This document discusses nerve injuries, fractures, and dislocations that can occur in neonates during birth. It begins by defining different types of nerve injuries such as facial palsy and brachial palsy. Common sites of fracture in newborns are then described, along with clinical features and management. Dislocations during birth, including of the hips, are also covered. Finally, preventive measures for minimizing birth injuries are discussed.

1. NERVE INJURIES ,FRACTURE
BONE AND DISLOCATIONS
Prepared by:
Shraddha Dahal
Roll no:25
B.Sc.Nursing 4th year

2. General Objective
At the end of this session, all the B.Sc.
Nursing 3rd year students will be able to
explain about nerve injuries, fracture bone
and dislocations in neonate.

3. Specific Objectives
At the end of this session, all the B.Sc.
nursing 3rd year students will be able to:
• define nerve injuries.
• list the types of nerve injuries.
• describe about facial palsy.
• describe about brachial palsy.
• describe about phrenic nerve paralysis.

4. • define fracture bone.
• state the common sites of fracture bone in
newborn.
• state the clinical features of fracture bone
in newborn.
• discuss the diagnosis for fracture bone in
newborn.
• explain the management of fracture bone
in newborn.
• discuss the prognosis of fracture bone in
newborn.

5. • discuss about dislocations during birth
process.
• discuss preventive measure of birth
injuries.

6. Nerve Injuries
Nerve injuries in neonate are those injuries
to the nerve that occurs during the process
of delivery. The most common injury is to the
facial nerve or to the brachial plexus nerve.

7. Types of Nerve Injuries

8. A. Facial Palsy
• Facial nerve palsy due to birth trauma is
the loss of voluntary muscle movement in
an infant's face due to pressure on the
facial nerve in the face just before or at the
time of birth.
• Facial palsy is also known as Bell's Palsy.
• Facial nerve gets injured as it remains
unprotected after its exit through the
stylomastoid foramen.

9. Facial Nerve

10. Causes
1. direct pressure of the forceps blades

11. …contd
• Compression of nerve against sacral
promontory.
• Much pressure on the ramus of the
mandible where the nerve crosses
superficially.

12. Diagnostic Features
• There is unilateral facial weakness with
eyelid affected side remaining open and
are immobile.
• No nasolabial fold is present.
• Absence of rooting reflex on the affected
side but sucking reflex remains unaffected.
However if the baby cannot form effective
seal on the nipple, some feeding
difficulties may arise.

13. …contd
• On crying, the angle of the mouth is drawn
over the unaffected side.
• It can be found bilateral ,if in association
with intracranial lesions.

14. Facial Palsy

15. Management
• There is no specific treatment as the
condition improves on 1-2 weeks unless it
is complicated by intracranial lesions.
• If the baby's eye does not close all the
way, an eyepad and eyedrops will be used
to protect the eye.
• If the eyelids remain open, regular
instillation of synthetic tear (1% methyl
cellulose eye drops) can help lubricate the
eyeball.

16. …contd
• Feeding difficulties are usually overcome
by the baby's own adaptation ,although
alternative feeding position can be tried.
Give expressed breast milk.
• Surgery may be needed to relieve
pressure on the nerve.
• Infants with permanent paralysis need
definitive treatment like nerve
transplantation.

17. Prognosis
Most of the cases of facial paralysis resolve
spontaneously in 2 weeks. If movement of
face is still limited at one year of age,
permanent paralysis is likely.

18. B. Brachial Palsy
• Brachial palsy refers to damage in the root
or the trunk of the nerves of brachial
plexus, a group of nerves at the apex of
the axilla, lying under the clavicle due to
stretching or effusion or hemorrhage
inside the nerve sheath or tearing of fibers.
• Unilateral involvement is common.

20. Causes
Hyperextension of
neck during attempted
delivery of shoulder
dystocia or even in
spontaneous vaginal
delivery and difficult
breech extraction.

21. Types of Brachial Palsy

22. 1. Erb’s Palsy
Erb's palsy refers to injury to upper brachial
plexus involving 5th and 6th and rarely the
7th cervical nerve roots.

23. Clinical Features
• Inward rotation of
arms with
extension of elbow
• pronation of the
forearm
• flexion of the wrist

24. Winging of Scapula

25. …..contd
• Arm limp although some movements of
the finger's is possible.
• Moro reflex and biceps jerk are absent on
affected side.
• This may be associated ipsilateral phrenic
nerve (diaphragmatic) paralysis (C3, 4, 5).

26. Management
• Splint the arm in position which will most
effectively relax the affected muscles. Use of
splint helps to hold the arm abducted to right
angle and externally rotated.
• Every joint of the affected arm should be kept
in full range of movement atleast once a day.
• Care of skin
• Physiotherapy

27. Splinting the Arm

28. …contd
• Suitable analgesics are prescribed for
relief of pain.
• Usually complete recovery takes place
within weeks or months ,but in severe
injury permanent disability may develop.
Follow up is recommended as early
surgical repair( nerve suture, nerve
grafting, and nerve decompression) has
been effective in the 5% of babies who do
not recover spontaneously within 4-6
months.

29. 2. Klumpke’s palsy
• Klumpke's palsy refers to damage to the
lower brachial plexus involving 7th and 8th
cervical nerve roots or even 1st thoracic
nerve roots. The upper arm has normal
movement but the lower arm ,wrist and
hands are affected.

30. Clinical Features
• Arm is flexed at the elbow
and the wrist is extended.
• Forearm is supinated and
a claw-like deformity of the
hand is observed.
• Wrist drop and flaccid
paralysis of the hand with
no grasp reflex.

31. Claw Like Deformity

32. …contd
• When the first thoracic nerve is involved,
there may be homolateral ptosis with small
pupil due to sympathetic nerve
involvement (Horner’s syndrome).

33. Horner’s Syndrome

34. Management
• Immobilization by splinting of arms and
prevention of contractures.
• Physical therapy ,gentle massage and
passive movements are advocated.
• Suitable analgesics are prescribed for
relief of pain.
• Full recovery takes weeks or even months.
Severe laceration and hemorrhage in
nerves may produce permanent disability.
If paralysis persists for more than 4-6
months, nerve repair surgery is
recommended.

35. 3. Total Brachial Plexus Palsy
• Total brachial plexus palsy refers to
damage to all brachial plexus nerve.
• Clinical features:
Complete paralysis of the arm and hand
with a lack of sensation and circulatory
problems.

36. Total Brachial plexus Palsy

37. Management
• Treatment to prevent contractures of the
paralysed arm by splinting and passive
movements of the joint and limbs under
direction of physiotherapist.
• Surgical repair of nerve may be
recommended.
• Medications is primarily used for pain.

38. Prognosis of Brachial Palsy
• Prognosis is usually good, if it is due to
stretching.
• Erb's palsy tends to resolve more quickly
than the other forms.
• Babies with no functional recovery by 4
months of age ( approximately 2 in 1000
births) may require surgical repair by 6
months of age to achieve full function.
• But if it is due to hemorrhage or avulsion,
the deformity may be permanent.

39. C. Phrenic Nerve Paralysis
• Phrenic nerve paralysis refers to damage
to phrenic nerve, a nerve that arises from
cervical plexus(C3,4,5) and innervates
diaphragm which causes paralysis of the
ipsilateral diaphragm.

40. Cervical Plexus

41. Cause:
• Excessive stretching of the neck at birth usually
during breech or difficult forceps delivery and
shoulder dystocia.
Clinical features:
• Injury to phrenic nerve is usually unilateral, the
lung on affected side doesn't expand and the
respiratory efforts are ineffectual.
• Infants present with respiratory distress,
cyanosis, tachypnea.
• Diagnosis is made by USG showing
paradoxical movement of the diaphragm.

42. Normal Breathing Movement

43. Management
• Treatment is supportive.
• To facilitate maximum expansion of the uninvolved
lung, the infant is positioned on the affected side.
• Adequate warm and humidified O2 in high
concentration. If oxygen saturation of blood cannot
maintained at a satisfactory level and carbon
dioxide level rises , infant will required ventilator
support.
• Recovery is usually complete in 1–3 months time.

44. B. Fracture Bone
• Fracture of bone as a common birth injury
is defined as any break in the continuity of
structure of bone during birth process.
• The fracture may be green stick or
complete type.

45. Common Sites of Fracture Bone in
Newborn
I. Clavicle fracture
II. Humerus fracture
III. Femur fracture
IV. Spinal fracture

46. Clinical Features of Fracture in
Newborn
• It is possible to feel distortion in the bone ,
crepitus and audible click sound.
• There is limitation of movement, deformity at
the site of fracture along with pain.
• In spinal fracture:
Flaccid paraplegia
Respiratory failure
Dull or absent of sensations below the site
of lesion.

47. Diagnosis of Fracture Bone

48. Management
• Careful handling ,cleaning and dressing of
the baby to reduce discomfort.
• Positioning the baby on the back or on the
unaffected side to make him more
comfortable.
• Analgesia according to doctor's instruction.
• Usually fractures of clavicle require no
treatment.

49. …contd
• In fractures of humerus: Strap the affected
arm to 900 to the side of the chest for
immobilization.
• In fracture of femur :
Limb motion are restricted.
The whole length of the affected limb may
be bandaged to the front of the abdomen
by hip spica cast or treated by vertical
extension by fastening the baby's ankle to
the cross bar placed above the cot.

50. Fracture of Humerus Fracture of Femur

51. Gallow’s Traction

52. • Closed reduction and casting are required
when bones are displaced.
• Follow up in one month to verify that
fracture has healed.

53. Management of Spinal Fracture
• Handle the baby gently when moving or
turning and teach the mother about log
rolling method to change the position of
the baby.
• Braces can be used to immobilize the
fractured part to promote bone alignment
and healing to protect the injured area
from motion or use.
• Rigid collar can also be used for fracture
of cervical spine.

54. Rigid Collar

55. Rigid collar and Braces for Spinal
Fracture

56. Prognosis
• Prognosis is good and rapid union occurs
with callus formation.
• Stable union of a fractured clavicle usually
occurs in 7-10 days, while the humerus
and the femur take 2-3 weeks.
• But the prognosis of spinal fracture is
grave.

57. Dislocations
• A dislocation as a common birth injury is
an injury in which the ends of bones are
forced from their normal positions during
birth process.
• The common sites of dislocations during
birth process are shoulder, hip and fifth-
sixth cervical vertebrae.

58. Dislocated Hips

59. Dislocated Hips
The acetabulum is abnormally shallow in
newborn.The femoral head loses contact
with the acetabulum and cannot firmly fit
into the socket.
Sometimes the ligament that help to hold
the joint into place are stretched.

60. …contd
Risk factors:
• Breech presentation (It is 10 times more
common in infants born by breech.)
• Muscle or spinal abnormalities are
important predisposing factors

61. Clinical Features

62. ….contd

63. Diagnosis

65. Management
• Immediate treatment by closed reduction
with plaster cast or splint.
• The baby can be placed in soft positioning
device known as pavlik harness for 1-2
month to keep the thigh bone in socket.
• Congenital dislocation of hip may require
open surgical reduction after 6 months of
age only if closed reduction fails.

66. Pavlik Harness

67. Prognosis
• Prognosis of dislocated hip diagnosed in
the neonatal period is excellent if
appropriate management is instituted.

68. Prevention of Birth Injuries
1.Antenatal period
• Identification of high risk cases ( especially
which may cause traumatic delivery) is
very important for early and subsequent
management ( elective caesarean section
is important for contracted pelvis,
cephalopelvic disproportion and
malpresentation like breech or transverse).

69. ….contd
2. Intranatal period
 During normal delivery:
• Continous fetal monitoring to detect early
evidences of fetal distress and manage it
promptly to prevent cerebral anoxia.
• Episiotomy is to be done carefully after
placing two fingers in between the head and
the stretched perineum, to prevent injury to
the scalp.
• The neck should not be unduly stretched
during delivery of shoulder to prevent injuries
to brachial plexus and sternomastoid muscle.

70. …..contd
Special care in preterm delivery
• Special care is to be taken during preterm
delivery to prevent anoxia or traumatic
delivery.
• Ventouse delivery should be avoided.
• Liberal episiotomy to minimize intracranial
compression.
• Administer vitamin K 1mg IM to prevent or
minimize hemorrhage from the traumatized
area.

71. Vaginal breech delivery:
To prevent intracranial injuries :
• The crucial period in breech delivery is
during delivery of the after coming head
,therefore never be haste during delivery
of the head which finds time for moulding.
• Episiotomy should be done as routine to
minimize head compression.

72. ….contd
To prevent spinal injury:
• Acute bending of the head is to be
prevented while forceps are being applied
to the after coming head or delivery of the
head.
To prevent injury to brachial plexus and
sternomastoid muscle:
• The trunk should not be pulled excessively
to one side as it causes too much
stretching of the neck.

73. …contd
To prevent fracture , dislocation and
visceral injuries:
• The limbs are delivered in a manner as
described in vaginal breech delivery.
• During delivery of the head by jaw flexion
and shoulder traction, the flexion is
preferably achieved by placing the fingers
over the molar prominences.

74. Any Queries????

75. References
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76. THANK YOU