General Pediatrics, The University of Chicago

Yingshan Shi, M.D. (773) 702-2600 04/2003, 2008

Peripheral Nerve Injuries

Disorders	Cause		S & S	Treatment
Brachial Palsy	45% associated with shoulder dystocia Paralysis prognosis due to · Edema and hemorrhage of the nerve fibers- return of function within a few months · Laceration of the nerve fibers- permanent damage may result · Involvement of the deltoid: may result in a shoulder drop 2^nd to muscular atrophy · In general, paralysis of the upper arm has a better prognosis than paralysis of the lower arm			· Intermittent immobilization and appropriate position while the infant is asleep and between feedings to prevent contractures. · Upper arm paralysis: abducted arm 90 degrees, with external rotation at the shoulder and with full supination of the forearm and slight extension at the wrist with the palm turned toward the face for 1^st 1-2 weeks · Lower arm or hand paralysis: splinted wrist in a neutral position and padding placed in the fist · Gentle massage and range of motion exercises (active and passive) may be started by 10 days of age · If the paralysis persists without improvement for 3-6 month, neuroplasty, neurolysis, end to end anastomosis, or nerve grafting offer hope for partial recovery
Erb-Duchenne Paralysis	Injury the 5^th & 6^th cervical nerves (C5, C6)	· Loses the power to abduct the arm, to rotate the arm externally, to supinate the forearm. · The arm on the position of adduction, internal rotation, with pronation of the forearm. · Absent of biceps reflex & Moro reflex · May be some sensory impairment on the outer aspect of the arm
Klumpke Paralysis	Rare form of brachial palsy Injury C7, C8 and the 1^st thoracic nerve	· Paralyzed hand · Horner syndrome- ipsilateral ptosis and miosis if T1sympathetic fibers are injured. · MRI will detect nerve root rupture or avulsion
Phrenic Nerve Paralysis	Injury C3-5 with diaphragmatic paralysis	· Usually unilateral, associated with ipsilateral upper brachial palsy · Cyanosis, irregular and labored breathing, thoracic breathing in type, breathing sounds are diminished on affected side · Dx: ultrasonography or fluoroscopic exam- elevation of the diaphragm on the paralyzed side and seesaw movements of the both sides of the diaphragm during respiration		· No specific treatment. Recovery usually occurs spontaneously by 1-3 mo, rarely, surgery may be indicated · Place the infant on the involved side and given oxygen if necessary · Feedings: IV, gavage or oral · Complication: pulmonary infection
Facial Nerve Palsy	Pressure over the facial nerve in utero, from the efforts during labor, or from forceps during delivery. Rarely, from nuclear agenesis of the facial nerve	Flaccid paralysis Peripheral paralysis: In the affected side forehead is smooth eye cannot be closed nasolabial fold is absent corner of the mouth droops Central paralysis: the forehead will wrinkle in the affected side. Usually with other intracranial injury, most commonly 6^th nerve palsy DD: may be confused with the absence of the depressor muscles of the mouth, which is a benign problems		Prognosis: Injured by pressure: improvement occurs within a few wks Injured by torn nerve fibers: may be persistent Tx Care of the exposed eye is essential Neuroplasty may be indicated when the paralysis is persistent.

Ref: Nelson 16th