ANNUAL INJURY OF NEWBORN.

ANNUAL INJURY OF NEWBORN. The factors predisposing to birth trauma are the incorrect position of the fetus, the mismatch between the size of the fetus by the size of the small pelvis of the pregnant woman (large fetus or narrowed pelvis), the features of fetal development (chronic intrauterine hypoxia), prematurity, endurance, length of labor (both rapid and prolonged Childbirth). The immediate cause of birth traumatism is often incorrectly performed obstetric aids when turning and extracting the fetus, applying obstetric forceps, vacuum extractor, etc.

Birth injury of soft tissues. Damage to the skin and subcutaneous tissue during labor (abrasions, scratches, hemorrhages, etc.), as a rule, are not dangerous and require only local treatment to prevent infection (treatment with 0.5% alcohol solution of iodine, application of an aseptic dressing); They disappear usually after 5 to 7 days.

To more severe include muscle damage. One of the typical birth injuries (often developed during labor in the breech presentation) is a lesion of the sternocleid-mastoid muscle, a hemorrhage, or a rupture. In the area of ​​damage, a small, moderately dense or test-like consistency is defined, a slightly painful palpation of the tumor. Sometimes it is detected only at the end of the first week of the child's life, when the torticollis develops: the child's head is tilted toward the injured muscle, and the chin is turned in the opposite direction. Differentiate the hematoma of the sternoclavicular-mastoid muscle with congenital muscular torticollis.

Treatment consists in creating a corrective position that helps to eliminate the pathological tilt and turn of the head (use rollers), the application of dry heat, electrophoresis of potassium iodide; In later terms, a massage is prescribed. As a rule, the hematoma resolves and after 2 - 3 weeks the muscle function is restored. If there is no effect from conservative therapy, surgical correction is indicated, which should be performed in the first 6 months of the child's life.

Kefalhematoma - hemorrhage under the periosteum of any bone of the cranial vault (usually one or both parietal, less often occipital). It must be differentiated with a generic tumor, which is a local edema of the skin and subcutaneous tissue of a newborn, usually located on the fetal front and occurs as a result of prolonged mechanical compression of the corresponding area. Generic swelling occurs usually with prolonged labor, as well as with obstetric benefits (application of forceps). Unlike kefalgematoma, the generic tumor extends beyond one bone, it does not have a soft-elastic consistency, fluctuations and a roller along the periphery; The generic tumor disappears after 1-2 days and does not require special treatment.

Children who have suffered a kind of soft tissue trauma usually recover completely.

Birth trauma of the osseous system. The most common lesions are the clavicle, humerus and femur. The reasons for this are improper obstetric care.

Fracture of the clavicle, usually subperiostic, is characterized by a significant restriction of active movements, a painful reaction (crying) with passive movements of the hand on the side of the lesion. With light palpation, note swelling, tenderness and crepitus over the fracture site.

Fractures of the humeral and femur bones are diagnosed by the absence of active movements in the limb, pain reaction with passive movements, the presence of swelling, deformation and shortening of the damaged bone. For all types of bone fractures, the diagnosis should be confirmed radiographically.

Treatment of a fracture of the clavicle consists in a short-term immobilization of the hand with the help of a dezo bandage with a roller in the axillary region or by tightly swaddling an elongated arm to the body for a period of 7-10 days (with the child placed on the opposite side). In fractures of the humeral and femur bones, immobilization of the limb (after repositioning if necessary) and its extension (more often with the help of adhesive plaster) is shown. The prognosis for fractures of the clavicle, humerus and femur is favorable.

Traumatic epiphysiolysis of the humerus is rare, manifested by swelling, tenderness and crepitus during palpation in the region of the shoulder or elbow joints, restriction of movements of the affected arm. In this case, the bending contracture in the elbow and radiocarpal joints often develops because of the paresis of the radial nerve. The diagnosis is confirmed by radiography of the humerus. Treatment: fixation and immobilization of the limb in a functionally advantageous position for 10-14 days with the subsequent appointment of physiotherapy procedures, massage.

Children who have suffered a birth trauma to bones, as a rule, completely recover.

Birth trauma of the internal organs is rare and, as a rule, is a consequence of mechanical effects on the fetus, with improper management of labor and various obstetric benefits. The liver, spleen and adrenal glands are most often damaged as a result of hemorrhage into these organs. During the first 2 days of a clear clinical picture, hemorrhage to the internal organs is not noted ("light" gap). A sharp deterioration in the child's condition occurs on the 3rd-5th day due to bleeding due to rupture of the hematoma and the increase in hemorrhage. Clinically, this is manifested by the symptoms of acute posthemorrhagic anemia and a violation of the function of the organ into which the hemorrhage occurred. When a ruptured hematoma is often noted bloating and the presence of free fluid in the abdominal cavity. The marked clinical picture has a hemorrhage in the adrenal gland, which is often found in the breech presentation. It manifests itself with severe muscle hypotension (up to atony), oppression of physiological reflexes, intestinal paresis, falling AD, persistent regurgitation, vomiting.

To confirm the diagnosis of the birth trauma of the internal organs, an overview radiograph and ultrasound examination of the abdominal cavity are made, as well as an examination of the functional state of the damaged organs.

With hemorrhage in the adrenal gland and the development of acute adrenal insufficiency, replacement therapy with glucocorticoid hormones is necessary. When rupture of the hematoma, intracavitary hemorrhage, surgical intervention is performed.

The prognosis of birth trauma of internal organs depends on the volume and severity of organ damage. If the child does not die in the acute period of the birth trauma, its subsequent development is largely determined by the safety of the functions of the affected organ. Many newborns who underwent hemorrhage to the adrenal glands subsequently develop chronic adrenal insufficiency.

Birth trauma of the central nervous system is the most severe and dangerous for a child's life. It combines various pathological, localized and severity pathological changes in the nervous system that result from the effects of mechanical factors on the fetus. Birth trauma of the nervous system in most cases occurs against a background of chronic fetal hypoxia caused by an unfavorable course of pregnancy (toxicosis, the threat of miscarriage, infectious, endocrine and cardiovascular diseases, occupational hazards, etc.).

Intracranial hemorrhages. The clinical picture of neurological disorders depends on the severity of hemorrhage, a combination with other disorders (hypoxia, hemorrhages of other localization). More often there are slight hemorrhages with such clinical manifestations as regurgitation, tremor of hands, anxiety, an increase in tendon reflexes. Sometimes neurologic symptoms can appear only on the 2nd -3rd day of life after putting the baby to the breast. With massive hemorrhages, children are born in asphyxia, they are disturbed, sleep disturbances, neck stiffness, regurgitation, vomiting , nystagmus, strabismus, tremors , convulsions. Muscle tone is elevated, all unconditioned reflexes are clearly expressed. On the 3-4th day of life, sometimes notice the Harlequin syndrome, manifested by a change in the color of the body half of the newborn from pink to light red; The other half is paler than normal. Clearly, this syndrome is revealed when the child is on the side. Change in color of the body can be observed for 30 to 20 minutes, during this period the child's well-being is not disturbed.

Treatment consists in correction of respiratory, cardiovascular and metabolic disorders. When developing reactive meningitis, antibacterial therapy is prescribed. With increasing intracranial pressure, dehydration therapy is necessary.

In the presence of light neurological disorders or asymptomatic flow, the prognosis is favorable. If the development of hemorrhage is combined with severe hypoxic and / or traumatic injuries, children tend to die, and few survivors usually experience such serious complications as hydrocephalus , seizures , cerebral palsy , delayed speech and mental development.

Trauma of the spinal cord is the result of the influence of mechanical factors (excessive traction or rotation) in the pathological process of childbirth, leading to hemorrhage, sprain, compression and rupture of the spinal cord at various levels. The spine and its ligamentous apparatus in newborns are more extensible than the spinal cord, which is fixed from above by the medulla oblongata and the roots of the brachial plexus, and from below by the pony tail. Therefore, lesions are most often found in the lower and upper thoracic parts, i.e. In places of greatest mobility and attachment of the spinal cord. Excessive spinal distension can lead to the lowering of the brain stem and its incidence into the large occipital foramen.

Clinical manifestations depend on the severity of the injury and the level of injury. In severe cases, a picture of spinal shock is expressed: lethargy, adynamia, muscle hypotension, areflexia, diaphragmatic respiration, weak cry. The bladder is stretched, the anus is gaping. The jerk reflex is sharply expressed: in response to a single prick the leg is bent and unbent several times in all joints. There may be sensitive and pelvic disorders. More often the phenomena of a spinal shock gradually regress, but the child still during weeks or months the hypotension is saved. Then it is replaced by spasticity, increased reflex activity. The legs assume the position of "triple flexion", a pronounced symptom of Babinsky appears. There are also vegetative disorders: sweating and vasomotor phenomena; Can be expressed trophic changes in muscles and bones. With a mild spinal trauma, there is a transient neurological symptomatology.

The diagnosis is made on the basis of information about the obstetric history (delivery in the pelvic presentation), clinical manifestations, survey results. Trauma of the spinal cord can be combined with damage to the spine, so it is necessary to conduct X-ray of the proposed area of ​​the lesion, the study of cerebrospinal fluid.

Treatment consists in immobilization of the prospective area of ​​trauma (cervical or lumbar spine); In the acute period, the dehydration therapy (diacarb, triamterene , furosemide) is administered, vikasol , rutin , ascorbic acid are prescribed, etc. In the recovery period, the orthopedic regimen, physiotherapy, massage, physiotherapy, electrostimulation are shown. Apply aloe, ATP, dibazol, pyrogenal, B vitamins, galantamine, proserin , xanthinal nicotinate .

In persistent neurological disorders, children need long-term restorative therapy. Prophylaxis presupposes proper management of births in the pelvic presentation and in the discoordination of labor, prevention of hypoxia of the fetus, the use of caesarean section in order to avoid over-expansion of its head, the detection of surgically correctable lesions.

Trauma of the peripheral nervous system involves trauma to the roots, plexuses, peripheral nerves and cranial nerves. The most common trauma is the brachial plexus, diaphragmatic, facial and median nerves. The remaining variants of traumatic injuries of the peripheral nervous system are less common.

Injury of the brachial plexus (obstetric paresis) is noted mainly in children with large body weight, born in the gluteal or leg presentation. The main cause of the injury are obstetric aids provided by tilting the upper limbs of the fetus, making it difficult to remove the shoulders and head. Traction and rotation of the head with fixed shoulders and, conversely, traction and rotation of the shoulders with a fixed head lead to tension of the roots of the lower and upper thoracic segments of the spinal cord over the transverse processes of the vertebrae. In most cases, obstetric paresis occurs on the background of fetal asphyxia.

Depending on the localization of damage, the brachial plexus paresis is divided into upper (proximal), lower (distal) and total types. The upper type of obstetric paresis (Duchenne-Erba) occurs as a result of damage to the upper shoulder bundle of the brachial plexus or cervical roots, originating from segments CV-CVI of the spinal cord. As a result, the paresis of the muscles that divert the shoulder, rotating it outward, raising the arm above the horizontal level, flexors and supinators of the forearm, the function of the proximal part of the upper limb is disrupted. The child's arm is brought to the trunk, unbent, rotated inward in the shoulder, penetrated into the forearm, the hand is in the state of palmar flexion, the head is tilted to the painful shoulder.

The lower type of obstetric paresis (Dejerin-Klumpke) occurs as a result of the lesion of the middle and lower primary bundles of the brachial plexus or roots originating from CV ThI, segments of the spinal cord. As a result of the flexor flexion of the forearm, hand and fingers, the function of the distal arm is impaired. Muscular hypotension is noted; Movements in the ulnar, radiocarpal joints and fingers are severely restricted; The brush hangs or is in the position of the so-called clawed paw. In the shoulder joint movements are preserved.

The total type of obstetric paresis is caused by damage to nerve fibers originating from CV-, Th1-segments of the spinal cord. Muscle hypotension is pronounced in all muscle groups. The hand of the child passively hangs down along the trunk, it can easily be wound around the neck - a symptom of a scarf. Spontaneous movements are absent or insignificant. Tendon reflexes are not caused. Skin pale, hand cold to the touch. By the end of the neonatal period, muscle atrophy usually develops.

Obstetric paresis is more often unilateral, but can be bilateral. In severe paresis, along with the trauma of the nerves of the brachial plexus and the roots forming them, the corresponding segments of the spinal cord are involved in the pathological process.

Treatment should begin from the first days of life and be carried out continuously with the goal of preventing the development of muscle contractures and training active movements. The hand is given a physiological position by means of tires, longet; Prescribe massage, exercise therapy, thermal (ozokerite applications, paraffin wax, hot wrapping) and physiotherapy (electrostimulation) procedures; Drug electrophoresis (potassium iodide, proserine, lidase, euphyllin, nicotinic acid). Drug therapy includes vitamins B, ATP, dibazol, propermil, aloe, proserin , galantamine.

With timely begun and proper treatment, limb functions are restored within 3 to 6 months; The period of recovery with pareses of medium severity lasts up to 3 years, but often compensation is incomplete; Severe obstetric paralysis lead to a persistent defect in the function of the hand. Paresis of the diaphragm - restriction of the function of the diaphragm as a result of the damage to the roots of CIII-CV or the diaphragmatic nerve with excessive lateral traction in childbirth. Clinically manifested by shortness of breath, rapid, irregular or paradoxical breathing, repeated attacks of cyanosis, swelling of the chest on the side of the paresis. The right side is injured in 80% of patients, bilateral defeat is less than 10%. Paresis of the diaphragm is not always clinically expressed and is often found only with chest X-ray. The dome of the diaphragm on the side of the paresis is high and slightly mobile, which in newborns can contribute to the development of pneumonia. Paresis of the diaphragm is often combined with a trauma of the brachial plexus.

Treatment is to ensure adequate ventilation of the lungs before restoring independent breathing. The child is placed in a so-called swinging bed. If necessary, carry out artificial ventilation of the lungs, percutaneous stimulation of the diaphragmatic nerve. Most children recover within 10 to 12 months.

Paresis of the facial nerve - damage in the birth of the trunk and (or) branches of the facial nerve. It arises as a result of compression of the facial nerve with the cape of the sacrum, with obstetric forceps, with fractures of the temporal bone.

Clinically, asymmetry of the face is noted, especially with screaming, widening of the eye gap ("hare eye"). When crying, the eyeball can be shifted upwards, and in the loosely closed eye-slit the protein membrane is visible. The angle of the mouth is lowered relative to the other, the mouth is moved to a healthy side. A rough peripheral paresis of the facial nerve can make it difficult to suck. Recovery often occurs quickly and without specific treatment. With a deeper lesion, ozokerite, paraffin and other thermal procedures are performed.

Trauma of the median nerve in newborns can be in the antekubital fossa and in the wrist. Both types are associated with percutaneous puncture of the arteries (humerus and radial, respectively).

The clinical picture is similar in both cases: the finger grasping of the object is broken, which depends on the flexion of the index finger and the withdrawal and contrast of the thumb of the hand. Characteristic position of the brush, due to the weakness of flexion of the proximal phalanges of the first three fingers, the distal phalanx of the thumb, and also associated with the weakness of the removal and opposition of the thumb. There is an atrophy of the elevation of the thumb. Treatment includes the imposition of longes on the wrist, exercise therapy, massage. The prognosis is favorable.

Trauma of the radial nerve occurs when the shoulder is fractured with compression of the nerve. This can be caused by inadequate intrauterine position of the fetus, as well as by the severe course of labor. Clinically, the fatty necrosis of the skin is above the epicondyle of the radius, which corresponds to the compression zone, weakness of extension of the hand, fingers and thumb (dangling of the hand). In most cases, the brush function is quickly restored.

Injury of the sciatic nerve in newborns occurs as a result of improper intramuscular injection in the gluteal region, as well as when introducing hypertonic solutions of glucose, analeptics, calcium chloride in the umbilical artery, resulting in the development of spasm or thrombosis of the lower gluteal artery that supplies blood to the sciatic nerve. It is manifested by a violation of the hip abduction and restriction of movement in the knee joint, sometimes necrosis of the buttock muscles is observed. Treatment includes the imposition of longes on the foot, massage, therapeutic physical training, thermal procedures, drug electrophoresis, electrostimulation.

Tactics of management of children who have suffered a trauma of the central and peripheral nervous system. These children are at risk of developing further neurological and mental disorders of varying severity. Therefore, they should be put on dispensary records and in the first year of life every 2 to 3 months to undergo examinations of the pediatrician and neurologist.

This will allow timely and adequate conduct of medical and corrective measures at early stages of development. Treatment of children with cerebral palsy and severe motor impairment after trauma to the brachial plexus should be carried out continuously for many years until the maximum compensation for the defect and social adaptation. Parents take an active part in the treatment of the child from the first days of life. They should explain that treating a child with a lesion of the nervous system is a lengthy process, not limited to specific courses of therapy; It requires constant training with the child, during which the motor, speech and mental development is stimulated. Parents should be trained in the skills of specialized care for a sick child, basic methods of therapeutic gymnastics, massage, orthopedic treatment, which must be performed at home.

Mental disorders in children who have suffered a trauma of the nervous system are expressed by various manifestations of the psychoorganic syndrome, which in the late period of the genus of the craniocerebral trauma in children corresponds to the organic defect of the psyche. The severity of this defect, as well as neurological symptoms, is associated with severity and localization of brain damage (mainly hemorrhages). It consists of intellectual insufficiency, convulsive manifestations and psychopathic behavioral features. In all cases, a cerebral-senic syndrome is necessary. Various neurotic disorders can also be observed, and sometimes psychotic phenomena occur.

Intellectual deficiency in birth trauma, associated with the defeat of the nervous system, manifests itself primarily in the form of oligophrenia. A distinctive feature of this oligophrenia is the combination of mental underdevelopment with signs of organic decline in personality (grosser memory and attention disturbances, exhaustion, complacency and uncriticality), convulsive seizures and psychopathic behavioral peculiarities are not uncommon. In more mild cases, intellectual failure is limited to a secondary retardation of mental development with a picture of organic infantilism.

With encephalopathy with the prevalence of convulsive manifestations, various epileptiform syndromes, asthenia disorders and decreased intelligence are observed.

Significant spread among the long-term consequences of craniocerebral trauma in children have psychopath-like behavioral disorders with increased excitability, motor disinhibition and the detection of gross impulses. Cerebrasthenic syndrome is the most constant and characteristic, it manifests itself in the form of prolonged asthenic conditions with neurosis-like disorders (tics, fears, enuresis , etc.) and signs of organic psychosis. Psychotic disorders are rare, in the form of episodic or periodic organic psychosis.

The general distinctive feature of mental disorders in the birth traumatic brain injury (except for oligophrenia) is the lability of symptoms and the relative reversibility of painful disorders, which is generally associated with a favorable prognosis, especially with adequate treatment, which is mainly symptomatic and includes dehydration, resorptive, sedative And stimulating (nootropic) therapies. Psychocorrectional and therapeutic-pedagogical measures are of significant importance.