This document discusses various types of birth injuries that can occur in infants. It describes soft tissue injuries, skull injuries like cephalohematomas and fractures, and intracranial hemorrhages. It also covers facial injuries like subconjunctival hemorrhages and brachial plexus injuries. Risk factors for birth injuries include primiparity, fetal macrosomia, and mechanical forces during delivery. Diagnosis involves physical examination, imaging, and assessment of neurologic function. Management depends on the type and severity of injury but may include wound care, splinting, ventilation support, or surgery.

1. Birth
Injuries
Dr. Fathi Neana, MD
Chief of Orthopaedics
Dr. Fakhry & Al-Garzaie Hospital
Saudi Arabia
May, 7 - 2017

2. • An impairment of the infants
body function or structure due to
adverse influences that occur at
birth
• Injuries to the infant may result
from mechanical forces (i.e.,
compression, traction) during the
birth process
Birth Injuries
BIRTH INJURIES
Aruna. A P
I Year MSc Nursing

3. • 0.7% (Seven of every 1,000) births
result in birth injuries. though most
women give birth in modern
hospitals surrounded by medical
professionals
• Birth injuries account for fewer than
2% of neonatal deaths
• Infant mortality resulting from birth
trauma fell from 64.2 to 7.5 deaths
per 100,000 live births from 1970-
1985
Birth Injuries
BIRTH INJURIES
Aruna. A P
I Year MSc Nursing

4. • Primiparity
• Small maternal stature
• Maternal pelvic anomalies
• Prolonged or unusually rapid labor
• Oligohydramnios
• Malpresentation of the fetus (breech)
• Cephalopelvic disproportion
• Deep transverse arrest of presenting part of the
fetus
Factors predisposing to injury
include the following

5. • Use of mid forceps or vaccum
extraction
• Versions and extractions
• Very low birth weight or extreme
prematurity
• Fetal macrosomia birth weight over
about 4,000 grams
• Fetal macrocephali (Large head)
• Fetus anomalies
Factors predisposing to injury
include the following

6. • Soft tissue injuries
• Head and neck injuries
• Facial injuries
• Cranial nerve injuries
• Spinal cord injuries
• Peripheral Nerve injury
• Fractures - Torticollis
• Intra-abdominal injury
CLASSIFICATION OF BIRTH
INJURIES

7. CLASSIFICATION OF BIRTH
INJURIES
Soft tissue
- Abrasions
- Erythema petechia
- Ecchymosis
- Lacerations
-Subcutaneous fat necrosis
Skull
- Caput succedaneum
- Cephalohematoma
- Subgaleal hemorrhage
- Linear fractures
-Intracranial hemorrhages
Face
- Subconjunctival hemorrhage
-Retinal hemorrhage
Cranial nerve & spinal cord
injuries
- Facial palsy
Peripheral nerve
- Brachial plexus palsy
- Unilateral vocal cord paralysis
- Radial nerve palsy
-Lumbosacral plexus injury
Musculoskeletal injuries
- Clavicular fractures
- Fractures of long bones
-Sternocleido-mastoid injury
Intra-abdominal injuries
- Liver hematoma
- Splenic hematoma
- Adrenal hemorrhage
- Renal hemorrhage

8. SOFT TISSUE INJURIES
- Abrasions
- Erythema petechia
- Ecchymosis
- Lacerations
- Subcutaneous fat necrosis

9. May occur as scalpel cuts during Cesarean
delivery or during instrumental delivery (i.e,
vacuum, forceps)
Infection remains a risk, but most uneventfully
heal
Management
Careful cleaning, application of antibiotic
ointment, and observation
Lacerations occasionally require suturing
Abrasions and lacerations

10. Irregular, hard, nonpitting,
subcutaneous induration with
overlying dusky red-purple
discoloration on the extremities,
face, trunk, or buttocks
May be caused by pressure during
delivery.
No treatment is necessary
Subcutaneous fat necrosis
sometimes calcifies
Subcutaneous fat necrosis

11. - Caput succedaneum
- Cephalohematoma
- Subgaleal hemorrhage
- Skull fractures (Linear-Depressed)
- Intracranial hemorrhages
SKULL INJURIES

13. • Oedema of the presenting part
caused by pressure during a
vaginal delivery
• This is a serosanguineous,
subcutaneous, extraperiosteal
fluid collection with poorly
defined margins, non fluctuating
Caput succedaneum

14. • Subperiosteal collection of
blood between the skull and
the periosteum.
• It may be unilateral or
bilateral, and appears within
hours of delivery as a soft,
fluctuant swelling on the side
of the head.
• A cephalhaematoma never
extends beyond the edges of
the bone or crosses suture
lines
Cephalhematoma

15. Cranial X-ray of the girl with Cephalohematoma

16. Bleeding in the potential space between
skull periosteum & scalp galea aponeurosis
Crosses suture lines
Subgaleal hematoma
(і) Shock and pallor: tachycardia, a low blood pressure, within 30
minutes of the haemorrhage the haemoglobin and packed cell
volume start to fall rapidly.
(ii) Diffuse swelling of the head. Sutures usually are not palpable.
The amount of blood under the scalp is far more than is
estimated. Within 48 hours the blood tracks between the fibres of
the occipital and frontal muscles causing bruising behind the ears,
along the posterior hair line and around the eyes.

17. Cephalhematoma
If infection is suspected, aspiration of the mass
If sepsis, antibiotics
hyperbilirubinemia – photo therapy
Subgaleal hematoma
Transfusions may be required if blood loss is
significant.
In severe cases, surgery may be required to cauterize
the bleeding vessels.

18. Skull fractures
Linear skull fractures
Usually the parietal bones.
Compression forceps, or skull against symphysis or ischeal
spines.
Rarely, dural tear, with leptomeningeal cyst.
Depressed skull fractures
Indications for surgery include
radiographic evidence of bone
fragments in the cerebrum
presence of neurologic deficits
signs of increased intracranial pressure
signs of cerebrospinal fluid beneath the galea
failure to respond to closed manipulation.
Indications for nonsurgical management include
Depressions less than 2 cm in width and depressions over a
major venous sinus
Without neurologic symptoms

19. • Bleeding can occur
– External to the brain into the epidural, subdural or subarachnoid space
– In to the parenchyma of the cerebrum or cerebellum
– Into the ventricles from the subependymal germinal matrix or choroid
plexus
• Intracranial haemorrhage
• Epidural hemorrhage
• Subdural hemorrhage
• Subarachnoid hemorrhage
• Intraparenchymal haemorrhage
• Germinal matrix hemorrhage / intraventricular haemorrhage
Intracranial hemorrhages

20. Intracranial hemorrhages

21. Intracranial hemorrhages
• Extradural (epidural)
• Subdural
(i) Shock and/or anaemia due to blood loss
(ii) Neurological signs due to brain compression, e.g.
convulsions, apnoea, a dilated pupil or a depressed
level of consciousness
(iii) A full fontanelle and splayed sutures due to
raised intracranial pressure

22. Subarachnoid hemorrhages (SAH)
(i) Attacks of secondary asphyxia and apnoe, irregular
breathing, bradycardia.
(ii) Hyperestesia, tremor, seizures, bulging of fontanella.
“Sunset” and Grefe symptoms are positive.
(iii) Changes of spinal fluid in lumbar puncture: it becomes
xanthochromic or/and contains blood
Intraventricular (IVH) hemorrhages
Intracranial hemorrhages

23. Periventricular hemorrhage, intraventricular hemorrhage.
Periventricular hemorrhagic infarction (PVHI) on MRI.

24. Periventricular hemorrhage, intraventricular hemorrhage.
Severe or grade III hemorrhage (subependymal with
significant ventricular enlargement) in ultrasonography.

25. - Subconjunctival hemorrhage
-Retinal hemorrhage
-Other ocular injuries
-Nasal septal dislocation
FACIAL INJURIES

26. Subconjunctival hemorrhage
Breakage of small blood vessels in the
eyes of a baby. One or both of the eyes
may have a bright red band around the
iris
This is very common and does not
cause damage to the eyes. The redness
is usually absorbed in a week to ten
days

27. Other Ocular injuries
• Rupture of Descemet’s membrane
of the cornea
• lid lacerations
• hyphema (blood in anterior
chamber)
• vitreous hemorrhage
• Purtscher’s retinopathy
• corneal edema,
• corneal abrasion

28. Nasal Septal dislocation
Clinical features
airway obstruction.
deviation of the nose to one side
The nares are asymmetric, with
flattening of the side of the
dislocation (Metzenbaum sign).
Application of pressure on the tip
of the nose (Jeppesen and
Windfeld test) causes collapse of
the nostrils, and the deviated
septum becomes more apparent.
Management
Definitive diagnosis can be
made by rhinoscopy
manual reduction
performed by an
otolaryngologist using a
nasal elevator.
Reduction should be
performed by 3 days of age
Involves dislocation of the triangular cartilaginous
portion of the septum from the vomerine groove

29. - Brachial plexus palsy
- Phrenic nerve injury
- Laryngeal nerve injury
(unilateral vocal cord paralysis)
- Radial nerve palsy
-Lumbosacral plexus injury
PERIPHERAL NERVE
INJURIES

30. PERIPHERAL NERVE INJURIES

31. Brachial plexus injury
• Erb-Duchenne palsy
(C5-C6) common
phrenic N (C3-5)
• Klumpke palsy
(C 7-8, T1) rare
Horner syndrome (T1 S)
Sternocleidomastoid Hem vs
clavicle fracture
• Total plexus palsy
(Kerer’s paralysis) worst

32. Risk factors
Macrosomia
Shoulder dystocia
Instrumented deliveries
Malpresentation
Brachial plexus injury

33. Brachial plexus injury
• Erb-Duchenne palsy (C5-C6)
• The most common
• Lack of shoulder motion.
• The involved extremity lies adducted, prone,
and internally rotated.
• Moro, biceps, and radial reflexes are absent
on the affected side.
• Grasp reflex is usually present.
• Erb’s palsy may be associated with injury to
the phrenic nerve, innervated with
fibers from C3–C5

34. - This baby presents with an asymmetric
posture of the arms.
• The left arm is not flexed and hangs
limply. Adduction and internal rotation of
the arm with pronation of the forearm.
• Biceps reflex is absent
• Moro reflex is absent
• Grasp reflex is present
• The involved arm is held in the ‘‘waiter’s
tip’’ position, with adduction and internal
rotation of the shoulder, extension of the
elbow, pronation of the forearm, and
flexion of the wrist and fingers.
- The baby demonstrates the findings of a
left-sided ERB PARALYSIS.

35. Brachial plexus injury
• Klumpke paralysis (C 7-8, T1)
Rare
Weakness of the intrinsic muscles of the
hand; and long flexors of the wrist and
fingers (clawing not writing)
Grasp reflex is absent
Biceps reflex is present
• If cervical sympathetic fibers of the Th 1
are involved, Horner syndrome is
present (ptosis, miosis, and anhydrosis).
• Hematomas of the sternocleidomastoid
muscle, and fractures of the clavicle and
humerus.

36. • The total plexus palsy (Kerer’s
paralysis)
is the most disturbing of all. Its clinical
features are:
 adynamy
 muscle hypotony
 positive “scarf” symptom
Kofferate syndrom (C 3-4)
is the diaphragm paralysis. Because of
irregular breathing, cyanosis pneumonia can
be suggested mistakenly.
Brachial plexus injury

37. Erb-Duchenne palsy
(C5-C6)
Klumpke palsy
(C 7-8, T1)
Total plexus palsy
(Kerer’s paralysis)

38. Brachial plexus injury
Case report
Elbow is flexed (C5C6)
Biceps reflex is not absent
Moro reflex is not absent
IT IS NOT Erb palsy (C5-C6)
Grasp reflex is present
No clawing of hand
IT IS NOT Klumpke palsy (C 7-8, T1)
Additional data
Painful shoulder movements, Tender Rt
deltoid region, 2nd day significant swelling
redness same region, X-rays –ve

39. • Neuropraxia with temporary
conduction block
• Axonotmesis with a severed
axon, but with intact
surrounding neuronal elements
• Neurotmesis with complete
postganglionic disruption of the
nerve
• Avulsion with preganglionic
disconnection from the spinal
cord
Brachial plexus injury
Types

40. • Physical examination.
• Radiographs of the shoulder and upper arm
• Initial treatment is conservative.
• The arm is immobilized across the upper abdomen vs elevated
in abduction external rotation of shoulder during the first
week
• Physical therapy with passive range-of-motion exercises at the
shoulder, elbow and wrist should begin after the first week.
• Infants without recovery by 3 to 6 months of age may be
considered for surgical exploration
Brachial plexus injury
Diagnosis & Management

41. Brachial plexus injury

42. • The phrenic nerve arises from the third through fifth cervical
nerve roots.
• Injury to the phrenic nerve leads to paralysis of the ipsilateral
diaphragm.
• respiratory distress, with diminished breath sounds on the
affected side.
• Chest radiographs show elevation of the affected diaphragm,
with mediastinal shift to the contralateral side.
• Ultrasonography or fluoroscopy can confirm the diagnosis by
showing paradoxical diaphragmatic movement during
inspiration
Phrenic nerve injury

43. • Initial treatment is supportive
• Oxygen
• Respiratory failure may be treated with
continuous positive airway pressure or
mechanical ventilation.
• Gavage feedings.
• Plication of the diaphragm
Phrenic nerve injury
Treatment

44. Laryngeal nerve injury
Treatment
Small frequent feedings may be
required to decrease the risk of
aspiration.
Intubation
Tracheostomy
Bilateral paralysis tends to
produce more severe distress, and
therefore requires intubation and
tracheostomy placement more
frequently
Symptoms
Stridor
respiratory distress
hoarse cry
dysphagia,
Aspiration
Diagnosis
By direct laryngoscopy

45. -Facial palsy
-Spinal cord
injuries
-
CRANIAL NERVE
& SPINAL CORD INJURIES

46. • can be caused by pressure on the facial
nerves during birth or by the use of forceps
during birth. The affected side of the face
droops and the infant is unable to close the
eye tightly on that side. When crying the
mouth is pulled across to the normal side.
• protection of the involved eye by
application of artificial tears and taping to
prevent corneal injury.
• neurosurgical repair of the nerve should be
considered only after lack of resolution
during 1 year of observation
Facial paralysis

47. Excessive traction or rotation
 failure to establish adequate respiratory
function
 the baby usually is posing as frog
 “oscillation” test is positive
(prick leg of the newborn with needle  leg will flex
and extend in all joints several times)
Spinal cord injury

48. • Clinical findings
• decreased or absent
spontaneous movement
• absent deep tendon
reflexes
• absent or periodic
breathing
• lack of response to
painful stimuli below the
level of the lesion.
Spinal cord injury
• Lesions above C4 are
almost always
associated with apnea
• Lesions between C4
and T4 may have
respiratory distress
secondary to varying
degrees of involvement
of the phrenic nerve
and innervation to the
intercostal muscles

49. Spinal cord injury

50. • If cord injury is suspected
in the delivery room,
• The head, neck, and spine
should be immobilized.
• Therapy is supportive.
Spinal cord injury
Management

51. - Clavicular fractures
- Fractures of long bones
-Sternocleido-mastoid injury
MUSCULOSKELETAL
INJURIES

52. The clavicle & long bone
fracture
Clavicle is the most frequently bone
injure in the neonate during birth and
most often is an unpredictable
unavoidable complication of normal birth.
The infant may present with
pseudoparalysis.
Examination may reveal crepitus, palpable
bony irregularity, and sternocleidomastoid
muscle spasm.
Desault's bandage should be used for 7-
10 days.

53. Sternocleido-mastoid injury
Congenital muscular torticollis
• atrophic muscle fibers
surrounded by collagen and
fibroblasts.
• tearing of the muscle fibers
or fascial sheath with
hematoma formation and
subsequent fibrosis.
• The head is tilted toward the
side of the lesion and rotated to
the contralateral side,
• chin is slightly elevated.
• If a mass is present, it is firm,
spindle-shaped, immobile, and
located in the midportion of the
sternocleidomastoid muscle,
without accompanying
discoloration or inflammation.

54. Sternocleido-mastoid injury
Congenital muscular torticollis
• DIAGNOSIS
• physical examination
• Radiographs should be
obtained to rule out
abnormalities of the
cervical spine.
• Ultrasonography may be
useful both diagnostically
and prognostically.
• TREATMENT
• active and passive
stretching
• Surgery < 2years

55. - Liver hematoma
- Splenic hematoma
- Adrenal hemorrhage
- Renal hemorrhage
INTRA-ABDOMINAL
INJURIES

56. Intra abdominal
injuries
Liver injury is the most common
• Three potential mechanisms lead to intra-
abdominal injury:
• (1) direct trauma,
• (2) compression of the chest against the surface
of the spleen or liver
• (3) chest compression leading to tearing of the
ligamentaous insertions of the liver or spleen

57. Intra abdominal injuries
• Clinical manifestations
• With hepatic or splenic rupture, patients
develop sudden pallor, hemorrhagic
shock, abdominal distention, and
abdominal discoloration.
• Presentation of a liver rupture with
scrotal swelling and discoloration has
been described.
• Subcapsular hematomas may present
more insidiously, with anemia, poor
feeding, tachypnea, and tachycardia.
• Adrenal hemorrhage may present as a
flank mass
• Diagnosis
• abdominal ultrasound
• Computed tomography
• Abdominal radiographs may
show nonspecific
intraperitoneal fluid or
hepatomegaly.
• Abdominal paracentesis is
diagnostic if a hemoperitoneum
is present

58. • volume replacement
• Correction of any coagulopathy
• Hemodynamically stable infant, conservative
management is indicated
• With rupture or hemodynamic instability, a
laparotomy is required to control the bleeding
• With adrenal hemorrhage hormone
replacement therapy may be required
Intra abdominal injuries
Treatment

59. CONCLUSIONS
1- Recognition of trauma
2- Careful physical and neurologic evaluation
3- Establish whether additional injuries exist
4- Injury may result from resuscitation
5- Assess Symmetry of structure & function
6- Specific examination such as cranial
nerve, joint range of motion, scalp/skull
integrity.

60. THANK YOU