeletal system. Adv Neonatal Care 2006;6:7-14.  Back to cited text no. 11
    


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