Common neonatal birth injuries–recognizing and managing

Question 1

When can neonatal birth injuries occur?

Answer 1

They can occur during labor, delivery or after delivery (during resuscitation)

Question 2

What are some risk factors for neonatal birth injuries?

Answer 2

They include fetal macrosomia, maternal obesity, maternal pelvic anomalies, precipitous delivery, and any fetal presentation other than vertex position. The use of forceps or a vacuum device also increase the risk of neonatal birth injury.

Question 3

What are the 4 major categories of neonatal birth injuries that can occur?

Answer 3

1. Brachial plexus injuries
2. Soft tissue injuries
3. Extracranial injuries
4. Fractures.

Question 4

Brachial plexus injuries are thought to be due to what mechanisms?

Answer 4

Stretching or traction, compression or oxygen deprivation. With lateral traction of the fetal head typically seen in shoulder dystocia is thought to be the most common.

Question 5

What is the most common physical presentation for brachial plexus injury?

Answer 5

Arm weakness, almost always unilateral in the brachial plexus nerve distribution. An asymmetric Moro reflex is a red flag for brachial plexus injuries.

Question 6

What are some associated injuries with brachial plexus injuries?

Answer 6

BlocksFractures of the clavicle and humerus, plus Tatian of the shoulder may occur.

Question 7

What are the 4 types of brachial plexus injuries?

Answer 7

1. Erb palsy
2. Klumpke”’s palsy
3. Erb-Klumpke’s palsy
4. Horner syndrome

Question 8

What level of the brachial plexus is involved in an Erb palsy and what are the resulting clinical manifestations?

Answer 8

Injury occurs at C5-6 or–7 resulting in paralysis of the upper arm (hand and wrist movements are unaffected). There is a waiters tip configuration if C7 is involved. The grasp and extension of the hand are intact.

Question 9

With brachial plexus injury how can and associated respiratory distress occur?

Answer 9

Due to phrenic nerve injury look for broken clavicle resulting in a unilateral diaphragmatic paralysis, often associated with LGA babies, breech deliveries and C-sections.

Question 10

What level of the brachial plexus is involved with Klempke’s palsy?

Answer 10

Injury occurs at C8-T1 this affects the lower arm and hand, carries a worse prognosis because nervous typically torn and results in a claw hand deformity which there is inability to grasp.

Question 11

Describe the injury of Erb-Klumpke’s palsy?

Answer 11

Weakness in the arm and hand due to injury from C5-T1 known as flail arm.

Question 12

What other syndrome may accompany the brachial plexus palsies?

Answer 12

Horner syndrome

Question 13

What are the classic features for Horner syndrome? And at what level as the injury occurred in the brachial plexus?

Answer 13

A T1 lesion results in proptosis, miosis, and and hydrocephalus with the affected eye having a droopy lid, small pupil (anisocoria close parentheses and the eye is dry.

Question 14

What is the mainstay of treatment or management in infants with brachial plexus injuries?

Answer 14

Referral for physical and Occupational Therapy, which will focus on preventing contractures, including passive range of motion exercises and perhaps splints. The majority of infants with neurologic injury recover spontaneously. Surgery may be necessary if recovery does not occur in approximately 6 months.

Question 15

What are the range of soft tissue injuries in neonates?

Answer 15

Several types include swelling, bruising, petechiae, and perhaps lacerations which generally occur on the presenting part of the infant’s body.

Question 16

What specific presenting areas in a newborn are common with bruising etc.?

Answer 16

Genitalia are frequently seen with breech presentation and have bruising and edema, edema and petechiae of the head neck are seen in vertex presentation especially face presentation.

Question 17

When due lacerations typically occur in neonates?

Answer 17

Generally occur with emergent C-sections and on presenting part of the infant’s body most often the face or scalp.

Question 18

How does subcutaneous fat necrosis generally present and how to recognize?

Answer 18

May occur in the first few weeks of life, recognized by firm, indurated nodules (reddish, blue, or flesh-colored) and plaques typically over bony prominences on the back, buttock, limbs, or cheeks.

Question 19

How are soft tissue injuries generally managed?

Answer 19

Bruising, edema and petechiae are typically self-limiting and recover spontaneously. Platelet counts may be necessary in evaluation of extensive petechiae or other areas of bleeding. Bilirubin should be monitored and hyperbilirubinemia treated for extensive bruising. Subcutaneous fat necrosis is self-limiting and resolves over the course of several weeks. Risk factors may include hyper calcium Mia. Lacerations only require Steri-Strips etc.

Question 20

What mechanism is generally responsible for extracranial injuries in neonates?

Answer 20

Edema or hemorrhage into the various layers of the scalp and skull are more likely after prolonged labor or after instrumentation assisted deliveries.

Question 21

What are the subcutaneous layers of the head, or scalp?

Answer 21

Most superficial layers the skin of the scalp with underlying fatty tissue, the next layer is the galea aponeurotica, then comes the skull and periosteum. Underneath that follows the dura mater, the arachnoid membrane closely adhered to the brain.

Question 22

What is the typical presentation in a neonate with the caput succedaneum?

Answer 22

There is edema of the scalp, occasionally hemorrhagic, above the periosteum layer. And the swelling does cross suture lines.

Question 23

What are the common mechanisms leading to a caput?

Answer 23

.They may occur after prolonged labor due to pressure on the scalp, or after vacuum extraction

Question 24

Described the typical presentation and neonate with a cephalohematoma?

Answer 24

May present with edema of the scalp and are due to rupture of small blood vessels between the periosteum and the skull resulting in swelling that does not cross suture lines. More likely are common if forceps or vacuum is used during delivery.

Question 25

What is an occasional complication of cephalohematomas.?

Answer 25

Occasionally heals with calcification, causing deformities of the school.

Question 26

What is a subgaleal hemorrhage?

Answer 26

Subgaleal hemorrhages occurred due to accumulation of blood in the space between the galea aponeurotic and the periosteum, caused by damage veins between the scalp and the dural sinuses.

Question 27

Are subgaleal hemorrhages life-threatening and why?

Answer 27

yes they are life-threatening due to the potential for large blood losses

Question 28

Describe the swelling pattern of subgaleal hemorrhages?

Answer 28

The swelling does cross suture lines and may extend from forehead anteriorly to nape of the neck into the ears laterally, the swelling is fluctuant and may shift with movement. Associated tachycardia and pallor may occur along with dropping hematocrit, had ultrasound confirmed the location of the hemorrhage.

Question 29

How is a caput managed?

Answer 29

They are typically benign and self-limited resolved within a few days. Rarely the lesion may become necrotic leading to later scarring and alopecia

Question 30

How are cephalohematomas managed?

Answer 30

They are typically self resolving but may take several weeks to do so. They can be associated with increased risk of hyperbilirubinemia. Potential complications of cephalohematomas include skull deformities from calcification, infection and sepsis with E. coli.

Question 31

How are subgaleal hemorrhages managed?

Answer 31

Because they can be severe and life-threatening early recognition of this diagnosis is key. Monitor vital signs frequently as well as head circumference and hematocrit. CT and or MRI helps to identify the location of the hemorrhage. Monitor CBC frequently treat with blood products and volume resuscitation in consider transfer to the ICU.

Question 32

What are the 4 types of fractures seen in neonatal injuries?

Answer 32

1. Clavicular fractures
2. Humeral fractures
3. femur fractures
4. Skull fractures

Question 33

How are clavicular fractures manifest in newborns?

Answer 33

Signs and symptoms may include lack of movement of the affected arm, asymmetric Moro reflex, crying with passive motion, edema, and perhaps crepitus. Diagnosis confirmed by x-ray.

Question 34

How are humeral fractures manifest in the newborn?

Answer 34

They will present similar to clavicular fractures, lack of movement in the arm, and a asymmetric Moro, crying with passive motion, edema etc. X-rays helpful for diagnosis and MRI for very proximal or very distal fractures may be necessary. (Due to poor ossification)

Question 35

How are femoral fractures manifest in the neonate?

Answer 35

They have an increased pain response to manipulation of the leg, asymmetric movement and possible crepitus. X-ray confirms the diagnosis.

Question 36

What are the most common or typical scenarios for skull fractures in newborns.

Answer 36

These occur more frequently during for sepsis associated delivery, or with spontaneous vaginal delivery as well as pressure against maternal structures. Premature infants are at increased risk.

Question 37

What are the common types of skull fracture seen in neonates?

Answer 37

The fractures may be linear or depressed and if occurring after forceps delivery are more likely be associated with intracranial hemorrhage or cephalohematoma. They are typically diagnosed with plain radiographs sometimes CT if there is bleeding suspected

Question 38

How are most neonatal fractures managed?

Answer 38

Most of these fractures are managed conservatively. For clavicular and humeral fractures the arm can be pinned to the chest at 90 degree angle. Immobilization in a Pavlik harness for several weeks for femur fractures. Tylenol for pain, radio grafts can be repeated to help document healing. Look for associated brachial plexus injuries and all fractures may be associated with diffuse osteoporosis or osteogenesis imperfecta. And cranial fractures may be associated with intracranial and extracranial hemorrhage.