I- NTRODUCTION :
1- Definition :
- C & rsquo; is a traumatic paralysis of the brachial plexus occurring at the time of birth, Consecutive often a difficult birth of Ion & rsquo; expulsion
- Can also be a row by cesarean uterine malposition.
- May be partial or total of the arm and / or hand.
2- Epidemiology :
- Rare in children : 0.05 – 0.145%
- Slight predominance in males : 51%
- 2x greater than Right / Left
- rarely bilateral : 1.5- 5 %
- Despite advances in obstetric PEC, obstetric paralysis n & rsquo; has not disappeared and remains stable. Some factors are correlated to its occurrence .
maternal factors :
Primiparity if the vertex weight jack > at 20 kg during gestation
fetal factors :
Birth weight > 4 Kg if vertex presentation.
Prematurity in case of breech presentation
obstetric factors :
Shoulder dystocia found in 80-90 %
Lengthening the duration of the expansion phase late commitment of fetal presentation
II- DESCRIPTIVE ANATOMY :
- PB is formed by the union of Br. Ant December N.R C5 DI + C4 of the anastomosis
- It provides the & rsquo; sensory innervation and motive of the shoulder girdle and MS
Constitution : it is made up of
- trunks Primary (TP) = TP Soups(C5C6 and C4 anast), TP Moy(C7),TP lnf(C8Dl)
- trunks Secondary (TS) = TP fall into Br Ant and Post and s & rsquo; anastomose to give TS. TS Antéro-Ext = Br ant TP Sup+Br ant TPMoy.
TS Post = Br post des 03 TP.
Antero TS-Int = TP Brant Inf.
Location and Reporting : it is compared to a triangle internal cervical base( NO) and outer vertex (axilla).
- TP located region of scalene parade
- TS located rétroclaviculaire region
- Br Terminals are located axilla
III- PHYSIOPATHOLOGY DAMAGE :
* PATHOLOGY OF NERVE INJURY (CLASSIFICATION DE SEDDON) :
– Subjected to tensile, the developing nerve (03) types of lesions :
neurapraxia = Elongation seamless nerve sheath localized interruption of nerve conduction recovery is fast ( 2 to 3 months)
AXONOTMESIS = Interruption in the continuity of the & rsquo; axon with respect to the sheath of Schwann, was a spontaneous axonal regeneration
NEUROTMESIS = Complete interruption of & rsquo; axon and connective tissue sheaths no spontaneous recovery
* PATHOLOGY BY PRESENTATION :
– whatever the type of presentation ,it s & rsquo; d & rsquo acts; a trauma exerted on the roots of PB by pulling on the & rsquo; shoulder or head
1- Birth by cephalic presentation : maneuvers of the first head in rotation and lowering of the & rsquo; shoulder
2- Breech birth : retention last head
- atteintes PROXIMAL (HIGH) C5 C6 Paralysis of the & rsquo; shoulder, elbow, supination and & rsquo; radial deviation of the wrist = paralysis Erb + 75% case
- Distal ACHIEVEMENT (BASSES) C8 D1 Paralysis of the hand
- TOTAL AFFECTED C5 D1 represent 25% cases
IV- PHYSICAL EXAMINATION :
Variable according to the & rsquo; age with common characteristics
– MS flange ,painful (tears)
– MS healthy hypertonic with physiological bending
– Normal joint liability balance
INFANT and CHILD, With bone growth was:
– vicious attitudes (RI arm, main ballante,F ° elbow)
– joint limitations shrink or muscle imbalance between agonist and antagonist
– muscle Testing
– neurological ex ( removing a central pathology)
– Reflexes and Tonus
D & rsquo; s other signs come & rsquo; add to those already described :
SIGN-CLAUDE BERNARD HORNER the side of the lesion by tearing the C8ou Tl root has the & rsquo; within the spinal canal (association ptosis, énophtalmie et myosis),
Reaching the phrenic nerve (C3 C4),resulting in paralysis of the diaphragm ipsilateral often leading to respiratory distress,
V- REVIEWS PARACLINIQUES :
– Allows diagnosis
– Determines the injured level
RX STANDARD = Broken collarbone or the & rsquo; humerus
EMG = Is from the 3rd month, interpretation difficult, painful
IRM = To see the roots and pseudoméningocèles
WE- EVOLUTION :
- Recovery begins once past trauma
- spontaneously in most cases ,or surgically by nerve grafting on exploration and 2 a 3 years favoring hand
- Treatment of sequelae will be considered that & rsquo; after stagnating recovery beyond 03 years.
VII- TREATMENT :
- The goals of rehabilitation are to preserve joint mobility to allow the achievement of movements when recovering muscles. It begins just after the first three weeks of life so as not to cause d & rsquo; additional and allow proper healing nerve stretching, l & rsquo; children are more painful. For it, the upper limb is held in a sling in internal rotation elbow against the body.
- During the recovery period, three types of work associated : passive and active mobilization especially, maintaining postures and & rsquo; occupational therapy.
- L & rsquo; use & rsquo; posture splints is often essential to d & rsquo; avoid vicious positions or placing the limb segment in a functional position.
- Rehabilitation must also take into account the different sensory disorders even s & rsquo; they are difficult to assess. This rehabilitation includes repeated stimulation type manuals contact, massages, d & rsquo; alternating hot and cold, stimulation by touch structures, different form and consistency
nerve surgery :
- mainly occurs between 06 lan months after collecting clinical evidence and laboratory to d & rsquo; assess the prognosis of recovery of the & rsquo; child. There are several possibilities :
- Complete recovery and early results mostly neurapraxiques lesions of the brachial plexus. This recovery is usually quick in a few days to weeks and does not require surgery. Only a physiotherapy treatment allows d & rsquo; maintain joint mobility and stimulate the recovery of active mobility of the & rsquo; child beyond the first month when the & rsquo; n & rsquo child, is more painful.
- L & rsquo; no recovery coincides generally with the & rsquo; & rsquo existence; severe plexus palsy, or total. This possibility implies the realization of & rsquo; additional tests to search for d & rsquo signs root avulsion (magnetic resonance) and denervation (electromyogram). L & rsquo; surgical indication is then placed at the 3rd month.
Finally, recovery may be partial in its topography or in & rsquo; intensity of muscle strength of different groups. When & rsquo; s it & rsquo; paralysis is proximal (elbow flexion and abduction, External rotation of the & rsquo; shoulder) testifying d & rsquo; a C5-C6 lesion or C5-C6-C7, l & rsquo; absence of
Surgery sequelae :
The secondary surgery of the brachial plexus n & rsquo; intervenes when nerve recovery possibilities have been exhausted. In the majority of cases, muscle transfer interventions are not carried out before the & rsquo; age 2 at 3 years when spontaneous recovery or acquired after surgery s & rsquo; exhausts. Moreover, bone procedures are performed much later, to the & rsquo; puberty.
- tendon transfer
- Bone palliative interventions (s & rsquo; & rsquo s osteotomy, arthrodesis)
VIII- CONCLUSION :
- The different processing techniques are complementary and allow, When & rsquo; they are associated, to give three-quarters of children sufficient traction to a non-dominant upper limb.
- Even if progress is made in the & rsquo; future, surgery n & rsquo; is that & rsquo; a take-up means.
- Prevention finds its place both in the monitoring of pregnancies (prevention of obese mothers) in the cesarean indications.
- Finally multidisciplinary PEC with the parents' cooperation deserves more & rsquo; interest .
- The PEC Psychological involved at all stages (school age +++)
Courses of Dr. Belghoul – Faculty of Constantine