Damage to the cervical spine in newborns. Treatment and rehabilitation of a child diagnosed with cerebral palsy

Birth injuries can be caused by many factors, the most common being:

time of delivery (rapidly fast or too long);
time of stay of the fetus in the womb (premature and post-term babies);
application of the vacuum extraction method;
discrepancy between the anthropometric data of the mother’s pelvis and the child’s head;
usage caesarean section;
incorrect positioning of the fetus at the time of labor;
asynclitic insertion of the head;
use of forceps during childbirth.

There are many reasons and factors influencing the course of the process. According to statistics birth trauma There are 3 main groups:

trauma associated with maternal pathologies;
deviations in the course of pregnancy and fetal development;
features of the natural course and conduct of childbirth.

Maternal pathologies include the age of the pregnant woman, the presence women's diseases, malfunctions cardiovascular system, narrow pelvis new passage, gestational age at the onset of labor, etc.

Mostly, the bulk of birth injuries include deviations in the course of pregnancy and the formation of the fetus. Their appearance is caused by the breech presentation of the child, its size, short term, etc.

The occurrence of injury is caused by the abnormal course of the birth process, its rapidity, and the need for stimulation during low or intense labor.

This causes mechanical injury to the newborn with obstetric devices and instruments, incompetent behavior of doctors and medical personnel.

Suppression of the central nervous system of a newborn during and after childbirth can occur for three main groups of reasons: ischemic-hypoxic lesions, traumatic and infectious-toxic. Let's look at each group in more detail.

Ischemic and hypoxic lesions of the central nervous system in newborns are caused by a lack of oxygen in the child’s blood during childbirth. This may be due to long and protracted labor, weakness of labor, abnormalities of the placenta and umbilical cord. With ischemia (complete absence of oxygen), brain cells die, and the further picture of the disease depends on which part of the cortex this happens.
Traumatic lesions CNS - in the vast majority of cases occur during childbirth. Immediate cause may result from an early birth (the baby’s head is born very quickly and is injured), a large fetus, unskilled actions of the obstetrician, etc.
Infectious and toxic lesions may be related to viral infection, alcohol, smoking during pregnancy, etc.

Brain lesions most often have an ischemic-hypoxic nature, while the spinal cord is most often affected by physical injury baby's neck during childbirth.

To prevent this, it is very important to give birth in a good maternity hospital with a competent obstetrician, and in the first days after discharge, go to see an osteopath.

In many ways, birth injuries are determined by the pregnant woman’s belonging to a risk group for one or another indicator. Thus, the age of the expectant mother has a significant influence on the outcome of childbirth.

Optimal age for the first birth - 20-25 years, since such women have much less chronic diseases and a history of abortions. The consequences of childbirth may be associated with trauma to the mother and baby if they occur over 30 years of age (for repeat pregnancies- over 35 years old).

Perinatal pathology occurs more often in the presence of the following risk factors:

incorrect positioning of the fetus during labor;
clinically, anatomically narrow maternal pelvis;
large fruit or low body weight;
intrauterine oxygen starvation of the fetus;
premature, post-term fetus;
weakness of labor;
rapid labor;
fetal malformations, such as hydrocephalus;
a history of bone injuries in a pregnant woman.

What are the symptoms

Immediately after birth clinical picture perinatal pathology may be very different from that after a certain period of time. Below are the main signs of injuries by type that a neonatologist discovers as a result of the first examination of the child.

Soft tissue injuries

Represent damage subcutaneous tissue, skin and muscles. These include a variety of abrasions and hemorrhages, most of which are not dangerous and heal quickly after local treatment.

The consequences for the child may be more severe if there is a muscle injury. Most often, birth trauma affects the sternocleidomastoid muscle, in which fibers can be torn.

Symptoms of the pathology are the appearance of a hematoma in the affected area, as well as a lump that is sharply painful when touched. Sometimes these signs appear only after the child is discharged from the hospital, and in this case they are almost always accompanied by deviations in the normal position of the neck (torticollis, or tilting the head in the direction where the muscle is torn).

About diagnosis and therapy

Diagnosis of spinal column injury caused during childbirth includes the following steps:

identification mechanical damage, for example, compression or hemorrhage;
ultrasound diagnostics(ultrasound) is often used to make a more accurate diagnosis;
Depending on the age of the baby, as well as its condition, radiography methods can be used.

As for the treatment of spinal column injuries received during childbirth, all actions of specialists will be aimed at ensuring normal blood supply and circulation in the brain.

In some cases, fixation may even be required cervical spine until the lost or impaired functions are completely restored, or until the intracranial pressure normalizes.

To treat birth injuries, experts quite often recommend manual therapy. In this case, she has proven herself to be high level, since in many cases manual intervention gives positive results.

The doctor also prescribes medications. Drug treatment can also be given on its own or in combination with manual therapy to achieve better results. In especially severe cases, surgical intervention may be prescribed to get rid of the pathology.

Postpartum trauma is diagnosed using modern methods, which are selected depending on the type of injury, on the recommendation of a pediatrician, traumatologist, or obstetrician.

Diagnostics include:

Among the methods for identifying birth injuries, which are used both in the perinatal period (up to 7 days after birth) and in the first year of life and beyond:

examination of the newborn;
palpation of the head, neck, limbs;
Ultrasound and radiography;
MRI, CT;
functional tests;
consultations with narrow specialists.

Osteopathic treatments

To ensure a minimum of risks during childbirth, Mother Nature has taken every means to avoid injury and complications for mother and child. She provided the baby with elastic bone tissue and natural shock absorbers so that he could transform and fit into the mother’s narrow birth canal.

But in some cases, failures occur that require treatment.

In some cases, a tight bandage is sufficient, while in others, plaster casting is necessary. The consequences of injuries are eliminated with the help of massage, electrical stimulation, and exercise therapy.

When treating fractures in children mandatory There is a pediatric traumatologist present.

With cephalohematoma, treatment comes down to monitoring the small patient. Usually the injury goes away on its own and without complications, leaving no trace or changing appearance child.

But in practice, there are cases when subcutaneous hematomas continue to grow; this occurs in children predisposed to poor blood clotting. The disease is inherent in genes and occurs due to a lack of vitamins K, C, P.

The baby is given hemostatic substances (vitamins, calcium chloride) and complement treatment with antibiotic therapy.

For torticollis, special massage techniques are used, electrophoresis with potassium iodide, the baby’s head is positioned and secured on the sides with bolsters.

If damaged internal organs The child is treated with therapy focused on reducing blood loss. At internal bleeding use the method of laparoscopy or laparotomy.

Damage skin require processing local antiseptics(iodine, alcohol) to prevent infection. As a rule, minor injuries heal by 5-10 days after birth.

Muscle ruptures and hematomas are treated by providing a corrective position for the child, eliminating incorrect position limbs, head, neck, physiotherapy, massage, administration of various absorbable drugs.

Sometimes in the first half of life a baby needs surgical correction birth muscle injury.

For fractures it is carried out standard treatment, including:

immobilization of limbs using splints, Deso bandages;
tight swaddling;
traction (traction);
physiotherapy;
massage.

Consequences of head injury

The consequences of a birth head injury can be very diverse. It all depends on how early the injury was identified and treatment started.

Of course, late diagnosis can lead to a number of diseases:

development in child with cerebral palsy,
mental retardation,
delay speech development,
acquired epilepsy.

http://gidpain.ru/travma/rodovye-novorozhdennyh.html Birth injuries in children must be treated immediately to avoid complications and pathologies. In infancy, everything is much easier to correct because anatomical features the structure of bone tissue and the child’s body. If measures are not taken in time, the child may become disabled and suffer the following consequences of birth injuries:

headache, indigestion;
increased blood pressure, vegetative-vascular dystonia;
diseases of the musculoskeletal system;
delay mental development;
underdevelopment of fine motor skills, etc.

Prevention of birth injuries in newborns

Prevention of injuries during childbirth in infants involves determining the level of threat of injury during the observation period of pregnancy, and extremely careful handling of the newborn during childbirth.

During pregnancy and when planning it, it is important to follow the recommendations of doctors:

it is necessary to prepare for pregnancy;
undergo treatment for chronic diseases;
protect yourself from viral and respiratory infections;
eat properly and balanced;
see a gynecologist;
lead healthy image life;
at the stage of childbirth, follow the instructions of the obstetrician and conduct labor correctly.

Injuries during childbirth are common. Many do not pose a threat to the child’s life, and the child’s body copes with the problem on its own.

But in severe episodes, the help of a specialist in the field of neurosurgery, neurology and traumatology is necessary. And a mother must do everything possible to keep her baby healthy.

Unfortunately, it is impossible to completely prevent birth injuries. But to reduce its likelihood, obstetricians should promptly identify pregnant women at risk for perinatal pathology and competently apply various techniques and manipulations during childbirth.

It is advisable for a woman to plan a pregnancy before treatment or correction of chronic diseases, and also to register for pregnancy on time.

More information

The birth of a baby does not always go smoothly. Due to the fact that the birth process is an unpredictable event, problems may arise for the mother and child, and then birth trauma in newborns occurs, associated with damage to the internal organs, skeleton, and soft tissues of the baby. This is the response of a small organism to the disturbances that have arisen.

It is impossible to predict the course of labor. Modern diagnostics and experience of obstetricians make it possible to minimize complex, unplanned situations that arise, and try to do everything possible to avoid serious injury to small patients.

Reasons

There are many reasons and factors influencing the course of the process. According to the statistics of birth injuries, there are 3 main groups:

trauma associated with maternal pathologies;
deviations in the course of pregnancy and fetal development;
features of the natural course and conduct of childbirth.

Maternal pathologies include the age of the pregnant woman, the presence of gynecological diseases, malfunctions of the cardiovascular system, a narrow pelvic meatus, gestational age at the onset of labor, etc.

The occurrence of injury is caused by the abnormal course of the birth process, its rapidity, and the need for stimulation during low or intense labor. This causes mechanical injury to the newborn with obstetric devices and instruments, and incompetent behavior of doctors and medical personnel.

During childbirth, several factors often combine to disrupt the normal biomechanics of the process and lead to birth trauma.

Species

Birth injuries of newborns are recognized by type:

craniocerebral – complex damage to the structures of the brain or bones of the child’s skull, based on the level of severity, leading to death or severe disability. Particularly dangerous when combined with contamination amniotic fluid fecal particles (aspiration) and long-term deficiency in supplying the fetus with oxygen (hypoxia). The largest part of the child’s body is the head, and when the baby passes through the birth canal, it is subjected to the greatest load and pressure. But due to the transformation, softness and flexibility of the bones, they overlap each other and thereby lead to a decrease in the volume of the skull. Birth trauma to the head can occur from compression of the head in the birth canal, which will cause damage to brain tissue;
Damage to internal organs quite often occurs due to pressure or impact on the fetus. This leads to rupture or tearing of the spleen, liver, adrenal glands and causes internal subtle bleeding;
soft tissue injury – damage to the skin and subcutaneous tissue. Birth trauma to the neck (torticollis) occurs when the sternocleidomastoid muscle is damaged;
hemorrhage under the periosteum (cephalohematoma) occurs at the stage of movement of the head through the narrow places of the pelvis of a woman in labor, when the skin on the skull is displaced and the subcutaneous vessels are ruptured. From the accumulation of blood, a growth forms, which increases over 3 days;
Skeletal injuries are usually a medical mistake. A fracture of the collarbone or skeletal limbs often occurs during trauma in newborns, as well as joint displacement of the hip or shoulder (dislocations). Possible fracture of the humerus, radius or femur;
Birth trauma of the cervical spine leads to damage to the central and peripheral nervous system. In this case, the spinal cord and central nervous system trunks are affected. When facial nerve paresis occurs, it prolonged compression. Paresis of the diaphragm occurs due to the use of instruments and during fetal asphyxia, etc.

Symptoms

When skeletal bones are injured without displacement, newborns develop edema and swelling at the site of injury. When bone fragments shift, in addition to swelling, limited movement of the limb or disruption of the functioning of a nearby joint appears. There is an acute pain syndrome when moving the injured limb of a child. A fracture of the humerus, radius or femur is characterized by an acute pain reaction, a visually noticeable change in the length of the injured limb, and swelling.

When soft tissue is damaged, visually noticeable hematomas, abrasions, and wounds appear.

If internal organs are damaged, symptoms are visible 4-5 days after birth. Because of internal hemorrhage, noticeable hypotension of muscle tone, intestinal obstruction, decreased blood pressure, observed intestinal colic, regurgitation and vomiting.

Certain symptoms in case of injury to the cervical spine or spinal cord does not exist, it is simply not visually noticeable. The deviation can be predicted by reduced reflexes in the child (swallowing, sucking), hypotonia of muscle tone, shortening or lengthening of the neck. The muscles of the area are tense, and when palpating the area, the child becomes noticeably worried, cries, and changes his facial expressions.

Diagnostics

Postpartum traumatism is diagnosed using modern methods, which are selected depending on the type of injury, on the recommendation of a pediatrician, traumatologist, or obstetrician.

Diagnostics include:

to identify disturbances in the blood flow of blood vessels and the integrity of the membranes of the spinal cord - neurosonography and Dopplerography of the vessels of the spinal cord and brain. For head and spine injuries, and skeletal bone fractures - lumbar puncture ( lumbar puncture), radiography and MRI;
in case of cephalohematoma, diagnostics aimed at identifying pathogens of infectious diseases (PCR) are recommended;
In case of damage to internal organs, ultrasound and x-ray examination are prescribed.

Treatment

In case of joint injuries or displaced fractures, a structure is used to traction the limbs and they are temporarily fixed. The ability to restore bone tissue in children is significant, so it is restored very quickly. In some cases, a tight bandage is sufficient, while in others, plaster casting is necessary. The consequences of injuries are eliminated with the help of massage, electrical stimulation, and exercise therapy. When treating fractures in children, a pediatric traumatologist is required to be present.

With cephalohematoma, treatment comes down to monitoring the small patient. Usually the injury goes away on its own and without complications, leaving no trace and without changing the child’s appearance. But in practice, there are cases when subcutaneous hematomas continue to grow; this occurs in children predisposed to poor blood clotting. The disease is inherent in genes and occurs due to a lack of vitamins K, C, R. The baby is administered hemostatic substances (vitamins, calcium chloride) and the treatment is supplemented with antibiotic therapy.

For torticollis, special massage techniques are used, electrophoresis with potassium iodide, the baby’s head is positioned and secured on the sides with bolsters.

If internal organs are damaged in a child, therapy is used that focuses on reducing blood loss. For internal bleeding, laparoscopy or laparotomy is used.

Rehabilitation

After the massage, the consequences of birth trauma in the baby are absent and present good result during recovery.

The treatment method includes drugs aimed at normalizing the functioning of the central nervous system and providing nutrition muscle tissue. Consequences birth injuries will be eliminated if you use massage, electrophoresis and prepare relaxing baths for your baby with herbs, pine needles and sea salt. Treatment for complex episodes lasts about six months. Later baby is under the supervision of doctors - a neurologist or orthopedist.

Consequences

Birth injuries in children must be treated immediately to avoid complications and pathologies. In infancy, everything is much easier to correct due to the anatomical features of the structure of bone tissue and the child’s body. If measures are not taken in time, the child may become disabled and suffer the following consequences of birth injuries:

headache, indigestion;
increased blood pressure, vegetative-vascular dystonia;
diseases of the musculoskeletal system;
mental retardation;
underdevelopment of fine motor skills, etc.

The consequences of injury largely depend on the resulting shape and size of the lesion, as well as the speed with which they are identified and assistance is provided.

Prevention

During pregnancy and when planning it, it is important to follow the recommendations of doctors:

it is necessary to prepare for pregnancy;
undergo treatment for chronic diseases;
protect yourself from viral and respiratory infections;
eat properly and balanced;
see a gynecologist;
lead a healthy lifestyle;
at the stage of childbirth, follow the instructions of the obstetrician and conduct labor correctly.

Injuries during childbirth are common. Many do not pose a threat to the child’s life, and the child’s body copes with the problem on its own. But in severe episodes, the help of a specialist in the field of neurosurgery, neurology and traumatology is necessary. And a mother must do everything possible to keep her baby healthy.

Birth trauma to the cervical spine in newborns, like other types of severe injuries during childbirth, is a rare but dramatic ending to childbirth for both the baby and the mother. Obstetricians are not always to blame for what happened: injuries also occur spontaneously, during physiological childbirth.

Now let's look at this in more detail.

Birth injuries in newborns: what are they?

There are two types of damage during childbirth - mechanical and hypoxic. Mechanically, tissues, bones and internal organs can be damaged during childbirth, and hypoxic injuries occur with acute or repeated oxygen starvation- for example, with asphyxia.

Mechanical injuries include:

abrasions, scratches, hematomas on the skin of the child’s limbs, face, and torso;
muscle injuries;
hemorrhages under the bones of the skull ();
swelling of tissues in contact with the mother’s pelvic bones during childbirth (birth tumors);
bone injuries - fractures, cracks, dislocations and subluxations;
damage to the brain when it is compressed by the pelvic bones of a woman in labor (intracranial injuries);
spinal cord injuries.

Not all mechanical types of birth injuries in newborns are dangerous, although they look scary in appearance.

Abrasions and scratches go away on their own within a few days with appropriate treatment.
Does not pose a danger and birth tumor: traumatic swelling disappears in a couple of days.

Hypoxic injuries are a group of injuries to the brain and spinal cord that occur as a result of suffocation or in the fetus. These include:

hypoxic-ischemic,
damage to the spinal cord and brachial plexus.

Severe birth injuries: how do they manifest?

The brain (spinal and head) and limbs are the most severely injured. Such injuries, despite their severity, are not always recognized immediately after birth: sometimes only a few days later the first signs of injury appear.

Intracranial head injuries

Intracranial birth trauma of newborns is most often subarachnoid, subdural, epidural, and parenchymal.

Subdural injury

It occurs when there is a sharp displacement of the cranial bones, resulting in damage to the sinuses and vessels of the tentorium of the cerebellum. This is one of those injuries in which there are no clear neurological symptoms immediately after birth: they appear from the fourth day or even later, and rapidly increase.

Her symptoms:

cold, pale skin;
from the respiratory system - shortness of breath;
arrhythmia;
many reflexes are depressed or absent altogether;
The baby does not latch on to the breast and does not swallow.

Later, the baby’s condition is aggravated by increasing intracranial pressure, bulging fontanelles, increasing head size, and convulsions.

Treatment of subdural injury - only surgical removal hematomas.

Epidural injury

This is a hematoma that appears when the vessels located in the space between the cranial bones and hard shell brain It is often combined with hemorrhage under the periosteum of the cranial bones -.

The first manifestations of the injury become visible 3-5 hours after the birth of the child, the condition quickly and sharply worsens - up to falling into a coma a day or a little later.

Symptoms:

sharply restless behavior of the child 6 and even 12 hours after birth;
the pupil on the damaged side is significantly dilated;
convulsions;
partial paresis (paralysis) of the side of the body opposite to the lesion;
rare heart rate;
suffocation;
drop in blood pressure.

Treatment: surgery only.

Subarachnoid hemorrhage

The most common injury, occurring mainly in premature, low birth weight babies, when obstetricians have to use forceps or an extractor to extract the fetus.

The first symptoms also do not appear immediately: they become noticeable only on the 3-4th day, when the baby is put to the breast.

SAC can be recognized by:

a specific “brain” cry;
wide open eyes, smoothed nasolabial fold;
pronounced muscle tone, excessive mobility;
strabismus;
bulging of a large fontanel;
, regurgitation after eating.

Subarachnoid hematoma is often combined with other types of brain injuries.

Parenchymal hemorrhage

This is a consequence of rupture of the terminal arteries of the brain. Hematomas with this type of injury can be small or large. Minor hemorrhages give mild symptoms:

lethargy, drowsiness;
regurgitation of eaten food;
weak muscle tone;
nystagmus, convulsions, bluish triangle around the lips, shallow breathing and other signs of Graefe's symptom.

With extensive hematomas, the symptoms intensify and resemble the manifestations of PIVC - peri-intraventricular hemorrhage, which is characterized, in addition to Graefe's symptom, by bulging of the fontanelles, decreased muscle tone, breathing disorders (apnea), and hypotension. Occasionally, these newborns experience seizures and bradycardia.

Cervical spine injuries

During childbirth, babies' necks can be injured - they are the most vulnerable vertebral region. There are also injuries to the lumbar region.

Birth trauma of the cervical spine in newborns becomes a consequence of:

stimulation of labor;
a not entirely successful caesarean section. Features after cesarean;
intrauterine oxygen deficiency - ;
attempts to pull the child out with forceps or an extractor.

Factors that can lead to such a birth outcome also include prematurity, too little or heavy weight fetus

When the cervical spine is damaged, increased intracranial pressure develops, and there is a lag in the physical, mental and intellectual development of children.

How to determine this? In the maternity hospital, pay attention to the following symptoms:

difficulty turning your head to the right or left;
breast sucking on one side only;
child's restlessness.

After a year, unformed physiological curves of the spine and gait disturbances become visible. In the future, injured children suffer from headaches, blood pressure instability, absent-mindedness, excessive excitability, and fall behind in school.

Stages of the course, treatment and prognosis

Birth head trauma in newborns goes through several stages:

acute – 7-30 days;
subacute – 3-4 months;
late – 4 months-2 years.

Full-term and premature babies respond differently to brain damage. Thus, in full-term newborns, the acute period is characterized by alternating phases of excitation and depression of the central nervous system. Symptoms gradually smooth out and disappear in approximately 50-70 percent of babies. The remaining 50-30 percent are subsequently treated for hemosyndrome and other abnormalities of brain development.

In premature infants, there is often no clear clinical picture of PCI: the injury does not make itself felt at all or manifests itself with very scanty symptoms - signs of central nervous system depression or increased excitability, various respiratory disorders.

Symptoms gradually smooth out and disappear in 50-70% of children.

Treatment of injuries (emergency measures)

Birth injuries of the central nervous system in newborns require special measures treatment. Injured children are placed in a specialized box of the maternity hospital, where a special temperature regime and provisions for 24/7 monitoring of vital signs.

Such children are fed through a tube or from a bottle, and when their condition improves, they begin breastfeeding. You can read what a mother should do in a separate article.

The goal of treatment is to quickly restore breathing, ventilation of the lungs and normalize biochemical parameters, combat neonatal seizures.

Coma and cerebral edema require connection to a ventilator, the prescription of barbiturates, corticosteroids, and dry plasma.

The prognosis with modern medical capabilities depends not so much on the severity of the injury, but on the timeliness and completeness of the measures taken. If the injury is quickly detected and correctly diagnosed using ultrasound, CT, EEG and EchoEG, and adequate treatment is carried out, then about 80 percent of babies make a full recovery.

Main causes of damage

To protect your long-awaited baby from injury, and yourself from difficult experiences, you need to know about the risks that can lead to damage to the fetus during childbirth.

There are many of them: there is no one main prerequisite for birth trauma to the central nervous system in a newborn.

Women expecting childbirth or just planning a pregnancy need to know that some features of the course of pregnancy can cause severe damage to the head, limbs or internal organs during childbirth:

prematurity;
The child’s weight is too low – less than 2.5 kg;
too much weight - more than 4 kg;
intrauterine oxygen deficiency in children whose mothers smoke during pregnancy or work in hazardous work;
intrauterine infections that affect the fetal brain, the walls of its blood vessels, and the liver.

The cause of birth injury may be a doctor’s mistake during a cesarean section, as well as too rapid insertion. intravenous drugs, excessive saturation of the brain with oxygen during certain medical procedures prescribed for the child.

To minimize the risk of injury to the child during childbirth and after it, expectant mothers should be conscientiously and regularly observed by specialists throughout pregnancy, neutralize identified infections, and part with bad habits or change harmful jobs.

In conclusion, we suggest watching a video in which a specialist talks about the causes of birth injuries:

During childbirth, try to be calmer, correctly and accurately follow the instructions of the doctor and obstetricians: specialists have all the skills to give their patients the joy of happy motherhood.

Birth injuries are problems that arose in the perinatal period or during the birth process. In newborns, the spine is very sensitive to any kind of mechanical influence.

This is due to the fact that ossification barely begins to appear, and at the time of birth the spine consists of cartilaginous tissue.

What are the symptoms

Often, birth trauma to the spine in newborns occurs in cases where labor was stimulated or used. obstetric forceps or an operation was performed.

It is worth noting that the child’s weight also plays an important role in this matter. Thus, babies with a small weight, for example, less than three kilograms, as well as newborns with a large weight, more than 4 kg, may be at risk.

As for the symptoms of birth trauma of the cervical spine, they are very diverse, and sometimes even unnoticeable and can be delayed over time. In general, due to the fact that the arteries were compressed, the following symptoms can be identified:

impaired brain functions;
increased intracranial pressure;
the occurrence of problems with the nervous system;
delayed speech and motor development;
hyperexcitability and hyperactivity;
disorders associated with the musculoskeletal system;
enuresis;
allergic reactions of various types;
other autonomic abnormalities (these include migraines, fainting, weather sensitivity, general fatigue, and even diarrhea).

Please note that in each individual case the symptoms may be different. It is necessary to carefully monitor the child to provide the doctor with more detailed information.

Varieties

There are 3 mechanisms that can lead to spinal injuries during childbirth:

Compression - it occurs in cases where there is big difference uterine pressure and forces that prevent the fetus from moving further along the birth canal.
Distraction - this mechanism is associated with the artificial extraction of the fetus by the pelvis or head.
Rotational – it is associated with improper management of labor.

These mechanisms can occur separately or can be combined.

We propose to consider the main types of spinal injuries caused during childbirth:

“Short neck syndrome” - it is especially noticeable when the baby is in a lying position. Looking at the child, it seems that he has no neck. This feeling disappears when the baby is picked up. Short neck syndrome is associated with displacement of the first and second vertebrae. What does this mean for the future? A person may develop conditions such as headaches, scoliosis, and decreased vision;
“Transverse folds syndrome on the neck” - outwardly this looks approximately the same as in the first case, however, this syndrome is distinguished by the presence of a large number of folds on the neck, which are constantly swelling;
“Cervical insufficiency syndrome” - this condition is characterized by decreased strength in the baby’s arms. This is expressed in the fact that, for example, the baby does not have enough strength to rise up by grabbing onto the fingers of mom or dad. It happens that only one arm of a baby is weakened. This condition is called “Robinson syndrome”. What could be the consequences of this injury? In adulthood, a person may develop scoliosis, flat feet, and even bowed legs;
If your baby is extremely flexible and can twist his legs incredibly, don't worry about it. This may indicate a fairly serious injury in the sacral region;
Injury to the cervical spine is also indicated by frequent fainting, as well as a regularly stuffy nose.

Keep in mind that the above list of possible spinal injuries during childbirth is far from complete. Each case must be considered separately, with its symptoms and possible consequences.

About diagnosis and therapy

Diagnosis of spinal column injury caused during childbirth includes the following steps:

identification of mechanical damage, for example, compression or hemorrhage;
Ultrasound diagnostics (ultrasound) is often used to make a more accurate diagnosis;
Depending on the age of the baby, as well as its condition, radiography methods can be used.

As for the treatment of spinal column injuries received during childbirth, all actions of specialists will be aimed at ensuring normal blood supply and circulation in the brain.

In some cases, it may even be necessary to fix the cervical spine until the lost or impaired functions are completely restored, or until the intracranial pressure normalizes.

To treat birth injuries, experts quite often recommend manual therapy. In this case, it has proven itself at a high level, since in many cases manual intervention gives positive results.

The doctor also prescribes medications. Drug treatment can also be done on its own or in combination with manual therapy to achieve better results. In especially severe cases, surgical intervention may be prescribed to get rid of the pathology.

We would like to note that diagnosis, as well as treatment of spinal injuries received during the birth process, must be carried out strictly under the supervision of a specialist. Do not self-medicate, even if it concerns massage.

Birth injuries to the vertebrae should be corrected only by appropriate doctors, because we're talking about about the prosperous future of your child!

Disclaimer

The information in the articles is for general information purposes only and should not be used for self-diagnosis of health problems or medicinal purposes. This article is not a replacement for medical consultation see a doctor (neurologist, therapist). Please consult your doctor first to know the exact cause of your health problem.

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Birth trauma leading to paralysis of the upper limbs accounts for 0.1-0.4% of the number of children born. Natal trauma of the cervical spine dominates. As a result of traction on the head with fixed shoulders, displacement of the vertebrae in the cervical spine occurs. This causes disruption of blood flow through the vertebral artery and ischemia of the anterior horns of the spinal cord with subsequent disruption of segmental circulation in the vertebrobasilar area. Traction by the head causes tension on all trunks of the brachial plexus, the same thing occurs with traction by the legs and pelvis during leg or breech presentation. If at the same time the handle is thrown back behind the head, then the brachial plexus bends around the collarbone, the trunks are stretched and pressed against the head humerus, experiencing additional compression in addition to tension. With breech presentation, the arm is thrown back behind the head and, in addition to tension along the length, the trunks of the brachial plexus experience pressure from the clavicle, the head of the humerus and the transverse processes of the vertebrae. Stretching of the nerve fibers of the brachial plexus beyond the limits of physiological strength can also occur when stretching the arm, throwing the arm behind the head, abducting the shoulder to a right angle with rotation of the shoulders. A sharp deviation of the head in the direction opposite to the fixed half of the shoulder girdle causes damage to the upper spinal nerves. Birth trauma also leads to rupture of the scalene muscles, fascia, hemorrhages, ruptures and tears of plexus branches. Over time, scars form around the brachial plexus, which cause secondary compression of the plexus and permanent disruption of nerve conduction. The formation of scars and the proliferation of connective tissue contributes to further circulatory disorders and the formation of intrastem neuromas.

O.V. Dolmitsky, using the experience of microsurgical operations on the brachial plexus in newborns, described the macro- and microsymptoms of morphological disorders. During operations, gross scar changes in the tissues surrounding the brachial plexus, disruption of its anatomical topography, obliteration of the outer jugular vein, cicatricial degeneration of the subcutaneous muscle of the neck and deep fascia of the neck. The scalene muscles in the area where the brachial plexus exits were subjected to the greatest cicatricial degeneration. Spinal nerve ruptures were observed at the level or distal to their exit from the spinal foramina. All victims had neuromas.

Depending on the level of damage to the brachial plexus and the degree of this damage, there are three types of RPVC.

The upper radicular type of lesion - Duchenne-Herb's palsy - was first described by the French neurologist G. Duchenne in 1872. He observed this in newborns after traumatic obstetric manipulations. In 1876, the German physician W. Erb described the clinical and anatomical picture of lesions of the upper trunk of the brachial plexus in adults and explained its pathogenesis.

The lower radicular type of paralysis - Dejerine-Klumpke's palsy - was described by the French neurologist A. Dejerine-Klumpke in 1889. This lesion is characterized by paralysis of the muscles of the hand, changes in sensitivity and trophic disorders, as well as pupillary disorders associated with the damage sympathetic fibers, passing to the eye through the root and spinal nerve Th 1 - Bernard-Horner syndrome.

Mixed type of lesion - mosaic damage to all three trunks of the brachial plexus C5-Th 1 without a complete break and with their complete rupture.

Stages of the disease

Clinical picture of damage upper limb undergoes changes throughout the child's life and growth. This depends on the severity of the lesion and the stage of the disease.

The stages of the disease are identified conditionally and correspond to periods of reinnervation.

Stage I – acute period of injury. Lasts from birth to 1 month.

Stage II – recovery period. Continues from the 2nd month of a child’s life until 1 year. During this period, complete or partial restoration functions of the injured limb.

Stage III – stage of residual effects.

Some experts distinguish stage IV - intermediate between II and III - the stage of the late recovery period. If we take into account the orthopedic problems of the course of the disease, then identifying this stage is justified. By the age of 1 year, reparative processes in the nerves and roots of the plexus have already ended, however, with intensive treatment during this period, the child develops new motor skills, coordination of movements develops, trophism of hand tissues improves, fine motor skills improve and intensively develop, and muscle strength increases. Fixed contractures have not yet formed, and it is very important to combine intensive orthopedic treatment during this period with neurological treatment. And in the period of residual effects, when all possibilities of non-operative rehabilitation treatment have been exhausted, the tactics of orthopedic treatment should be changed and issues of prompt elimination contractures, tendon-muscular plastics and joint stabilization.

Clinical characteristics

During the neonatal period during the acute period of injury, the clinical picture of damage to the upper limb is almost the same for all types of paralysis. Symptoms of birth trauma prevail. The child is restless, decreased muscle tone, weakened breathing, vicious position of the upper limb, active movements and even muscle contractions in the limb are not detected. With passive abduction of the arm, the child does not make any active movements with the arm. Sometimes only with the upper-radicular type of lesion there may be weak active movements in the joints of the hand and fingers. In the neck area on the injured side there is tissue swelling, there may be hemorrhage in soft fabrics, sometimes hemorrhage in the neck. The child does not react to passive irritations of the skin of the affected limb. The skin temperature of the affected limb is 1...2°C lower, the hand is paler, and there is pronounced atony on palpation. Bernard-Horner syndrome can be identified. Weakened breathing, asymmetry of chest movements during breathing, cyanosis during crying, feeding - all this may indicate paralysis of the diaphragm.

In the first month of life, active movements in the fingers and elbow joint may appear. This is a sign favorable course damage and good prognosis. If the child’s body weight increases well, then at the end of the 1st month a fold deepens between the shoulder and torso - the “doll’s hand symptom.”

In the future, as the child grows and depending on the degree of damage and level - clinical manifestations diseases become more local and pronounced.

The upper type of lesion is manifested mainly by impaired conduction of the suprascapular, subscapular, musculocutaneous, axillary and partially radial nerves with corresponding paralysis of the muscles innervated by them. Active abduction and flexion in the shoulder joint, flexion in the elbow joint, and external rotation of the shoulder become impossible. As a result of damage to the muscles innervated by the upper spinal nerves, internal rotation and adduction contractures develop in the shoulder joint and extension contracture in the elbow joint. The child cannot independently comb his hair, bring a spoon to his mouth, write on the school board, wash his face, etc.

Rotational alignment of the hand occurs from birth and remains stable as the child grows. Persistent muscle imbalance contributes to the development of humeral torsion by 3-4 years.

In children over 3 years of age, after the maximum possible restoration of the motor function of the hand with the upper-radicular type of lesion, the following disorders in the orthopedic status can be identified:

hypotrophy of the upper limb, especially its proximal parts and in the area of the deltoid muscle;

shortening of the arm;

adduction and internal rotational contracture;

small scapula symptom; should be differentiated from Sprengel's disease;

symptom of a mobile scapula - during movements in the shoulder joint, the scapula on the side of the injury moves excessively upward when the shoulder is abducted, and when the shoulder is flexed, it rotates excessively anteriorly;

scoliosis in the cervicothoracic region;

narrowing of the palpebral fissure on the injured side and enophthalmos;

slight weakening of the strength of the flexors of the forearm, hand and fingers, but the range of active movements in these joints is full.

Lower type of paralysis - affects the median and ulnar nerves and paralysis of the muscles that they innervate develops: flexors and extensors of the hand and fingers. All muscles of the flexor surface of the forearm are affected - flexors of the hand and fingers: pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor pollicis longus, flexor digitorum profundus and pronator quadratus, flexor carpi ulnaris, flexor digitorum profundus, adductor muscle. I finger, flexor pollicis brevis, lumbrical muscles, interosseous muscles. The forearm is supinated, the hand is extended at the wrist joint, and the fingers are extended at the metacarpophalangeal joints. The first finger is adducted and is in the same plane as the palm. A “clawed hand” is formed. The child cannot grasp and hold objects with his fingers and between them, and suffers graphic function, the hand is cyanotic, hypotrophic, cold, the skin is thinned, dry. Pathological mobility develops at the level wrist joint- “dangling brush”. Trophic disorders in the area nail phalanges. Tactilognosis suffers.

In the shoulder and elbow joints, movements are usually preserved; the strength of the shoulder muscles may be weakened, but the range of active movements is not impaired. The child usually does not use his hand.

A mixed type of paralysis is observed when all spinal nerves are affected. In this case, the function of all muscles of the limb may completely disappear, or there may be mosaic damage to all the nerves of the brachial plexus. Adduction and internal rotation contracture of the shoulder, flexion and supination contracture of the forearm, instability at the level of the wrist joint develop, and the function of the flexors of the fingers and hand is weakened. Trophic disorders in the area of the fingers are noted only with total paralysis. In some patients with severe damage, disturbances in sensitivity and tactile feedback are detected. The mixed type of lesion is the most common.

During the neonatal period, based only on clinical and neurological data, accurate topical and differential diagnosis of the level and severity of the lesion is impossible. Determination of the nature and severity of the primary lesion, identification of central hemodynamic disorders, severity secondary changes neuromuscular and musculoskeletal systems of the upper limb, adequate non-operative and surgical treatment in each clinical case is decided individually. This dictates the need to use additional research methods at all stages of the diagnostic and treatment process for RPVC.

Diagnosis of pathology

X-ray examination methods during the neonatal period are not informative. The range of passive movements in the joints of the limbs is preserved. During the process of growth in a child with consequences of RPVC with x-ray examination It is possible to identify only secondary deformations of the shoulder joint, scapula and proximal metaepiphysis of the humerus with its posterior subluxation or dislocation. When planning surgical treatment of secondary deformities, arthrography of the shoulder joint is recommended.

Spondylography of the cervical spine in some clinical observations RPVC indicates spinal origin pathological condition. The presence of cervical ribs is considered a “risk factor” for the occurrence of RPVC.

Clinical signs respiratory failure in newborns, they are an indication for chest X-ray to detect paresis of the diaphragm due to damage to the phrenic nerve.

To more accurately determine the location of brachial plexus damage, cervical myelography can be performed at the nearest preoperative period in children during neurosurgical operations. The most informative are computer myelography, CT, and MRI. Ultrasound is informative for assessing the condition of the shoulder joint and cervical spine in children of the first year of life, the severity of paralysis by measuring the speed of ultrasound along the humerus.

The most informative methods diagnostics are EMG and ENMG. Latest in acute period RPVC is more informative for determining the level of damage and evaluates the neuromuscular system. In dynamics, ENMG provides information about the degree and speed of reinnervation. In the period of residual effects or in the residual period it is more informative for topical diagnostics EMG. Its indicators determine the severity of muscle damage and clinically undetectable signs of reinnervation, assess the effectiveness of treatment and prognosis of the disease. Diagnosis of spinal cord injuries in newborns is possible by studying somatosensory evoked potentials. EMG and ENMG during the consequences of RPVC make it possible to determine the functional state of the muscles and their suitability for orthopedic operations. To assess the state of the neuromuscular system in patients with RPVC, the electrical excitability of muscles is also measured with the construction of a “strength-duration” curve.

Dynamometry is used to determine the muscle strength of a paralyzed limb. To study hemodynamic circulatory disorders in the vertebrobasilar region, Dopplerography of the vessels of the spinal cord and brain is used. Considering the difficulties in assessing sensitivity and circulatory disorders of the VC, especially in the acute period of birth paralysis, additional methods are used functional research– thermal imaging and rheovasography.

Treatment

Non-operative treatment of RPVC is a priority. Complete or partial restoration of the function of the affected VC, both spontaneously and under the influence of non-operative treatment, is observed in patients aged 6 months and older. up to 3 years and even later. Treatment must begin immediately after birth, carried out over a long period of time, in stages, using weight-bearing methods. In the acute period of paralysis, treatment should be carried out while ensuring rest of the affected upper limb and shoulder girdle.

The limb should be immobilized with a removable splint in a functional position. During the year, the splint is removed only during medical and hygiene procedures. After a year, the splint is used during sleep hours to place the arm in a functional position to relax the muscles and prevent contractures.

An approximate scheme of non-operative treatment in the acute period of the disease:

1) immobilization of the arm with a removable splint in the position of shoulder abduction 70°, external rotation 60°, elbow flexion 100-110°, forearm and hand in an average functional position; immobilization is carried out for 1 year; in severe cases – up to 3 years;

2) medications, neurotropic drugs and vasoactive;

3) FTL – ultrasound, electrophoresis of lidase, potassium iodide, mud therapy;

4) massage, passive exercise therapy, IRT.

During the period of acute phenomena, it is advisable to carry out a course of oxybarterania and RTI.

In case of birth injury of the cervical spine, non-operative treatment of spinal cord ischemia against the background of neuroorthopedic treatment is indicated, and in case of vertebral dislocation, closed one-stage reposition is indicated. Immobilization of the neck in newborns is carried out with a cotton-gauze ring or a Shants-type collar, a plaster crib, and in older children - by traction with a Glisson loop.

Drug treatment of RPVC includes the use of antispasmodics, vascular agents, nootropic drugs, reinnervation stimulants, absorbable treatment and biostimulants.

FTL is widely used in the complex of rehabilitation treatment of RPVC. Acupuncture stimulates the restoration of VC function.

Prediction of outcomes of RPVC in clinical practice is based on assessing the restoration of the functions of the biceps brachii and deltoid muscles at the age of 2-6 months, as well as through a comprehensive study of the functional state of the biceps and triceps brachii muscles, the extensor muscles of the hand and fingers. Concomitant diaphragmatic paralysis or clavicle fracture in newborns with RVC does not affect the prognosis for recovery of VC function.

Methods of non-operative treatment should be constantly adjusted depending on the dynamics of the course recovery processes and on the age of the child.

Treatment is carried out taking into account these additional research methods. Exercise therapy plays a significant role in the prevention of VC contractures. Range of motion exercises are shown. Massage should begin at 3 weeks of age, throughout the entire body, for 10-15 minutes, in courses of 10-20 procedures.

Electromyostimulation occupies a special place in treatment. Paralyzed muscles are stimulated at all stages of treatment until signs of reinnervation appear.

In the newborn period, the most affected muscles of the VC are subject to electromyostimulation: the deltoid muscle, the biceps brachii muscle, the extensor muscles of the hand and fingers, as well as the muscles of the hand. The duration of the procedure is on average 10 minutes. The number of sessions is 6-8 for each muscle group, but no more than two groups per session. The sinusoidally modulated current of the Amplipulse device is used. The course of treatment should be repeated after 1-2 months, the frequency is determined by clinical and ENMG data.

During the recovery period of RPVC, longer courses of electromyostimulation are carried out using the Stimul device in a subthreshold mode and with short breaks.

If clinical data and the results of additional research methods indicate a brachial plexus injury, then the complex of measures in the acute and recovery period includes early stimulation of damaged nerve fibers and FTL, aimed at relieving vascular spasm, resolving infiltrate and hematoma, and improving regional circulation.

Drug stimulation of muscle reinnervation includes the administration of dibazole in a dose of 0.0005 g three times a day, injections of proserin and vitamin B 0.3-0.5 ml once a day.

FTL is performed on patients from the first days of life. A course of treatment with an UHF electric field is prescribed in an oligothermic dose 4-6 times per lateral surface neck and supraclavicular area on the injured side. From 2 weeks of age, electrophoresis is performed with potassium iodide, galantamine, lidase, and antispasmodics. Electrophoresis course – 8-10 sessions. From the 1st month of life, paraffin or ozokerite applications are used on the entire affected VC for 10-15 minutes, 25-30 sessions at a temperature of 37-39°C, as well as warm baths. Compresses with Ronidase are applied to the shoulder area. If necessary, FTL is repeated after 5-6 weeks in courses up to 3-4 times a year.

In newborns with vertebrobasilar insufficiency, indicating a spinal component of RPVC, non-operative treatment is supplemented with a set of measures aimed at eliminating ischemia, improving blood supply and trophism of the spinal cord, as well as accelerating regenerative processes. This complex includes:

immobilization of the cervical spine with a cotton-gauze “donut”:

prescribing medicinal treatment in the 1st week of life, namely antispasmodics, nootropic drugs, vascular and stimulants, and from the 2-3rd week of life - absorbable agents and biostimulants;

electrophoresis of antispasmodics on the upper cervical spine using the transverse technique;

massage of the collar area during the recovery period.

Complex rehabilitation measures if necessary, it is repeated after a 4-8 week break in the conditions of the children's neurological department.

Clinical and ENMG monitoring of effectiveness therapeutic measures carried out once every 3 months.

Taking into account the dynamics of restoration of the function of the affected VC under the influence of the treatment, it is possible to predict the course of the disease.

If by 2-3 months of age an infant with RPVC does not have a significant restoration of active function in the distal segments of the VC, then subsequently they develop functionally significant orthopedic and aesthetic consequences in the form of pronounced atrophy, deformities and contractures requiring surgical correction.

The maximum possibilities for restoring the function of the affected VC occur in children under one year of age. In children older than 2-3 years, the dynamics of restoration of hand function continues. This is due both to the strengthening of muscles, the increase in their strength, and to the growing up of the child and his active development. Therefore, non-operative treatment should be continued, orthopedic treatment becomes the leading one, neurological treatment should be aimed at improving trophism, blood supply to muscles, and neuromuscular conduction.

Thus, in the acute and recovery periods of RPVC, early differentiated non-operative complex treatment depending on the period of the disease, topic and severity of the lesion.

If within 6 months. If there is no significant restoration of hand function, then further consequences will develop that require surgical correction. Non-operative treatment of children over 3 years of age is ineffective and does not prevent the formation and progression of persistent atrophies, deformations and contractures of the affected VC.

The identified patterns must be taken into account when providing specialized step-by-step care to this group of patients.

Surgical treatment

Surgical methods of treating RPVC appeared later than non-surgical ones. Methods of surgical treatment of RPVC are divided into:

neurosurgical;

orthopedic.

Interest in brachial plexus surgery for RPVC is currently due to advances in the development of microsurgical techniques, the use of additional research methods, as well as improvements in anesthesia.

Absolute indications for brachial plexus revision: total paralysis

Contraindications to early surgical treatment:

bilateral paralysis;

diaphragmatic paralysis;

positive dynamics with non-operative treatment.

Operations in the acute period: revision of the brachial plexus using microsurgical techniques, neurolysis, excision of damaged nerve trunks, suture, plastic surgery of brachial plexus bundles. The optimal age of the child is from 3 to 10 months.

Positive results with early surgical treatment are observed in 80-85% of cases.

A comparison of groups of children treated only nonoperatively and using neurosurgical methods showed that the latter significantly improve the outcomes of RPVC.

Surgical orthopedic treatment of children with consequences of RPVC.

Objectives of surgical treatment:

1) elimination of fixed contractures in the joints of the upper extremities;

2) elimination of the vicious position of the segments of the upper limb;

3) stabilization of joints in a physiological position in case of their instability, dislocations and subluxations;

4) restoration or increase in the range of active movements in the joints through tendon-muscular plastic surgery.

Adductor contracture of the shoulder.

To eliminate it, lengthen the adductor muscles of the shoulder. Lengthen the tendons of the pectoralis major and teres major muscles. IN postoperative period the limb is fixed with an abduction splint for 4 weeks. This operation is indicated as an independent intervention in children aged 3 to 10 years in the absence or minimal internal rotation of the shoulder and preserved function of the deltoid muscle. In older children, this intervention is performed as a stage of reconstructive surgery on the shoulder joint.

When adductor contracture is combined with pronation contracture in young children, a tenotomy can be performed in the modification of A. Chizhik-Poleiko - cutting off the tendon of the pectoralis major muscle and moving it to the deltoid muscle, dissecting the tendon of the latissimus dorsi and subscapularis muscles.

Extensor contracture in the elbow joint.

To eliminate it, perform a Z-shaped lengthening of the triceps brachii tendon in lower third and proximal movement of the attachment of the flexors of the hand in the area of the internal epicondyle of the humerus. Partial cutting of the internal epicondyle of the humerus with the tendons of the palmaris longus, radial and ulnar flexor muscles is performed. The insertions of the pronator teres and flexor digitorum superficialis tendons should be separated and left in place to prevent tension and the appearance of a “fist” phenomenon in the postoperative period. The mobilized part of the internal epicondyle is moved proximally along the anterior internal surface of the humerus by 5-6 cm and fixed to it with a screw in a pre-formed bone fossa. In the postoperative period, the upper limb is fixed with a thoracobrachial bandage with flexion at the elbow joint up to 70°, the hand and fingers are in the average functional position. During the rehabilitation period, you should not extend the limb at the elbow joint more than 160°.

Flexion contracture in the wrist joint.

Lavsanodesis of the hand is performed - linear or V-shaped. For a “dangling” hand in young children, you can perform lavsanodesis with a “loop”. To prevent the development of a fixed extension position of the hand as the child grows, it is advisable to use an elastic Mylar tape and measure its tension. The optimal age of the child is 10-12 years. In the postoperative period, the upper limb is fixed with a plaster cast along the anterior surface from the fingertips to the upper third of the shoulder for 4 weeks.

Extensor contracture in the II-V metacarpophalangeal joints.

Ligamentocapsulotomy of the II-V metacarpophalangeal joints is performed. The joint capsule in the dorsum of the hand is dissected, the extensor tendons of the fingers are lengthened in a Z-shape, the phalanges of the fingers are passively bent to 90° at the metacarpophalangeal joints and fixed with knitting needles to the metacarpal bones transosseously for 4 weeks. Immobilization in the postoperative period is carried out with a plaster splint along the back surface of the forearm and hand from the fingertips to the upper third of the shoulder for a period of 4 weeks.

Internal rotation contracture of the shoulder.

In children 3-5 years old, with preserved function of the deltoid muscle and the absence of pathological torsion of the humerus, lengthening of the teres major and pectoralis major muscles is performed and is supplemented with tenotomy of the latissimus dorsi muscle. In this case, the shoulder should be held passively in a position of external rotation. Fixation in the postoperative period is carried out with an abduction splint in the “voting” position for a period of 4 weeks.

If, after lengthening and tenotomy of the above muscles, the arm is not held passively in the position of external rotation, then the surgical intervention should be supplemented with an element of the operation according to J. Episcopo (Episcopo J.) and an element of the operation according to J. Sever (Sever J.). In the postoperative period, the upper limb is fixed with a thoracobrachial bandage for a period of 4 weeks. This surgery should not be performed on children with an unstable shoulder joint. It is not effective in children over 6 years of age and with severe adductor contracture of the shoulder.

In children over 7 years of age with a fixed internal rotation contracture of the shoulder, largely due to the torsion of the humerus developed as a result of constant pronation of the arm, a transverse subperiosteal derotational osteotomy of the humerus in the upper third, above the insertion of the deltoid muscle, is indicated. The first step is to lengthen the adductor muscles of the shoulder and develop its active abduction as much as possible. After osteotomy, the distal fragment is passively rotated outward until internal rotation is completely eliminated and fixed with an external compression plate. In the postoperative period, fixation of the arm is supplemented with a plaster cast according to Turner. The average consolidation time is 2-3 months. The posterior displacement of the attachment site of the deltoid muscle with the distal fragment of the humerus helps to increase the function of shoulder abduction.

Supination contracture of the forearm

Unfixed supination contracture of the forearm can be eliminated by surgery during which a T-shaped lengthening of the biceps brachii tendon is performed at the level of the elbow joint. The distal end of the tendon is moved behind and around the radius from the inside out and sutured to the proximal end with tension, while the biceps brachii muscle becomes not only a flexor of the forearm, but also its pronator. The forearm is placed in 90° flexion and pronation.

In the distal part of the forearm, a Kirschner wire is passed transosseously across both bones to maintain pronation of the forearm for a period of 4 weeks.

Fixation of the upper limb is supplemented with a plaster cast for a period of 4 weeks.

Fixed supination contracture of the forearm is eliminated by transverse subperiosteal derotational osteotomy of the radius at the level of the lower third of the forearm. The operation must be supplemented with detachment of the interosseous membrane from the radius, maximum pronation of the forearm and fixation of fragments with an intramedullary rectangular rod. Fixation is supplemented with a plaster cast in a position of flexion at the elbow joint up to 90° and maximum pronation of the hand. Consolidation – after 4-5 months.

Bringing and absence of oppositionIfinger of the hand.

Combined interventions are performed. To create opposition of the first finger when mixed type paralysis and with intact function of the superficial flexor of the fourth finger, the tendon of the latter is cut off transversely distal to the bifurcation in the projection of the base of the fourth finger, brought to the first metacarpal bone and sutured transosseously with lavsan threads to the base of the first metacarpal bone in the position of opposition of the first finger to the second. The hand is fixed with a plaster cast for 1 month.

To eliminate adduction and create opposition of the first finger in case of severe damage to the hand, the first stage is to deepen the first interdigital space by skin grafting with opposing triangular flaps.

In the second stage, the first finger is placed in a position in opposition to the second finger, and an autograft from the wing is placed between the first and second metacarpal bones ilium, which is fixed with knitting needles.

Fixation with a plaster cast lasts 3 months.

Joint stabilization.

Arthrodesis of the shoulder joint is indicated for children over 12 years of age with severe upper type RPVC in the absence of active movements in the shoulder joint and the presence of instability in it. Conditions for obtaining a positive effect: good function muscles that fix the scapula, good function of the muscles of the forearm and hand, the presence of active flexion in the elbow joint.

Cartilage is resected from the head and glenoid cavity and skeletonized bottom surface acromion, the shoulder is placed in a position of abduction 70°, flexion 30°, internal rotation 15°. Fixation of the shoulder to the scapula is carried out with two crossed screws. It is necessary to control the position of the scapula: its medial edge should be parallel to the axis of the spine. Additional fixation is carried out with a thoracobrachial plaster cast for up to 5 months. To reduce the consolidation time, you can use a compression bone fixator or an Ilizarov apparatus.

Arthrodesis of the wrist joint is performed in children over 12 years of age if there is instability and a positive test for external fixation. Conditions for arthrodesis: the degree of ossification of the carpal bones must be more than 75% and all the bones of the wrist, and most importantly the capitate bone, must be included in the arthrodesis zone. The hand is placed in a position of 20° dorsiflexion and 20° deviation to the ulnar side and fixed with two crossed knitting needles; external fixation devices are used to create compression. Consolidation period is 4-5 months. By creating a compression effect, the timing of arthrodesis is reduced. In children 10-12 years old with severe damage and severe delayed ossification of the wrist bones, bone autografts should be used to cover the arthrodesis area.

Restoring or increasing range of motion in joints.

To increase the amount of active shoulder abduction during top type lesions in children over 10 years of age, monopolar transposition of the trapezius muscle onto the shoulder into the position of the deltoid muscle can be performed. The condition for performing this operation is: good function of the trapezius muscle, absence of adductor contracture of the shoulder and instability of the shoulder joint.

The trapezius muscle is cut off from the clavicle and acromion, mobilized, lengthened with Mylar and transferred to the shoulder in the subcutaneous tunnel, where it is sutured subperiosteally with Mylar threads. In the postoperative period - fixation with a thoracobrachial bandage for 6 weeks. The disadvantage of this operation is the short lever and small excursion of the trapezius muscle.

Currently, with the development of microsurgical technology, transplantations of a complex of tissues have begun to be successfully used: a thoracodorsal flap with latissimus muscle back to the position of the deltoid muscle, bipolar transposition of the pectoralis major muscle on the neurovascular pedicle to the position of the deltoid muscle.

To increase the amount of active flexion in the elbow joint, a Steindler operation is performed. The conditions for its effectiveness are a stable shoulder joint and a full range of passive movements in the elbow joint.

Good results were also obtained with bipolar transposition of the thoracodorsal flap with the latissimus dorsi muscle into the position of the biceps brachii muscle.

To increase active finger movements and increase bilateral grip strength, tendon-muscle transfers should be performed in the forearm area. Conditions for their implementation: the wrist joint must be stabilized, there must be a full range of passive movements in all metacarpophalangeal joints and interphalangeal joints. Before surgery, it is necessary to conduct an accurate electrical diagnosis of the muscles. For transplantation, the radial and ulnar extensors of the hand and the radial and ulnar flexors of the hand are used. They are transplanted onto the extensors of the fingers, onto the muscle that abducts the first finger.

Postoperative rehabilitation must be carried out after each stage; its nature is determined by the nature of the surgical intervention.

In the complex of rehabilitation measures, an important role belongs to active exercise therapy, electrical stimulation of muscles, segmental massage and adaptive bioregulation with external OS.

The most labor-intensive process of rehabilitation treatment is after tendon-muscular plastic surgery. Active rehabilitation must be carried out after complete healing of the wound, elimination of the traumatic process in the transplanted muscles and after their complete implantation in the bed. During this entire period, it is necessary to continue constant immobilization and FTL aimed at enhancing reinnervation, relieving tissue edema and stimulation metabolic processes in tissues. It is constantly necessary to monitor the bioelectrical activity of the transplanted muscles. Clinical and neurophysiological adaptation of the displaced muscles under the influence of the active function of the VC occurs after 3-4 months. after surgery. Active rehabilitation should be carried out for 1 year to consolidate the result.

Most effective results surgical treatment is observed in children 6-8 years old; their growth and development of the upper limb is more aesthetically pleasing, while vicious attitudes and muscle imbalances are eliminated and adaptive mechanisms are developed more quickly.