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++++++++++++++++++++++++++++++++++++++++++++++++++++ + +++ + +++ ++++++++++++++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: MUSCULOSKELETAL DISEASE F OR EVERY 1,000 babies born, one will have a brachial plexus injury. * The brachial plexus is a network of nerves at the base of the baby's neck, which sends signals to control the muscles of the shoulder, arm, elbow, wrist, hand and fingers. A difficult birth can lead to the condition. In some instances, a brachial plexus injury resolves itself without interven- tion, but the condition may require therapy and surgery. The list of risk factors for a brachial plexus injury includes large gestational size, maternal diabetes, prolonged preg- nancy or labor, breech presentation and forceps delivery. The first sign of the injury is the lack of movement of the baby's arm after birth. Once the pediatrician determines there is cause for concern, specialists can verify the diagnosis. Having specialists from multiple disciplines, including physiatry, plastic surgery, neurosurgery, orthopedic surgery and occupational therapy, involved from the beginning is important since infants who are treated early tend to have the best outcomes. A s pa r t of the diagnostic process, other conditions must be ruled out. Infants with suspected brachial plexus injury may have a clavicle or humerus fracture instead. Many parents of infants with brachial plexus injuries referred for treatment are confused about their baby's condition. Sometimes, the mother's OB/GYN may be reluctant to talk about what happened dur- ing delivery. I would encourage OB/GYNs to have an open line of communication to help parents understand that in a life- threatening situation measures were taken to ensure the health of the infant and the mother. Delivery is a very emotional time to begin with and parents benefit from knowing what was at stake. For those infants with a brachial plexus injury, the next step in treatment is to pinpoint the type of nerve injury. Parents are given instructions on how to care for the baby to promote recovery. In some cases, parents are afraid to touch their baby, worried they might further injure the child, which can negatively impact proper bonding. By going through proper handling techniques, parents can feel more at ease with their infant. Parents also learn through therapy sessions how to help the baby develop correct move- ment habits. Without therapy, the infant can compensate for the lack of control with improper arm movements, resulting in learning an improper pattern of arm use that can be difficult or impossible to correct later. Specialists meet with parents and the infant regularly in the early months of care to evaluate the extent of the injury and the baby's responsiveness to less- invasive treatment. Many children will have a good recovery without any other intervention beyond therapy. Throughout the therapy sessions, spe- cialists monitor the child's progress in both strength and movement. Intervention is needed at the six-month mark if recovery isn't satisfactory. The treatment and evalu- ation for more invasive options differ for each case and involve a team approach to care. Preoperative tests often offer limited guidance in surgery since it's difficult to have a clear picture of the nerve damage. Surgical exploration can allow a physician to observe the full extent of the infant's injury and what course of action to take, such as transferring nerves from another part of the body or directly repairing the injured nerves. Postoperative care then involves therapy and ongoing evaluation. Dr. Mark Adamczyk is Co-Director of the Akron Children's Hospital Brachial Plexus Treatment Center. He is board certified in orthopedic surgery and is a member of Akron Children's Center for Orthopedics and Sports Medicine. ■ *Source: Piatt, Jr, Joseph H., MD, FAAP, "Birth injuries of the brachial plexus," Pediatr Clin N Am 51 (2004) 421-440. By Mark Adamczyk, MD Brachial Plexus Injuries Understanding 2 0 | Cleveland/Akron/Canton MD NEWS ■ M D N E W S . CO M ■ M AY/J U N E 2 0 1 4