Neonates: Birth Injuries

Question 1

Give 5 head shape abnormalities that may be present at birth

Answer 1

1) Cranial moulding - common after birth and resolves within a few days.

2) Caput succedaneum

3) Cephalhaematoma

4) Subgaleal haemorrhages

5) Craniosynostosis

Question 2

What is caput succedaneum?

Answer 2

A diffuse subcutaneous fluid collection on the scalp, outside the periosteum.

As the fluid is outside the periosteum, it is able to cross the suture lines.

Question 3

What is the periosteum?

Answer 3

The periosteum is a layer of dense connective tissue that lines the outside of the skull and does not cross the sutures (the gaps in the baby’s skull).

Question 4

Prognosis of caput succedaneum?

Answer 4

It does not require any treatment and will resolve within a few days.

Question 5

What is caput succedaneum caused by?

Answer 5

Caused by pressure on the presenting part of the head during delivery.

E.g. mechanical trauma of the initial portion of the scalp pushing through the cervix in a prolonged delivery or secondary to the use of ventouse (vacuum) delivery.

Question 6

What is a cephalohaematoma?

Answer 6

A subperiosteal haemorrhage which occurs in 1-2% of infants and may increase in size after birth.

The haemorrhage is bound by the periosteum, therefore, the swelling does not cross suture lines (in contrast to a caput succedaneum).

Question 7

Where does a cephalohaematoma collect?

Answer 7

Between the skull and periosteum.

Question 8

Does cephalohaematoma cross suture lines?

Answer 8

No - as the blood is below the periosteum.

Question 9

Cause of a cephalohaematoma?

Answer 9

Caused by damage to the blood vessels during a traumatic, prolonged or instrumental delivery.

Question 10

What is the most common site affected in cephalohaematoma?

Answer 10

Parietal region

Question 11

Presentation of a cephalohaematoma?

Answer 11

• typically within 24-48h of delivery
• fluctuant, non-pulsatile swelling overlying one or more cranial bones
• mass does not cross suture lines
• size depends on extend of bleeding
• blood can cause discolouration of the skin in the affected area

Question 12

What may develop as a complication of cephalohaematoma?

Answer 12

Anaemia & jaundice due to the blood that collects within the haematoma and breaks down, releasing bilirubin.

Monitor bilirubin.

Question 13

How long does a cephalohaematoma last?

Answer 13

Can last up to 3 months

Question 14

When does a cephalohaematoma present after delivery?

Answer 14

24-48h following delivery

Question 15

How will a cephalohaematoma feel on palpation?

Answer 15

Exhibits well-defined margins and should feel firm yet resilient without any signs of tenderness or warmth.

Question 16

In most cases, the diagnosis of cephalohaematoma can be made based on clinical examination alone.

What investigation may be indicated in cases of uncertainty?

Answer 16

Ultrasonography

Question 17

What may occur to a cephalohaematoma in its resolution phase?

Answer 17

Calcification:

Peripheral calcification of the hematoma may occur. In rare cases, this process can lead to ossification and formation of a bony mass known as ‘intraosseous hematoma.’

Question 18

What are the 2 key differentials for a cephalhaematoma?

Answer 18

1) Caput succedaneum

2) Subgaleal haemorrhages

Question 19

What is a subgaleal haemorrhage?

Answer 19

This occurs between the aponeurosis of the scalp and periosteum and form a large, fluctuant collection which crosses sutures lines.

They are rare but may cause life-threatening blood loss:
- pallor
- tachycardia
- hypotension
- shock

Question 20

What is a craniosynostosis?

Answer 20

One or more of the fibrous sutures in an infant skull PREMATURELY FUSES, changing the growth pattern of the skull.

This can result in raised ICP and damage to intracranial structures.

Question 21

Management of craniosynostosis?

Answer 21

Surgical intervention is required with the primary goal being to allow normal cranial vault development to occur.

This can be achieved by excision of the prematurely fused suture and correction of the associated skull deformities.

Question 22

What is microcephaly?

Answer 22

Describes a head that is smaller than expected for age and sex.

Microcephaly may be associated with reduced brain size or atrophy.

Question 23

What is macrocephaly?

Answer 23

Describes a head that is larger than expected for age and sex.

Macrocephaly may be normal but may also be associated with hydrocephalus, cranial vault abnormalities or genetic abnormalities.

Question 24

What does a tense bulging fontanelle suggest?

Answer 24

Raised ICP e.g. hydrocephalus

Question 25

What may a sunken fontanelle suggest?

Answer 25

Dehydration

Question 26

How can delivery affect the facial nerve?

Answer 26

Delivery can cause damage to the facial nerve. Facial nerve injury is typically associated with a forceps delivery.

This can result in facial palsy (weakness of the facial nerve on one side).

Function normally returns spontaneously within a few months. If function does not return they may required neurosurgical input.

Question 27

What is facial nerve paralysis during delivery often caused by?

Answer 27

Forceps delivery

Question 28

What is Erbs palsy?

Answer 28

A superior brachial plexus injury involving injury to the C5/C6 nerves.

Question 29

What nerve roots are implicated in Erb’s palsy?

Answer 29

C5 & C6 and occasionally C7.

Question 30

Most common cause of Erbs palsy?

Answer 30

Difficult delivery: shoulder dystocia, traumatic or instrumental delivery, large birth weight.

Question 31

Injury mechanism in Erbs palsy?

Answer 31

Traction injury due to excessive lateral neck flexion towards the contralateral side, or excessive shoulder depression, resulting in violent stretching +/- tearing of the upper portion of the brachial plexus

Question 32

Give some causes of Erbs palsy

Answer 32

1) Difficult or obstructed childbirt e.g. shoulder dystocia requiring emergency forceps delivery, or breech presentations with the arms raised above the head.

2) Falls onto neck/shoulder

3) Excessive traction on the arm, for example during sports (often known as “burner syndrome”)

4) Motorbiking accidents

5) Attempts to reduce a shoulder dislocation.

6) Direct trauma e.g. clavicle fractures, gunshot wounds or stab injuries.

Question 33

What nerves are injured in Erbs palsy?

Answer 33

1) Musculocutaneous nerve

2) Axillary nerve

3) Suprascapular nerve

4) Nerve to subclavius

Question 34

Clinical features of Erbs palsy?

Answer 34

1) Loss of sensation to skin over the “sergeant’s patch”, lateral arm and lateral forearm.

2) Wasting of deltoid, supraspinatus and infraspinatus muscles and the anterior compartment of the arm.

3) Loss of shoulder abduction and external rotation, elbow flexion, finger extension and wrist supination.

This leads to the affected arm having a “waiters tip” appearance:
- Limp, adducted, internally rotated shoulder
- Extended elbow
- Flexed wrist facing backwards (pronated)
- Lack of movement in the affected arm

Question 35

Where is sensation affected in Erbs palsy?

Answer 35

Loss of sensation to the skin over the:

1) “sergeant’s patch”
2) lateral arm
3) lateral forearm

Question 36

What movements are affected in Erbs palsy?

Answer 36

1) shoulder abduction

2) shoulder external rotation

3) elbow flexion

4) wrist supination.

Note - if C7 is involved, elbow and wrist extension will also be diminished and the wrist may be held in fixed flexion.

Question 37

Complications of severely affected untreated babies with Erb’s palsy?

Answer 37

May be left with stunted arm growth, joint contractures and circulatory problems.

Question 38

Management of Erb’s palsy?

Answer 38

Function normally returns spontaneously within a few months. If function does not return then they may required neurosurgical input.

Question 39

What is Klumpke’s palsy?

Answer 39

Injury to the inferior trunk of the brachial plexus (C8/T1).

Question 40

What is the mechanism of injury in Klumpke’s palsy?

Answer 40

Traction injury due to excessive force placed on an abducted shoulder results in violent stretching +/- tearing of the lower portion of the brachial plexus.

Question 41

What are the 2 main causes of Klumpke’s palsy?

Answer 41

1) Traction injury during difficult childbirth e.g. an arm presentation requiring force on the arm to successfully deliver the rest of the baby.

2) A falling person grabbing onto something (e.g. grabbing a branch when falling from a tree)

3) Other causes of excessive abduction such as motorbiking accidents.

4) Compression of the lower plexus by a mass in the root of the neck, such as lymphoma or lung cancer.

Question 42

What 2 nerves are injured in Klumpke’s palsy?

Answer 42

Median & ulnar

Question 43

What sensation is affected in Klumpke’s palsy?

Answer 43

Loss of skin sensation in the:

1) median and ulnar distributions of the hand

2) medial forearm and arm

Note - the sensory supply to the lateral dorsum of the hand is preserved as this comes from the radial nerve.

Question 44

Motor effects of Klumpke’s palsy?

Answer 44

1) All small intrinsic muscles of the hand. affected –> there is generalised wasting of hand muscles with a loss of MCPJ flexion, IPJ extension, finger abduction and adduction, and opposition.

2) Loss of wrist flexion –> ‘claw hand’ deformity, wrist is classically held supinated.

Question 45

Presentation of a claw hand deformity as a result of Klumpke’s palsy?

Answer 45

Deformity affecting all four fingers, characterised by IPJ flexion and MCPJ hyperextension at rest, and an inability to extend the fingers.

The wrist is classically held supinated.

Question 46

What may T1 injuries also be associated with?

Answer 46

Horner’s syndrome

Question 47

What nerve root is implicated in Horner’s syndrome?

Answer 47

T1

Question 48

What is Horner’s syndrome?

Answer 48

Any injury to the T1 nerve root associated with loss of sympathetic function.

Question 49

What is plagiocephaly?

Answer 49

Deformational, or positional, plagiocephaly is when a baby develops a flat spot on one side of the head or the whole back of the head.

It happens when a baby sleeps in the same position most of the time or because of problems with the neck muscles that result in a head-turning preference.

Question 50

Management of plagiocephaly?

Answer 50

1) Early recongition

2) Sleeping pattern & position

3) Physiotherapy

4) Helmets & bands

Question 51

The clavicle may be fractured during birth.

What is this typically associated with?

Answer 51

Shoulder dystocia, traumatic or instrumental delivery and large birth weight.

Question 52

How might a fractured clavicle can be picked up shortly after birth or during the newborn examination?

Answer 52

1) Noticeable lack of movement or asymmetry of movement in the affected arm

2) Asymmetry of the shoulders, with the affected shoulder lower than the normal shoulder

3) Pain and distress on movement of the arm

Question 53

Investigations & management of a fractured clavicle at birth?

Answer 53

US or Xray.

Management is conservative, occasionally with immobilisation of the affected arm. It usually heals well.

Question 54

What is the main complication of a fractured clavicle at birth?

Answer 54

Injury to the brachial plexus with a subsequent nerve palsy.