1. Is birth palsy always a medical malpractice?
Birth palsy is caused by mechanical injury, resulting from external forces that separate the neck and shoulder of the newborn. The external forces that cause birth palsy are not unique to assisted delivery methods such as forceps, but the large weight of the newborn is also an important risk factor for birth palsy. Brachial plexus injury can even occur intrauterine or before delivery of the fetal head. In addition, a large maternal body mass index and gestational diabetes can predispose the newborn to birth palsy. Therefore, all cases of birth palsy should not be considered as medical errors. Current technology, such as ultrasound, makes it difficult to predict and determine the excess weight of a newborn.
2. Is birth palsy rare?
The incidence of birth palsy is about 0,5‰ to 3‰. To some extent, its incidence is close to that of cerebral palsy, which is a common disabling condition in children. Some cases of birth palsy (e.g. Narakas type I) can recover on their own within a few weeks without showing obvious signs of paralysis, while others show a variety of symptoms.
3.What are the symptoms of birth palsy?
The cause of birth palsy is nerve damage in the cervical 5 – thoracic 1 region, which can have many different clinical manifestations depending on the location and extent of the injury, as well as progressive skeletal and muscular development and nerve regeneration problems. Babies with maternal palsy can have muscle atrophy of varying severity and extent, and as a result, the baby is unable to perform certain movements (e.g., putting a cookie to the mouth with a bent elbow motion without straining to lower the head and lift the shoulders, the cookie test); babies with maternal palsy can have sensory deficits in the affected limb (e.g., not knowing how to avoid and cry during acupuncture); babies with maternal palsy can have droopy upper eyelids (one of the Horner signs), signaling a severe injury Babies with birth palsy may have reduced range of motion, deformities and soft tissue contractures in the scapula, elbow and forearm, as well as shoulder dislocation (or subluxation) and radial tuberosity dislocation, and the bones at the dislocation are often poorly developed.
4.How is maternal palsy staged?
The staging of birth palsy is important for determining the severity of the disease and choosing the treatment. The most commonly used staging is Narakas staging, which was developed by Dr. A, O, and Narakas in the 1980s after summarizing 1000 cases of birth palsy. The method is as follows: Type I: spontaneous healing within weeks; Type II: incomplete recovery of the shoulder joint, fair elbow function, sometimes requiring tendon displacement to restore wrist and finger extension; Type III: upper trunk injury with cervical 7 avulsion, partial injury of the lower trunk, recoverable Horner’s sign; Type IV: similar to Type III but with persistent Horner’s sign, indicating cervical 8-thoracic 1 avulsion with partial recovery of cervical 5-6; Type V. Cervical 5-thoracic 1 avulsion with persistent Horner’s sign.
The other Tassin classification is based on the pathological presentation and it emphasizes that even in the mildest form of birth palsy, a small percentage of children will have residual shoulder dysfunction.
5. Does a baby with birth palsy have a crooked neck?
A baby with birth palsy will often turn his or her neck to the able-bodied side, which may mean that his or her brain pays less attention to the paralyzed side, which can make recovery from birth palsy more difficult. Another possibility of a crooked neck is that a soft tissue injury to the neck, such as a sternocleidomastoid hematoma, occurred at the same time as the birth palsy, resulting in what is commonly known as a “cranial neck”. When the hematoma is mechanized, a hard node can be palpated in the neck. Some cases of squint can be improved by early physiotherapy and massage, but severe cases require surgery.
6.What is birth palsy shoulder?
A baby with birth palsy has a deformed internal rotation of the shoulder joint and a winged external rotation of the scapula, commonly known as birth palsy shoulder. Shortening of the subscapularis, imbalance of the internal and external rotation of the shoulder, and paralysis of the serratus anterior and rhomboid muscles are the causes of birth palsy shoulder. The birth palsy shoulder is relatively common and therefore a focus of rehabilitation treatment.
7. Is there any point in rehabilitation for birth palsy?
Of course there is. For one thing, many babies with birth palsy need rehabilitation rather than surgery to improve upper limb function. For example, PNF (a training technique that induces movement through proprioceptive stimulation) and feedback therapy to induce correct movement, stretching and joint release techniques to combat soft tissue and joint contractures, various games and homework activities to increase the use of the affected limb, acupuncture for sensory stimulation, electrical stimulation and low power lasers to slow down muscle atrophy, etc. On the other hand, babies with birth palsy who undergo surgery should also undergo standardized rehabilitation, for example, those with displaced nerve grafts or displaced muscle tendons need to be trained to ensure that the newly put in place neuromuscular exercise responsibilities.
8. What is synchronous contraction?
When some babies with birth palsy perform shoulder forward flexion or abduction, the muscles responsible for internal rotation of the shoulder can become overexcited in an inappropriate manner, preventing the completion of the movement. This is called synchronous contraction of the shoulder internal rotators, also known as co-contraction or synchronous excitation. This condition is most likely due to a misdirected nerve convergence during nerve regeneration, where the nerve fibers that should innervate the shoulder abductor muscle grow into the shoulder internal rotator muscle. Another explanation is that the internal rotator muscle recovers earlier and the external rotator muscle recovers later. Regardless of the explanation, babies with birth palsy often have an imbalance in the transarticular force coupling and may have difficulty with shoulder abduction and external rotation (inability to touch the back of the head with the hand), or even deformity of the shoulder joint in internal rotation, subscapularis contracture, and posterior glenohumeral (shoulder) dislocation. Similar force-duplex imbalances can also occur in the elbow and forearm, which may result in flexion-elbow deformity and anterior rotation deformity of the forearm, resulting in radial tuberosity dislocation. In the past, treatment for this force couple imbalance has often opted for surgical release of the severed or displaced muscle. Botulinum toxin injections, which have emerged in the last decade, can temporarily block the local dominant muscle for a few months and re-establish the balance of the force couple with almost no adverse effects, making it a worthwhile rehabilitation treatment to try. Botulinum toxin needs to be used early because it is difficult to produce healing effects on contracted tissues.
9.How can I tell if a baby with birth palsy needs surgery?
Doctors determine whether a baby with birth palsy needs surgery by observing the function of the internal hand muscles, the presence or absence of Horner’s sign, and the performance of motor function and whether there is motor recovery at 3 months and 6 months after birth. One of the motor scoring methods (AMS) has an important reference value. Determining whether surgery is needed is sometimes a longer process.
10. Is it necessary to force a baby with birth palsy to exercise if he/she is miserable?
Whether the baby is undergoing rehabilitation or surgery, we encourage him/her to participate in sports, such as swimming, as much as possible. He/she should be encouraged to perform activities of daily living independently and to use the affected upper limb as much as possible. These activities are positive for the baby’s future development, life and character development.