Erba-Duchesne paralysis

Paralysis of Erba-Duchesne (proximal upper paralysis, obstetric paralysis) is a disease The peripheral nervous system that results from damage to a portion of the nerve fibers of the brachial plexus. Most often it is a consequence of birth trauma, from where it was called "obstetric" paralysis. However, this is not the only reason for this condition. The main clinical manifestations of Erba-Duchenne paralysis are muscle weakness in the upper (proximal) parts of the arm, restriction of movements in the shoulder and elbow joints, as well as violation sensitivity. In the brush movements are most often preserved. Diagnosis of this disease is based on a characteristic clinical picture and a number of additional research methods. Treatment can be both conservative and operative. The prognosis of the disease depends on its severity and completeness of treatment. About everything related to the Erba-Duchenne paralysis, you can learn by reading this article.

The disease has been known for more than a century. In 1872 the French neurologist G. Duchesne and independently of him in 1874. German doctor V. Erb described a clinical picture of paralysis associated with damage to the nerve bundles of the brachial plexus during obstetric delivery. Since then, paralysis has become known as the Erba-Duchesne paralysis.

Most often this disease occurs as a result of trauma to the upper parts of the brachial plexus in obstetric practice. According to statistics, the incidence of paralysis of Erba-Duchesne is currently 1-2 cases per thousand of newborns. Despite the fact that midwifery techniques are being improved and the level of medical care at birth has become much higher than in the last century, completely eliminate the occurrence of Erba-Duchesne paralysis until managed.

Causes

The most common cause of paralysis of Erba-Duchesne is a trauma of the upper trunk of the brachial plexus on the neck at obstetric aid. The fact is, sometimes in the process of delivery the obstetrician has to apply additional manipulations to help the child is born (thereby saving his life): turn on the foot, traction by the handle, releasing the shoulder, traction for the pelvis. I would like to emphasize that such actions are carried out only when necessary, when the child is not able to be born on his own, and it's too late to talk about Caesarean section. During such manipulations are possible:

• excessive stretching of the superior trunk of the brachial plexus, tears and even ruptures of its bundles (damage to the root of the C5-C6 cervical segments);
• traumatization of staircases and a number of located fascia on the neck (where the nerve trunks pass);
• small bleeding in the area of ​​the brachial plexus and stair muscles.

Direct damage to nerve fibers is initially accompanied by a breakdown of nerve conduction and the appearance of symptoms of the disease, and muscle injury and bleeding after reducing edema and resorption of the hematoma leaves behind cicatricial changes that can compress the nerve trunks, thereby disrupting nerve conduction and also creating a picture of the Erba-Duchesne paralysis.

In addition to injuries during childbirth, the upper bundle of the brachial plexus can be damaged by:

• falling on an outstretched hand;
• sharp traction (jerk) by the hand;
• a strong blow from above on the shoulder;
• contusion of the shoulder joint and neck area;
• gunshot or knife wound in the brachial plexus.

The described situations, of course, are much less likely to cause the paralysis of Erba-Duchene in comparison with obstetric problems.

Symptoms

The upper bundle of the brachial plexus is the source of nerve fibers for such nerves as musculo-dermal, axillary and partially radial. When the Erba-Duchen paralysis is disrupted, the function of the muscles that are controlled by these nerves (deltoid, brachial, brachial, biceps arm muscle), and sensitivity in the zone is lost their innervation. This is accompanied by the following symptoms:

• the inability actively (that is, independently) to bend the arm in the elbow joint (passive flexion is not limited in this case. Passive means "with someone's help");
• the inability to raise the hand to the horizontal level forward, take it to the side, that is, the limitation of movements in the shoulder joint. As a result, the hand "hangs" all the time;
• the impossibility to turn the affected arm outwards, as a result of which the hand is brought into the trunk in such a way that the palm turns away from the trunk and looks to the side and back;
• the rear extension of the hand is weakened, so the palm is in the free state in the position of palmar flexion (due to the prevailing tonus of flexor muscles);
• the extension of the fingers is weakened;
• impaired sensitivity to the lateral surface of the arm (outer surface of the shoulder and forearm);
• the flexion-ulnar reflex is not caused;
• in children, grasping and palatal-oral reflexes are also not caused (in adults, they are normally absent);
• muscle tone on the affected limb is reduced;
• the skin feels cold and pale in comparison with a healthy limb;
• painful pressure at the Erba point. The point is located above the clavicle outside from the place of attachment of the nodal (sternocleus-mastoid) muscle.

If the newborn child is held horizontally on his arms, the affected limb will hang (both in the abdominal position and in the position on the back).

The degree of severity of the symptoms described above depends on how much the nerve fibers are damaged. If a complete rupture of the beams occurs, the movements will be completely absent, and if the tear is partial, the movements will be limited in volume and force.

In the clinical period of Erba-Duchenne paralysis, three stages are distinguished:

• sharp;
• reductive;
• period of residual phenomena.

The acute stage lasts for the first month after the onset of paralysis, the recovery phase lasts up to a year (according to some data up to three years), and then comes a period of residual phenomena that lasts for the remainder a life. It is very important to take measures to treat the paralysis of Erba-Duchesne in acute and recovery stage, Since in the period of residual phenomena of radical changes in the improvement of the state, it is necessary.

By the end of the recovery period and in the period of residual events with poor recovery in the patient, the affected limb shortens, is hypotrophic (grows thin), in severe cases it looks underdeveloped, as in a baby (and remains so for the whole a life). It is possible to form contractures in the area of ​​the shoulder and elbow joints. In severe cases, a "pupal" furrow is formed, a line that limits the transition of the arm to the trunk. Atrophy of muscles can cause the formation of subluxation or even dislocation of the shoulder joint. The shoulder blade from the affected side turns, its edge as it were removed from the spine. Over time, because of the described changes, the curvature of the spinal axis develops in the cervicothoracic region, that is, scoliotic deformity.

Diagnostics

In general, the clinical manifestations of the Erba-Duchenne paralysis are quite typical, so it is possible to suspect its presence without additional research methods. Inspection neonatologist (orthopedist, neurologist) after birth allows you to suspect this pathology. From instrumental diagnostic methods can be used: roentgenography of the shoulder joint, ultrasound of the shoulder joint, electroneuromyography, CT-myelography, MRI diagnostics. Each of the described research methods poses a certain task in diagnosis and can not always be replaced by another method. So, for example, CT-myelography is the most informative from the point of view of establishing the degree of detachment of rootlets from the nerve plexus in the planned surgical intervention.

Treatment

The treatment of Erba-Duchesne's paralysis can be conservative and operative. Always begin with conservative treatment, because in an acute period it is not always possible to accurately determine the degree of damage to nerve fibers due to concomitant edema and inflammation of the tissues.

Conservative therapy includes, in the first place, treatment by position (that is, on the affected limb impose a special tire, which is removed only for the period of hygiene and medical procedures). Also shown:

• pharmacotherapy (non-steroidal anti-inflammatory drugs - Ibuprofen, painkillers, blood circulation improving drugs - Pentoxifylline, Papaverin; anticholinesterase drugs that enhance the conduct of the nerve impulse - Neuromidine, Proserin, Galantamine; drugs to improve metabolism - Actovegin, Mexidol, vitamins group B);
• physiotherapy (electrostimulation of damaged muscles, electrophoresis with various drugs, UHF therapy, ozocerite, paraffin applications and others);
• massage, physiotherapy exercises (starting from the 2 nd week from the onset of the disease).

We must understand that the treatment of the Erba-Duchesne paralysis is a painstaking exercise, requiring great patience from the child and his parents. It is necessary to strictly observe all recommendations in order to achieve maximum effect. Many events are held for months (especially in the field of physiotherapy and massage).

The effect of conservative treatment is possible only if the anatomical integrity of at least a part of the fibers of the superior bundle of the brachial plexus is preserved. This effect is expected for about 3 months, assessing the results of conservative treatment. If by the age of 3 months the child does not have active flexion movements in the elbow joint, then the question of the need for surgical treatment is raised. The essence of the operation is to restore the integrity of nerve fibers (their stitching in the place of separation), plastic nerve trunk is produced using microsurgical techniques. The best results show surgical treatment performed in the first year of life (even better in the period from 3 to 7 months). By itself, the plasticity of nerve fibers does not yet clear all the symptoms of the disease, it only restores the "path" by which the nerve impulses reach the muscles and skin. Further conservative restorative treatment with the use of medications, massage, physiotherapy exercises, physiotherapy, so that the motor defect in the period of residual phenomena was the minimum.

If active measures to eliminate the symptoms of Erba-Duchesne's paralysis were not taken in the first months after the onset of the disease, then in the future good prospects for it is necessary. "The way is a spoon for dinner as they say.

In cases where the cause of Erba-Duchesne paralysis is not obstetric pathology, the approach to treatment remains the same. The terms of treatment are individually reviewed. For example, in the case of gunshot or stab wounds, the establishment of a complete break of the nerve bundles in the first weeks after the injury is an indication for prompt intervention. Otherwise, the methods of conservative treatment are the same as in obstetric paralysis, but the arsenal used medicinal products is a bit wider (as far as newborns can not apply all medicines).

Forecast

How will Erba-Duchesne's paralysis end: full recovery or disability? It depends on many factors:

• from severity of damage to nerve fibers;
• from the timeliness and correctness of treatment;
• from scrupulous implementation of all the recommendations of the attending physician (which means, patience of the patient and his parents).

With partial damage to the superior bundle of the brachial plexus, even a 100% recovery is possible (according to statistics, up to 20% of patients with partial damage have such chances). With complete separation, unfortunately, the chances are much less. However, timely surgical treatment increases their percentage.

Thus, Erba-Duchenne's paralysis is a disease that can be defeated. Its main symptoms in the form of restriction of movements in the shoulder and elbow joints can be minimized if you seek medical help in a timely manner and do not let the situation drift.