Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury.

OBJECTIVE: To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment. STUDY DESIGN: Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data. RESULTS: There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%. CONCLUSIONS: In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

The assisting hand assessment for children and youth with brachial plexus birth injury: a study of validity and item hierarchy of AHA-Plex.

OBJECTIVE: Functional assessments that focus on activity performance and that produce valid outcome measures for people with brachial plexus birth injury are lacking. The primary aim of this study was to re-evaluate the internal scale validity of the Assisting Hand Assessment specifically for children and adolescents with brachial plexus birth injury. Two further aims were investigating whether the scale could be shortened for this group while maintaining psychometric quality, and exploring and presenting its item difficulty hierarchy. DESIGN: A cross-sectional psychometric study. SUBJECTS: A convenience sample of 105 children and adolescents (aged 18 months to 18 years, mean 6 years, 7 months, standard deviation (SD) 4 years, 4 months) from Sweden, Norway, and the Netherlands with brachial plexus birth injury. METHODS: Participants were assessed with the Assisting Hand Assessment. Data were analysed with Rasch measurement analysis. RESULTS: The 20 Assisting Hand Assessment items together measured a unidimensional construct with high reliability (0.97) and the 4-level rating scale functioned well. Item reduction resulted in 15 items with good item fit, unidimensionality, reliability and acceptable targeting. CONCLUSION: Assisting Hand Assessment for people with brachial plexus birth injury, called AHA-Plex, has 15 items and good internal scale validity. A unique item hierarchy for people with brachial plexus birth injury is presented.

A prospective study on neonatal ophthalmic injuries associated with forceps delivery.

BACKGROUND: Assisted delivery by forceps is needed to expedite vaginal delivery in certain maternal and fetal conditions. The aim of this study was to evaluate the incidence and the extent of ophthalmological injuries in neonates after forceps delivery. METHODS: Women with cephalic fetuses delivered vaginally by forceps from July 2020 to June 2022 were recruited prospectively. Ophthalmologists would be consulted when there were signs of external ophthalmic injuries, such as periorbital forceps marks or facial bruising. Demographic data, pregnancy characteristics, delivery details, and perinatal outcomes were evaluated to identify any associated risk factors for neonatal ophthalmological injuries. RESULTS: A total of 77 forceps deliveries were performed in the study period, in which 20 cases (26%) required ophthalmological consultations. There were more right or left occipital fetal head positions in the group requiring ophthalmological assessment than those that did not require assessment (35% vs 12.3% [P = 0.023]). The degree of moulding of the fetal head was more marked in the former group (65% vs 28% [P = 0.001]). The overall incidence of detectable ophthalmological lesions was 16.9% (13/77). All ophthalmic injuries were mild, and most resolved with conservative management. CONCLUSIONS: In our study cohort, external ophthalmic injuries were common after forceps delivery. We recommended ophthalmological consultation in newborns delivered by forceps with evidence of compressive trauma to rule out serious ophthalmological trauma.

Skeletal injuries after cesarean section - a rare differential diagnosis of child abuse.

Birth-related fractures are an important differential diagnosis of child abuse in early infancy. While fractures associated to vaginal deliveries are well known, cesarean section is not necessarily known to cause such injuries. Nevertheless neonatal fractures have been described after cesarean sections. To give an overview over the frequency and typical locations of such fractures, the appearance of symptoms and the timespan until diagnosis, a literature research was conducted via Google scholar and Pubmed, using the key words "cesarean section" and "fractures". Birth-related fractures after cesarean sections are rare but can occur, with the long bones being particularly affected. Therefore, birth injuries should always be considered in the forensic medical assessment of fractures in early infancy, even after cesarean section. To enable a differentiation between birth trauma and physical abuse, birth and operation records should be checked for surgical manoeuvres, possible difficulties during the procedure or other risk factors. Birth-related fractures are usually detected early; in rare cases, the diagnosis is made only weeks after birth.

Validity and Reliability of Wearable Motion Sensors for Clinical Assessment of Shoulder Function in Brachial Plexus Birth Injury.

The modified Mallet scale (MMS) is commonly used to grade shoulder function in brachial plexus birth injury (BPBI) but has limited sensitivity and cannot grade scapulothoracic and glenohumeral mobility. This study aims to evaluate if the addition of a wearable inertial movement unit (IMU) system could improve clinical assessment based on MMS. The system validity was analyzed with simultaneous measurements with the IMU system and an optical camera system in three asymptomatic individuals. Test-retest and interrater reliability were analyzed in nine asymptomatic individuals and six BPBI patients. IMUs were placed on the upper arm, forearm, scapula, and thorax. Peak angles, range of motion, and average joint angular speed in the shoulder, scapulothoracic, glenohumeral, and elbow joints were analyzed during mobility assessments and MMS tasks. In the validity tests, clusters of reflective markers were placed on the sensors. The validity was high with an error standard deviation below 3.6°. Intraclass correlation coefficients showed that 90.3% of the 69 outcome scores showed good-to-excellent test-retest reliability, and 41% of the scores gave significant differences between BPBI patients and controls with good-to-excellent test-retest reliability. The interrater reliability was moderate to excellent, implying that standardization is important if the patient is followed-up longitudinally.

Assessment of approaches to estimate scapular orientation in children with brachial plexus birth injury.

BACKGROUND: Challenges in measuring dynamic scapular orientation limit assessment of scapulothoracic and glenohumeral contributions to shoulder function in children with brachial plexus birth injury (BPBI). Double calibration acromion marker cluster (D-AMC) and linear model approaches have been validated to estimate scapular motion in healthy adults, but neither has been evaluated in BPBI. RESEARCH QUESTION: Are the linear model and D-AMC approaches able to accurately estimate scapular orientation in children with BPBI at functional arm postures? METHODS: Seventeen children with BPBI positioned their affected limbs in 11 static positions while their segment orientations were measured with motion capture. Linear model and D-AMC estimates of scapular orientation were compared against palpation at six of the static positions with functional relevance to BPBI using a three-way repeat measures ANOVA and a comparison of root mean square errors (RMSE) against literature AMC values for healthy adults. RESULTS: The D-AMC was similar to palpation across all positions and scapular axes while the linear model differed from palpation in a few instances. RMSEs of the D-AMC (3.7-14.8°) and particularly the linear model (4.6-24.8°) were generally at or beyond the upper range of past AMC analyses on healthy adults (1.6-14.2°), especially for more complex, multiplanar arm postures. Despite the D-AMC outperforming the linear model, this approach still produced clinically meaningful (>10°) errors for roughly (12.7-22.5%) of subjects. SIGNIFICANCE: Current methods for estimating dynamic scapular orientation remain less than ideal for BPBI. Use of the D-AMC may be appropriate to gain broad insights into general dynamic scapulothoracic and glenohumeral function; however, given their potential for producing clinically meaningful errors, the D-AMC and linear model are not recommended for diagnostic purposes or outcomes assessment on an individual patient basis unless their patient-specific accuracy has been evaluated and confirmed prior to use.

Brachial plexus birth palsy: incidence, natural-course, and prognostic factors during the first year of life.

OBJECTIVE: To evaluate the incidence of brachial plexus birth palsy (BPBP) in a large, single cohort and stratify clinical 1-year outcomes. STUDY DESIGN: A cohort study of all births occurring at a single institution between 2011 and 2015. Hospital discharge papers were analyzed, and structured telephone interviews were conducted. RESULTS: Among 76,000 livebirths, 98 (0.13%) cases of BPBP were diagnosed. Of cases who fully responded to interview (66/98), at 3 months of age 77% infants made a complete recovery, and by 1 year of age an additional 20% had recovered completely. Only 3% of infants had residual longer-term neurological deficits. CONCLUSIONS: Predictors of a longer course of recovery were the presence of shoulder dystocia (p < 0.04) and right-sided palsy (p < 0.02). Birth weight, neonatal head circumference, and sex were not correlated with outcome. Future reports of BPBP should differentiate between infants showing early recovery from those with true BPBP.

Association of traction force and adverse neonatal outcome in vacuum-assisted vaginal delivery: A prospective cohort study.

INTRODUCTION: Traction force is a possible risk factor for adverse neonatal outcome in vacuum extraction delivery, but the knowledge is scarce and further investigation is needed. Our hypothesis was that high-level traction force increases the risk of admission to the neonatal intensive care unit. MATERIAL AND METHODS: The study was a hospital-based prospective cohort study on low- and mid-vacuum extractions at the labor and delivery ward, Karolinska University Hospital, Huddinge, Sweden. Traction forces were measured in 331 women. An electronical handle was used to measure and register traction force. The main exposure variable was high-level traction force (≥75th percentile) during the first three pulls and the primary outcome was admission to the neonatal intensive care unit. Logistic regression was used to estimate the adjusted risk. RESULTS: Among the exposed, 14/84 (16.7%) were admitted to neonatal intensive care, and among the unexposed 10/247 (4%). The crude odds ratio (OR) of admission to the neonatal intensive care unit when exposed to high-level traction force was 4.7, and the adjusted (birthweight, gestational length, cup detachment, number of pulls, duration, duration >15 minutes, mid-cavity fetal head station, failed extraction, indication and parity) OR was 2.85 (95% confidence interval [CI] 1.09-7.48). No significant effect was seen in Apgar scores <7 at 5 minutes or pH <7.1. CONCLUSIONS: High-level traction force may be a risk factor for neonatal complications. Although these results do not mandate any alterations in clinical guidelines, perioperative feedback on traction force may be useful to alert the obstetrician to a timely conversion to cesarean section. To study plausible traction force specific outcomes such as head traumas, a larger sample size is required.

Comparison of image quality in brain MRI with and without MR compatible incubator and predictive value of brain MRI at expected delivery date in preterm babies.

Objectives MR compatible incubators (MRcI) offer the examination of preterm and critically ill infants in controlled environment. The aim of the study was to compare objective and subjective image quality as well as diagnostic value of MRI brain examinations with and without using the MRcI. Thus, predictive value of brain MRI at expected delivery date in general was investigated. Methods This retrospective study included MRI brain examinations conducted at patients' corrected age ≤6 months and presence of four standard sequences (PD TSE transversal, T2 TSE transversal, T2 TSE sagittal and T1 SE transversal). Signal-to-Noise Ratio (SNR) and Contrast-to-Noise Ratio (CNR) was calculated. Subjective image quality was estimated using a 5-point Likert scale. Findings of MRI were compared with those of previous transfontanellar ultrasound because of additional diagnostic information. Severe brain abnormality scaled by score of Kidokoro was related to results of Munich Functional Developmental Diagnostics (MFDD) within first year. Results One hundred MRI brain examinations (76 with MRcI, 24 without MRcI) were performed in 79 patients. Using the MRcI SNR and CNR were significantly higher in PD- and in T2-weighted sequences (p<0.05). TSE PD transversal demonstrated a higher risk of non-diagnostic quality using MRcI (OR 5.23; 95%-CI 1.86-14.72). MRcI revealed additional diagnostic information (OR 5.69; 95%-CI 1.15-28.24). Severe brain abnormality was associated with walking deficits (r=0.570; p=0.021). Conclusions The MRcI increased objective image quality and revealed additional diagnostic information to transfontanellar ultrasound. Nevertheless, prediction of infants' future development remains limited.

Brachial Plexus Birth Injury in the Preterm Infant: Suspecting the Unsuspected.

BACKGROUND: Prematurity is usually considered as a protective factor for brachial plexus birth injury (BPBI). However, BPBI can occur in the preterm infant, and can cause significant dysfunction and morbidity. There is scant literature regarding this subgroup of patients with BPBI. METHODS: Patients were identified through a retrospective search of a prospective BPBI registry at a single tertiary pediatric referral center. Prematurity was defined as birth at or before gestational age of 36 (6/7) weeks. Thirty-six arms in 34 patients were included in this study. Data were obtained from patient charts documenting standardized brachial plexus clinical examinations at each visit, medical imaging, questionnaires for parents, and outside perinatal records brought in by parents. RESULTS: The youngest infant identified with BPBI was born at 23 weeks' gestation. Median birth weight was 3005 g (range: 580 to 4600 g). Twenty-nine arms in 28 patients were categorized into the "late preterm group" [34 to 36 (6/7) weeks gestation], and 7 arms in 6 patients were categorized into the "early preterm group" (<34 wk). Four of 6 (67%) subjects in the early preterm group were delivered vaginally in the breech position, compared with 4 of 28 subjects (14%) in the late preterm group (P=0.02). All 3 twin gestation infants with BPBI were the younger twin and born vaginally in the breech position. Delayed diagnosis (>7 d) occurred in 11 arms in 10 subjects (31%). Median delay in diagnosis was 73 days (range: 10 to 1340 d). Spontaneous recovery of antigravity elbow flexion occurred in 65% of arms (at median 5 mo, range: 1 to 17 mo). Overall, 89% (32/36) of arms with BPBI had residual neurological deficit and 53% (19/36) of arms underwent at least 1 surgical intervention at latest follow-up (median age at latest follow-up: 60 mo, range: 1 to 237 mo). CONCLUSIONS: BPBI in preterm infants is rare but does occur and can cause significant morbidity. Delayed diagnosis of BPBI is common in preterm infants. A high index of suspicion should be maintained to avoid delayed diagnosis that may jeopardize treatment options. Preterm infants may be more susceptible to birth trauma from breech deliveries and shoulder dystocia, as evidenced by far higher incidence of these factors compared with term infants with BPBI in literature. LEVEL OF EVIDENCE: Level IV-case series.

The relationship between the location of neonatal clavicular fractures and predisposing factors.

BACKGROUND: The aim was to investigate the maternal and fetal predisposing factors of clavicle fracture locations in newborns. METHODS: A retrospective evaluation was made of 77 clavicle fractures identified from a total of 33,480 live newborns between September 2016 and September 2018 at a single center in Turkey. Fractures were grouped according to the Allman classification: Group I mid third, Group II lateral distal third, Group III medial proximal third of the clavicle, respectively. Demographic features compared between the groups included maternal age, parity and height and infantile gestational age, gender, birth weight and length. Neonatal clinical features were also compared between the three groups and included mode of delivery, Apgar score, fracture laterality, time to diagnosis, mode of diagnosis, and presence of symptoms of brachial plexus palsy. RESULTS: There were no statistically significant differences between the three groups when the demographic characteristics of the mothers and newborns were compared. In terms of clinical characteristics Group 3 contained a higher proportion of patients with symptoms of brachial plexus palsy than Group 1 (61.5% versus 22%, p = 0.017). There was no statistically significant difference between Groups 2 and 3 and Groups 1 and 2. CONCLUSION: A significant association was found between the occurrence of brachial plexus palsy and fracture of the medial third of the clavicle (Allman type III).

Neonatal birth fractures: a retrospective tertiary maternity hospital review.

We aimed to identify the incidence and types of neonatal birth fractures in a single tertiary maternity hospital in the United Kingdom and to find possible associated factors, including all live births born between 2000 and 2016. We reviewed hospital records and imaging of all neonates who had any imaging done to identify birth fractures. We identified 87,461 consecutive live births. Sixty-six sustained a fracture during delivery: 46 clavicle-, 13 humerus-, four skull-, one femoral-, one rib- and one tibial fracture. Five neonates with a clavicle or humeral fracture had an Erb's palsy. Sixty-five fractures were in singletons. Twenty-five fractures were diagnosed after discharge. Binary logistic regression analysis with R-Studio showed a significant association between 'Fracture' and 'Birthweight' (p < .0005), 'Delivery Mode' (Forceps: p < .001, Ventouse: p < .0004) and 'Gestation' (p < .0005) but not with 'Sex', 'Day' and 'Time' of delivery, 'Number of deliveries per day', 'Singleton/Multiple Births' and 'Breech'. The incidence of birth fractures (0.075%) was low with 24 hours obstetrician support on site in comparison to published data. We recommend to include data on neonatal birth injuries in addition to the existing clinical safety markers for delivery units.Impact statementWhat is already known on this subject? Most birth fractures affect the clavicle with a large variation in published incidences from 0.035% to 3.2%. High birthweight is the most frequently identified risk factor. An increased risk for out of hours deliveries (16.00-8.00) and inverse association between fracture rate and level of experience and academic qualification have also been reported. Between 14% and 39% of fractures are diagnosed after discharge but many studies are based on birth certificate and discharge diagnoses coding only.What the results of this study add? This is the first study on neonatal birth fractures from the United Kingdom and the only study for which radiological investigations of all neonates were reviewed. Our fracture rate of 0.075% for all fractures is therefore most likely the most accurate, showing no significant difference in the fracture risk between our six defined time intervals and days of the week, with experienced midwifes managing many high risk pregnancies and an obstetrician being present on site all the time.What the implications are of these findings for clinical practice and/or further research? Our findings support to use data on neonatal birth injuries as one indicator to assess the quality and safety of maternity units.