NEONATAL SURGERY - 1976

2. SPECIAL SECTIONS

10. Trauma

   Traumatic injuries in newborns occur during delivery or in the immediate postnatal period. Birth injuries account for 3 to 8% of all types of trauma in children in their first month of life (R. Ya. Usoskina et al., 1969). The causes of birth trauma include errors in obstetric care during manipulations, application of forceps, HEAD traction, extraction of the shoulders or arms, and podalic version in pathological labor. Fetal soft tissue injuries in the form of lacerations may be inflicted by the surgeon's scalpel during Cesarean Section. The Nature and severity of injuries vary and are generally determined by The Mechanism of trauma, the identification of which is straightforward.

Birth injuries and neonatal trauma can in most cases be classified as so-called medical injuries. Their Prevention is not only a surgical problem but an organizational one as well.

Neonatal Craniocerebral Trauma

The incidence of birth injuries to The Skull and Brain ranges from 1 to 10%, which among all Other types of neonatal pathology accounts for 70–80% in full-term infants and 52–62% in premature infants. This type of trauma is one of the leading causes of perinatal mortality (28%), mental disability, cerebral palsy, Epilepsy, and other brain disorders among surviving children (25%).

Structure/149.html">The problem of neonatal craniocerebral trauma is of social significance and attracts the attention of researchers worldwide. An important milestone in The Study of this problem was the All-Union Symposium (1969), which generalized modern data regarding the Etiology AND Pathogenesis of birth brain injuries, data on pathophysiological reactions and morphological changes associated with them, as well as experience in comprehensive Treatment and The Use of neurosurgical diagnostic Methods in newborns with birth craniocerebral trauma.

Etiology and pathogenesis. Decisive importance is attributed to impaired uteroplacental Circulation and fetal asphyxia (A. F. Tur, 1960; I. T. Milchenko et al., 1960; Keuth, 1966). Brain Hypoxia leads to Blood Coagulation disorders followed by diapedesis. In some cases, The Development of intracranial pathophysiological and pathomorphological changes is caused by direct mechanical trauma at the moment the fetal head passes through the birth canal or during obstetric assistance. The anatomical and PHYSIOLOGICAL CHARACTERISTICS OF the newborn create the prerequisites

for the development of functional and organic Changes in the Central Nervous system—disorders of hemodynamics and CEREBROSPINAL FLUID dynamics, cerebral edema and Swelling, and intracranial and intracerebral hemorrhages.

Clinical presentation. Three periods are distinguished: the period of early manifestations—from the first hours of the child's life to the 7th–10th day; the repair period—from the 7th–10th day to 1–1 ¹/₂ months; and the period of immediate consequences (M. F. Deshchekina, 1968).

The clinical picture of early manifestations of intracranial birth trauma comprises neurological symptoms, somatic deviations, and Metabolic Disorders. Common signs include acute agitation from the first hours of life, restlessness, Sleep disturbances with the open-eye sign, a periodically painful "cerebral" cry, muscular hypotonia, hyporeflexia, hyperkinesia, and clonic seizure episodes. With increased intracranial pressure, bulging of the anterior fontanelle, Graefe's sign, strabismus and nystagmus, and a bright, red, persistent dermographism are observed. The described clinical picture is characteristic of cerebral edema. In cases of a favorable course, an improvement in the child's general condition is noted after 3–4 days.

When intracranial trauma is combined with adrenal insufficiency, the child's condition is more severe. Lethargy, lack of active movements, sluggishness, and decreased physiological Reflexes are characteristic.

The most frequent morphological manifestation of birth trauma is intracranial Hemorrhage—epidural, subdural, subarachnoid, intracerebral, and intraventricular. In subdural and Subarachnoid Hemorrhage, blood accumulates in the posterior cranial fossa and flows into the spinal canal, leading to compression of the Brainstem and disruption of respiratory and circulatory centers.

A distinction is made between a pure form of subdural and subarachnoid hemorrhage, without damage to the brain parenchyma, and a combined form with parenchymal involvement. The former is characterized by a severe condition and the absence of focal signs (paralysis and paresis). On the 2nd–3rd days, meningeal symptoms appear with body Temperature rising up to 39°C. Children assume a forced posture: the head is thrown back, often an opisthotonos posture, the face is anguished, the Skin is grayish, and generalized clonic-tonic seizures are periodically observed. These seizures in intracranial hemorrhages occur as the spilled blood changes and Hemoglobin is released, which is a powerful irritant to the central nervous system. Muscle tone is increased. The reflexogenic zone of tendon reflexes is expanded, and limb tremors, nuchal rigidity, a positive Kernig's sign, and a lower Brudzinski's sign are prominent. The large fontanelle is tense, and Separation of the parietal and frontal bones along the sagittal suture is possible.

In the combined form, alongside general symptoms, paresis and paralysis are observed. Phenomena of impaired vital Functions of Respiration and Cardiac Activity are added. Neurological examination most frequently reveals the pathological Rossolimo sign and the loss of Components of the Perez reflex. The latter belongs to tonic cutaneous reflexes. Upon digital stroking of the child's skin from the coccyx to the occiput, it manifests as: a) apnea followed by a cry; b) flexion of the upper and lower extremities; c) short-term Hypertension; d) involuntary urination and defecation. The Perez phenomenon has important prognostic significance: the absence of all its components indicates a severe degree of cerebral circulation impairment and a serious prognosis.

General symptoms of central nervous system damage also include thermoregulation disorders (increase or decrease in body temperature, tendency toward hypothermia).

As the pathological process develops, the regulatory function of the central nervous system is lost, especially when the autonomic centers of the diencephalic region are damaged. Consequently, the described symptom complex is joined by a picture of somatic disorders affecting the Lungs, Cardiovascular system, gastrointestinal tract, and Endocrine System, particularly the Adrenal Glands. Depending on the severity of the symptoms, cardiovascular, pseudopneumonic, gastrointestinal, and neural clinical forms are distinguished.

The cardiovascular syndrome is manifested by impaired peripheral circulation and cardiac activity. Heart rate and rhythm are disrupted. Bradycardia is replaced by tachycardia. Peripheral vascular tone changes (skin flushing, periodic color changes, generalized cyanosis). Additional Diagnostic Methods (capillaroscopy, fluorimetric test, Nesterov and McClure tests) reveal the dependence of capillary pattern disturbances and permeability on the severity of intracranial trauma. Changes in acid-base

balance (ABB) indicate metabolic disorders in intracranial birth trauma, specifically deep metabolic acidosis.

In children with birth craniocerebral trauma, non-specific Immunity is impaired, greater physiological weight loss is noted, malnutrition (hypotrophy) may develop, the umbilical cord remnant falls off late, and epithelialization of the umbilical wound is delayed. The depth of somatic and metabolic disorders, along with the severity of neurological deviations, characterizes the degree of severity of the pathological process.

Thus, the clinical picture of birth craniocerebral trauma is complex and diverse. Evaluation of the obstetric history, Features of the course of Pregnancy and labor, and clinical and neurological examinations of newborns are of great importance because they make it possible to suspect intracranial trauma. However, these data are generally insufficient to determine the nature and localization of traumatic brain lesions. Special diagnostic methods acquire paramount importance.

Diagnosis of birth trauma in modern conditions involves establishing the nature and localization of the newborn's traumatic brain lesion. This is achieved through a comprehensive clinical examination, provided that neurosurgical methods are obligatory used. The latter include lumbar and ventricular punctures, neuro-X-ray Examination using artificial contrast (E. D. Fastykovskaya, 1969), as well as transfontanelle puncture of the subdural space (A. I. Ospov, V. P. Galanov, 1969). A comprehensive examination of the newborn in most cases allows for an accurate diagnosis.

Differential diagnosis. Birth craniocerebral trauma is differentiated from congenital heart disease, isolated facial cyanosis, respiratory disorders of non-central origin, congenital stridor, hypocalcemia, neonatal Sepsis, and severe general illnesses.

Treatment. Therapeutic measures begin already in the maternity hospital. In the presence of asphyxia, resuscitation is performed. Knowledge of emergency therapy and intubation techniques facilitates the proper execution of resuscitation measures. Infusion therapy aimed at normalizing peripheral circulation and rapidly eliminating acidosis and exicosis acquires vital importance in providing emergency care.

According to MODERN CONCEPTS OF the pathogenesis of asphyxia and intracranial birth trauma, ensuring adequate respiration is essential following resuscitation during the early manifestation period. This involves Oxygen therapy, along with the administration of analeptics and cardiac medications. Further measures to manage metabolic acidosis are determined by acid-base balance (ABB) parameters. A 4% sodium bicarbonate solution is administered, with the dosage calculated using the formula (see the section «Infusion Therapy»). It is recommended to administer half of the solution as a bolus and the second half as an infusion combined with a 20% glucose solution. Intravenous or intramuscular administration of cocarboxylase at 25 – 30 mg per day for 7 – 10 days, and aminophylline at 0.005 g twice daily, is indicated.

In cases of profound metabolic disturbances that are refractory to correction, exchange blood transfusions are indicated at a rate of 100 ml per 1 kg of body weight.

The infant requires gentle handling and strict rest. Feeding is carried out using expressed breast milk via a pipette or a feeding tube. For hemostasis, antihemorrhagic agents are used: vitamin K at 0.005 g daily for 3 days, Vitamin C, calcium preparations, and local cold application to the head.

For cerebral edema and convulsive syndrome, dehydration therapy is indicated: a 20% glucose solution 10 – 15 ml daily, hyperoncotic plasma 15 – 20 ml per day, and a 25% magnesium sulfate solution at 0.2 ml per 1 kg of body weight daily. Neuroplegic agents are used (chlorpromazine 1 – 2 mg/kg per day in three divided doses intramuscularly for 10 – 12 days; the drug is discontinued 3 days after the cessation of seizures and normalization of ABB), along with nipolfen at 0.001 g/kg per day. Luminal and bromides are given in standard dosages.

The identification of symptoms of adrenal insufficiency requires the inclusion of hormonal drugs in the treatment regimen: hydrocortisone at 5 mg/kg or prednisolone 1 – 2 mg/kg per day. To normalize metabolic processes, glutamic acid is prescribed at a dosage of 0.05 – 0.1 g/kg of body weight per day in three divided doses. Treatment is continued throughout the period of early manifestations and into the repair phase. For 15 – 20 days, the infant receives B-complex Vitamins (B₁₂ and B₆). Plasma preparations, gamma-globulin, and blood transfusions are prescribed for stimulation. Therapeutic measures for somatic disorders are carried out in accordance with the clinical syndrome form.

Recent years have been marked by attempts at Surgical treatment for the most common meningeal hemorrhages — subdural and subarachnoid (A. I. Osna et al., 1968). Hematoma evacuation is performed via Craniotomy or subdural space puncture.

During the repair period, reabsorptive therapy is prescribed (0.1% solutions of potassium or sodium iodide, 2 drops twice daily for 2 weeks).

The prognosis depends on the severity of the pathological process. Severe maceration of brain tissue is usually incompatible with life. In cases where the child survives, traumatic brain injury leads to severe complications. During the first 1 ½ – 2 years of life, paresis and paralysis of the limbs and Cranial Nerves, epileptic seizures, and physical and mental developmental delay are observed.

Injury to the corpus striatum presents with a picture of athetosis; lesions of the globus pallidus lead to muscle rigidity. Damage to the substantia nigra manifests as parkinsonian symptoms with gross tremor, early athetosis, and myoclonus. Lesions of the cerebellar pathways and pyramidal system lead to ataxia. Clinical practice encounters mixed forms of pyramidal and extrapyramidal symptoms. Among children who have suffered intracranial trauma, the proportion of debiles reaches 39%, and imbeciles 13.7% (Heike, Schulze, 1962).

Soft Tissue Injury

Soft tissue wounds in newborns occur As a result of the application of obstetrical or scalp forceps, or a vacuum extractor. They are usually localized on the head, less frequently on the buttocks, i.e., in areas that serve as the direct point of application for instrumental delivery AIDS during difficult labor. Wounds may be linear, flap-like, or stellate. Wounds inflicted by a vacuum extractor have a distinct character: a central Hair loss defect surrounded by extensive skin detachment, with the periosteum forming the Base of the wound. Soft tissue injuries require special attention because these wounds are generally infected and can be a source of neonatal sepsis.

Wound treatment in our clinic (A. I. Lenyushkin, A. M. Egorova, 1963) is performed using dressings with Vishnevsky ointment. With the appearance of granulation tissue, Thiersch skin grafting is indicated. For a sluggish wound healing process in debilitated and premature infants, dressings with maternal blood combined with oxygen insufflation are used.

«Caput succedaneum» — subcutaneous tissue edema — is accompanied by localized BLOOD AND Lymph circulation disorders, and sometimes hemorrhagic infiltration of the Tissues of the fetal presenting part. Caput succedaneum is most frequently localized on the newborn's head and clinically manifests as a doughy swelling that does not respect the boundaries of a single cranial vault bone. A newborn with caput succedaneum does not require special treatment, as the soft tissue edema typically resolves spontaneously on the 3rd – 4th day after birth. In contrast to caput succedaneum, some authors distinguish «birth swelling,» in which local circulatory and lymphatic disturbances resolve within 1 – 2 days.

Cephalhematoma — Hemorrhage into the subperiosteal tissue — occurs in 0.1 – 1.8% of cases. Cephalhematoma may occur in spontaneous deliveries, but is more frequently the result of instrumental interventions (T. S. Rabtsevich, 1964).

A cephalhematoma presents as a doughy or fluctuating swelling that does not extend beyond the borders of a single cranial vault bone. Such subperiosteal hematomas can be either single or multiple. Grosch and Ch. Grosch (1964) described atypical «paramedian» cephalhematomas. Blood extravasated beneath the periosteum typically resolves within a period ranging from several days to 2 – 3 weeks after birth. In some cases, the subperiosteal hematoma becomes encapsulated and organizes.

Craniograms show localized soft tissue bulging with a sharp, dense outer contour. The older the child, the more pronounced the tissue density. The underlying bone thins under the pressure of the hematoma, and hyperostosis develops.

Treatment. Small cephalhematomas do not require treatment. For extensive cephalhematomas, puncture with aspiration of the contents followed by the application of a moderately compressive bandage is indicated. Puncture of the hematoma in the first hours after birth is undesirable. Suppurated cephalhematomas are incised, the cavity is evacuated of pus, and it is flushed with antiseptic solutions.

In some patients, the cephalhematoma tends to calcify. The calcium shadow is usually clearly visible on radiographs. In such cases, surgical removal of the hematoma at the age of 2 months is indicated (Yu. S. Brodsky, 1967).

In most cases, newborns with extensive or suppurated cephalhematomas require not only local surgical treatment, but also general symptomatic therapy aimed at eliminating anemia and preventing the generalization of purulent infection.

Birth Fractures

   Skull Fractures

Skull fractures in newborns generally occur during delivery. Domestic trauma is also possible (falling from a stroller, crib, etc.). Birth-related skull fractures are in most cases the consequence of obstetric intervention (compression of the head by forceps during delivery) or cephalopelvic disproportion. In either case, conditions are created for the development of depressed fractures of the cranial vault. The frontal and parietal bones are most commonly affected. In some instances, excessive Displacement of the cranial vault bones can lead to the rupture of Connective Tissue sutures, injury to the venous sinus wall, and the development of intracranial hemorrhage.

In domestic trauma, linear fractures of the enveloping skull bones are observed more frequently.

Clinical and radiological presentation. Depressed and linear bone fractures without accompanying intracranial injuries manifest predominantly with local symptoms. A distinctive feature of depressed fractures in newborns is the possibility of bone indentation over a limited area without disrupting the integrity of its individual poorly differentiated layers. Such «ping-pong ball» type fractures are generally not accompanied by hematoma or soft tissue edema and are easily diagnosed upon inspection and Palpation.

Linear fractures, by contrast, are almost always accompanied by The formation of a significantly fluctuating hematoma along the injury line. In some cases, the hematoma extends beyond the boundaries of one, two, or even three bones, and is tense and painful upon palpation (Fig. 121).

Class="center">Fig. 121. Diagram of cerebrospinal fluid leakage mimicking a cephalohematoma.

The close TOPOGRAPHIC AND ANATOMICAL relationship between the dura mater and the inner surface of the cranial vault bones creates conditions for its injury during linear convexal fractures, which are often accompanied by the escape of cerebrospinal fluid through the bone fracture line beneath the aponeurosis.

The general symptoms characteristic of skull fractures combined with intracranial trauma are detailed in the section "Birth-Related Craniocerebral Trauma."

The diagnosis of skull fractures in newborns is based on clinical (inspection, palpation) and radiological findings. Typical local signs of linear and depressed fractures allow for an accurate diagnosis in the majority of patients even before X-ray examination. Nevertheless, craniography helps refine the clinical diagnosis, determine the fracture Location, the depth of depression in impression fractures, and the extent of linear skull fractures. In doubtful cases, a detailed neurological examination is mandatory, and if necessary, other diagnostic methods should be performed to rule out intracranial injuries.

Treatment. Depressed fractures require surgical intervention. The most conservative Procedure is burr-hole trepanation of the skull with elevation of the depressed bone fragment using a Deschamps needle or a modified Doyen raspatory (autocranioplasty by reposition). Linear fractures generally do not require surgical treatment. A tense hematoma is an indication for puncture followed by the application of a moderately compressive bandage. If the hematoma enlarges, a repeat puncture is indicated. The linear bone defect usually disappears by the end of the 2nd to 3rd week. The prognosis for skull fractures in newborns without intracranial injuries is favorable.

   Clavicle Fractures

Clavicle fractures are the most common type of birth injuries. They account for 0.05–1.5% to 50% of all neonatal trauma (G. E. Zelenskaya, 1968; Lehmacher, Lehmann, 1962). The Anatomical and physiological characteristics and unique Development of the clavicle explain why fractures predominantly localize at the border of the middle and inner thirds. According to Lehmacher, during the passage of the shoulders through the birth canal, the clavicles lie almost parallel to the axis of the infant's body, which creates conditions for injury even during normal delivery. Clavicle fractures are observed with equal frequency on the left and right sides, in both boys and girls. They are relatively more common in large infants and following multiparous labor. Clavicle fractures in newborns can be complete, with fragment displacement, or incomplete (subperiosteal).

Clinical and Radiological Presentation. Clavicle fractures are characterized by limited or absent active movements on the affected side, smoothing of the soft tissues in the fracture area due to edema, the presence of a hematoma, and fragment displacement. Passive Movements of the arm cause distress to the infant, palpation of the injured clavicle is painful, and bone crepitus may be elicited.

Diagnosis is established based on clinical findings, supported by an understanding of the birth mechanism and radiological data. In most cases, diagnosing a clavicle fracture is straightforward. However, in maternity hospitals, clavicle fractures—especially subperiosteal ones—frequently go unnoticed, and the correct diagnosis is made only on the 7th to 9th day post-injury, when a callus has formed and the fracture has effectively already healed. Often, a clavicle fracture is mistakenly diagnosed as a Duchenne–Erb birth palsy, and the possibility of sternocleidomastoid muscle injury is underestimated.

Treatment. Clavicle fractures in newborns do not require reduction. The mainstay of treatment is immobilization, which is achieved using a Desault bandage with a pad in the axillary region. Gauze should be placed between the arm and the torso to prevent chafing. Immobilization can also be achieved via the swaddling method (Fig. 122). The duration of immobilization is up to 10 days. Bone Structure recovery occurs rapidly, and a well-developed callus is formed. Subsequent clavicular deformity is not observed.

Fig. 122. Fixation for a clavicle fracture in a newborn: Desault-type bandage (a), swaddling method (b).

   Humeral Fractures

Humeral fractures rank second in frequency after clavicle fractures and occur in 0.01–0.04% of cases. This type of injury typically results from manual assistance during delivery. Diaphyseal fractures of the humerus are more common, while traumatic epiphyseolysis of the distal or proximal humeral epiphysis is less frequent.

Diaphyseal fractures of the humerus occur during the extraction of the shoulders when spontaneous delivery of the trunk is delayed and the fetus is threatened by asphyxia. In such situations, the urge to rapidly extract the "posterior" shoulder is justified. However, this causes the "posterior" shoulder to abut against the mother's Pubic Symphysis, where overly hasty and forceful maneuvers by medical personnel inevitably lead to a humeral fracture.

Clinical and Radiological Presentation. A humeral fracture can be diagnosed immediately after the birth of the fetus: characteristic signs include angular deformity in the middle third of the arm and an absence of active movements in the affected arm. Complete fractures present with a hematoma, pathological mobility, and fragment crepitus. Diaphyseal fractures of the humerus are frequently accompanied by radial nerve palsy, the injury to which occurs directly at the moment of the fracture or during vigorous examination. Therefore, the examination must be as gentle as possible. X-rays taken in two projections help clarify the fracture location and The Nature of fragment displacement.

Transverse or oblique diaphyseal fractures with complete fragment displacement are most commonly observed.

Treatment. Diaphyseal humeral fractures without displacement require immobilization of the injured limb for 10–12 days. Fixation methods vary: Desault bandage, abduction thoracobrachial cast, specialized plaster bed, U-shaped splint, vertical adhesive tape traction of the arm, etc. At the Clinic of Pediatric Surgery of TsOLUV, an abduction thoracobrachial cast made of quick-Setting material is used (Fig. 123).

Fig. 123. Fracture of the humerus in a newborn (electro-roentgenogram). Methods of fracture fixation: in an abduction plaster cast (a); on a U-shaped splint (b); by adhesive tape traction (c).

The upper extremity is fixed in a mid-physiological position extending to the interphalangeal JOINTS OF THE fingers, with the shoulder abducted at a 90° angle. In cases of radial nerve palsy, the hand and fingers are positioned in extension. For humeral fractures with fragment displacement, single-stage reduction followed by fragment fixation using one of the aforementioned methods is indicated. Reduction is performed under general or local anesthesia, aiming for complete correction of angular and rotational displacements. Overriding of fragments in length by up to 1.5–2 cm, as well as displacement in width even equal to the full diameter of the bone, are considered "acceptable" in newborns, as they completely resolve during callus remodeling. The results of reduction are verified by X-rays taken in the cast. The duration of fixation is approximately 2–3 weeks. To timely detect and correct secondary displacements, a control X-ray in the cast is indicated 5–7 days after reduction.

Prognosis. In isolated humeral fractures, limb function is restored 7–10 days after the removal of immobilization. For humeral fractures complicated by radial nerve palsy, the recovery period is prolonged. In such cases, comprehensive therapy involving a neurologist, physical therapist, and exercise therapy instructor is indicated. To prevent contractures of the fingers and hand, they are fixed with a removable plaster splint in a position of maximum extension until the complete recovery of lost Muscle Function. Concurrently, proserine, dibazol, injections of vitamins B₁ and B₁₂, thermal Procedures, and massage of the paralyzed Muscles are prescribed. Active and passive gymnastics for the fingers and hand of the affected limb are indicated. Movements in the elbow and shoulder joints are initiated after fracture union.

Traumatic epiphyseolysis of the humerus is diagnosed relatively rarely. This is due to a lack of familiarity with this type of birth injury among obstetricians and neonatologists. The mechanogenesis of birth-related epiphyseolysis involves not only forced pressure on the proximal or distal epimetaphysis of the humerus during manual and instrumental assistance in childbirth. Strong uterine contractions at the time of expulsion of a large fetus and abrupt rotational movements of the arm during precipitous and rapid labor also play a significant role.

Clinical presentation. Birth-related epiphyseolysis of the humerus is characterized by signs of a para- or intra-articular fracture: the shoulder or elbow joint region (depending on the localization of the epiphyseolysis) appears smoothed out due to edema, hemarthrosis, or a periarticular hematoma. Movement and palpation of the joint area are painful, and crepitus may be present. Epiphyseolysis of the distal humeral epiphysis is typically complicated by radial nerve paresis or paralysis, which manifests as flexion contracture in the elbow and wrist joints, along with sensory disturbances in the corresponding areas of the fingers and hand. In birth-related epiphyseolysis of the proximal humeral epiphysis, the forced posture of the arm largely resembles the limb position seen in Duchenne–Erb paralysis.

Radiological presentation. The absence of ossification centers in newborns, the radiolucency of cartilaginous epiphyses in the elbow or shoulder joints, and the early onset (on days 7–10 post-injury) of a periosteal reaction in the affected area—even with minimal periosteal stripping in the metaphyseal region—significantly complicate Diagnostics. On radiographs taken within the first 24 hours after injury, epiphyseolysis can only be inferred from abnormal spatial relationships of visible bone fragments within the joint: injury to the proximal epiphysis is characterized by lateral displacement of the central end of the humerus, whereas displacement of the forearm bones at the elbow joint in an ulnar and anterior direction indicates epiphyseolysis of the distal humeral epiphysis. In the latter case, a correct diagnosis is facilitated by a known radiological landmark: under normal conditions, the longitudinal axes of the humerus and ulna coincide (Marx's line). In birth-related epiphyseolysis, the longitudinal axis of the humerus, projected onto the radiograph of the newborn's elbow joint, deviates radially and coincides with the longitudinal axis of the radius (Fig. 124).

Fig. 124. Epiphyseolysis of the distal humerus in a newborn.

The diagnosis is established based on the displacement of the forearm bones relative to the central axis line. Normally, this line passes along the ulna (a); in epiphyseolysis, it passes along the radius (b)

The radiological presentation of humeral epiphyseolysis closely resembles that of dislocations and subluxations in the shoulder or elbow joints. In osteoepiphyseolysis, a barely noticeable bone fragment breaks off from the metaphysis and appears on the radiograph as a triangular or linear plate (V. S. Kostrikov, 1963). Thus, an essential condition for making a correct diagnosis is taking into account the birth history, local clinical signs, and radiological findings. In difficult cases, diagnosis is facilitated by a repeat radiological examination 3 to 5 days post-injury. Characteristic signs of birth-related epiphyseolysis include the early development (on days 5–7) of a well-defined callus and the early appearance of ossification centers in the humeral epiphyses due to irritation of the growth plates.

Treatment should be initiated in the maternity hospital, preferably on the day of the injury. The choice of method is determined by the degree of epiphyseal displacement. For epiphyseolysis without displacement, the injured limb is immobilized in a functionally advantageous position using an abduction plaster thorachabrachial splint for 10–14 days. When epiphyseolysis is accompanied by displacement, immobilization is preceded by single-stage closed reduction. In fresh cases, correction of the displaced epiphysis is achieved relatively easily through external digital pressure applied anteromedially while performing simultaneous traction along the axis of the supinated forearm.

Achieving correct anatomical alignment of the fragments, although difficult, is still possible on days 4–5 and even day 7 post-injury; however, this requires prior disruption of the fibrous or bony callus. The latter is performed at the time of reduction using a gentle, closed technique. If precise fragment apposition cannot be achieved, one must be content with correcting angular and rotational displacement, followed by reliable immobilization. The retaining bandage is applied taking into account the condition of the peripheral NERVES OF THE limb.

During the rehabilitation period, the early application of physical therapy and mechanotherapy is crucial.

The prognosis is generally favorable. Shortening of the humerus, hypoplasia of its condyle, and instability in the shoulder or elbow joints may occur if treatment is untimely or improper.

   Femoral Fractures

Femoral fractures are among the severe types of injuries, occurring most frequently in breech and transverse fetal presentations, and less commonly in face and vertex presentations. The birth history of most newborns who sustain this injury reveals a version on the leg or instrumental assistance during the delivery of the fetus by the pelvic end. In such cases, violations of obstetric care guidelines are not uncommon. Femoral fractures can also occur during forced breech deliveries. The frequency of femoral fractures varies depending on the level of the injury. Diaphyseal femoral fractures are observed most frequently. Let us examine specific types of femoral fractures.

Fractures of the proximal Femur are extremely rare, accounting for 0.003% of all fractures in newborns (according to V. S. Kostrikov and V. G. Chetaeva, 1963). According to the Classification proposed by these authors, three MAIN TYPES OF injuries in the Head and Neck region of the femur are distinguished: a) epiphyseolysis of the femoral head; b) osteoepiphyseolysis; c) combined birth-related epiphyseolysis and osteoepiphyseolysis of the proximal femur with hip subluxation. As with other localizations, the first Two Types of injuries can occur with or without fragment displacement.

Clinical and radiological presentation. Typical signs of peri- or intra-articular injuries include traumatic swelling, tenderness upon palpation and active movements in the hip joint area, and a forced posture of the leg. Crepitus and pathological mobility during movements of the distal end of the femur are possible.

In most cases, local symptoms are masked by the soft-tissue mass covering the hip joint. Radiological examination also yields limited diagnostic information. The radiological picture in this type of injury largely resembles that of congenital hip dislocation or subluxation—displacement of the proximal end of the femur outward and upward, disruption of Shenton's line, and alterations in The values of h, d, and other radiological parameters. In osteoepiphyseolysis, a fracture of the femoral neck is diagnosed based on the displaced bone fragment. In some cases, hip arthrography is indicated to clarify the diagnosis. Promising diagnostic methods include electroradiography and arthropneumography of the hip joint.

Treatment. For injuries to the femoral head and neck with displacement, early initiation of treatment is critical, as a strong union of fragments occurs by days 4–5 post-injury, rendering fracture reduction ineffective. Following single-stage or staged reduction of the fragments, the limb is immobilized using one of the splints designed for the functional treatment of congenital hip dislocation: the CITO splint, Sitenko splint, Pavlik harness, Vilensky spreader splint, etc. The choice of fixation device is determined by the severity of adduction contracture and the Nature of the fracture and fragment displacement. It is important to position the limb in such a way that the fragments are maintained in correct alignment. The total duration of fixation is at least 5 weeks. Objective criteria for assessing fragment union in the correct position include the near-total absence of a periosteal reaction in the fracture area on follow-up radiographs (B. V. Domansky, 1965) and the normalization of radiological parameters according to Hilgenreiner's scheme.

Prognosis. The absence of clear clinical and radiological signs in this type of injury in newborns often leads to diagnostic and tactical errors. This explains the relatively high percentage of unsatisfactory long-term outcomes following treatment. For instance, according to Baumgarten (1961), out of 30 children with this pathology, half developed coxa vara with insufficient anteversion several years after the injury, necessitating specialized orthopedic treatment. Serious complications include avascular Necrosis of the femoral head, limb shortening, and, at an older age, coxarthrosis. Consequently, children with birth-related INJURIES OF THE proximal femur require long-term orthopedic dispensary follow-up.

Diaphyseal fractures of the femur occur 13.4 times more frequently than fractures of the femoral neck and head, accounting for 0.012% to 0.04% of cases (N. N. Prutovykh et al., 1975). As a rule, closed fractures are observed, although open fractures are also possible.

Clinical and radiological presentation. Examination reveals a deformity in the middle third of the femur. Active movements are absent. The posture of the leg is characteristic: it is flexed at the Hip and knee joints and somewhat adducted due to reflex hypertonus of the flexor muscles. Clinical examination reveals all the classic signs of a complete bone fracture with displacement. This exact type of injury is characteristic of birth-related diaphyseal femoral fractures in newborns. In open fractures, the soft tissues are typically injured by the central fragment, which may be visible in the wound.

Diagnosis is based on clinical and radiological examination data. As with diaphyseal humeral fractures, the fracture plane in the femoral diaphysis runs transversely or obliquely. The characteristic displacement of fragments is determined by the action of the respective muscle groups: the proximal fragment is displaced anteriorly and laterally, while the distal fragment is displaced superiorly and posteriorly.

Treatment consists of local anesthesia of the fracture site followed by immobilization of the injured limb. The method of choice for treating birth-related diaphyseal femoral fractures in newborns is Blount adhesive skin traction. Within the first 3 days post-injury, angular displacement of the fragments and, in most cases, their overriding are successfully corrected. The effectiveness of traction is evaluated using follow-up radiographs. The average duration of fixation is 2–3 weeks, which corresponds to the time required for fracture consolidation. In some instances, significant skin irritation occurs along the adhesive strips, often forcing the removal of traction. To prevent this complication, S. V. Prantskyavichyus (1969) suggested securing the adhesive or gauze strips to the skin via a foam rubber pad glued to the outer and inner surfaces of the leg using cleol adhesive.

In open diaphyseal femoral fractures, prior to applying traction, primary surgical debridement of the wound is performed according to general rules, followed by the administration of Antibiotics. The outcome is favorable in the majority of cases. Malunited fractures may lead to femoral deformities and limb shortening.

Injuries to the distal femur. Epiphyseolysis or osteoepiphyseolysis is the rarest type of birth-related femoral fracture. Isolated clinical observations of this pathology are described in the literature (G. E. Zelenskaya, 1968).

Clinical and radiological presentation. The clinical picture is largely similar to analogous injuries in the shoulder, elbow, or hip joint regions (see corresponding sections). Radiological Diagnosis of epiphyseolysis (osteoepiphyseolysis) of the distal femoral epiphysis is significantly facilitated by the presence of radiopaque ossification centers in full-term infants, the so-called "points of maturity." THE POSITION OF the cartilaginous femoral epiphysis is judged by the displacement of these ossification centers. Notably, "points of maturity" are also present in the proximal epiphyses of the Tibia and Fibula. In dubious cases, a comparative evaluation of radiographs of both knee joints (healthy and injured) helps clarify the diagnosis.

Treatment consists of single-stage closed reduction followed by knee joint immobilization with a splint in the position of optimal fragment alignment for 10–14 days. During the rehabilitation period, physical therapy, massage, and therapeutic exercise are indicated.

The extent of the deformity depends on the severity of injury to the growth plate. Therefore, even if fracture fragments are properly reduced and maintained throughout the entire immobilization period, subsequent development of genu varum, Genu Valgum, and limb shortening remains possible. Children with this condition require long-term orthopedic follow-up.

Obstetrical Brachial Plexus Palsy

Birth palsy, or obstetrical paralysis, results from traumatic injury to the brachial plexus during labor due to obstetric maneuvers. It occurs in 0.15 — 0.3% of newborns.

The mechanism of injury varies, ranging from compression and rupture of the brachial plexus fascicles to damage of the spinal nerve roots. Birth palsy can develop in newborns even with minor nerve stretching, leading to secondary progressive degeneration of the nerve due to ischemia, hemorrhages, and subsequent scarring.

In some cases, obstetrical brachial plexus injury presents as plexitis with partial or complete recovery of motor function.

Three types of birth palsy are distinguished: upper ROOT palsy, caused by lesions of the V and VI cervical roots (Duchenne-Erb palsy); lower root palsy, resulting from damage to the VII, VIII cervical and I thoracic roots (Klumpke palsy); and a third type, caused by traumatic involvement of all roots from the V cervical to the I thoracic inclusive (total palsy). Among upper limb birth palsies, the first type on the right side is the most common.

Clinical Presentation. Symptoms depend on the type of palsy and associated injuries (fracture of the clavicle, humerus, scapular acromion, etc.). Isolated injury to the brachial plexus elements manifests as a loss of function in specific muscle groups, presenting as peripheral paralysis signs with their characteristic classic triad (atrophy, atonia, areflexia). Trophic changes and altered electrical excitability of the affected muscles are also observed.

In type I palsy, active shoulder abduction and elbow flexion are impaired or absent. All segments of the affected limb are internally rotated. Sensation, as well as finger and hand movements, remains intact.

In type II palsy, motor Disorders of the fingers and hand take precedence, caused by involvement of the ulnar and median nerves. At the same time, the function of the Shoulder and Elbow joint muscles typically remains unaffected.

Total palsy (type III palsy) is characterized by involvement of all upper limb muscles. The arm hangs limply along the trunk like a flail; active joint movements are completely absent.

Diagnosis is usually straightforward. Obstetrical history data and neurological examination, combined with the abnormal posture of the limb, allow for precise Determination of the palsy type and the level of peripheral nerve lesion in the upper extremity.

Characteristic signs of birth palsy include the "doll's arm" sign (M. S. Novik) and the "ischemic glove" sign (Rocher). The former is manifested by an elongation of the skin fold on the affected side between the newborn's shoulder and torso, while the latter is characterized by vasomotor Responses of the hand following compression (marked skin pallor rapidly giving way to hyperemia and subsequent pallor).

In cases of combined injuries to peripheral nerves, BONES OF THE shoulder girdle, and the free upper extremity, birth palsy can be identified using specialized diagnostic methods—determining muscle electrical excitability, chronaximetry, and skeletal radiography of the limb.

Treatment begins immediately after diagnosis. The treatment plan must be coordinated with a neurologist and orthopedist. Therapeutic measures involve rational immobilization of the upper extremity to prevent contractures, alongside pharmacotherapy (proserine, dibazol, injections of vitamins B₁ and B₁₂). Physiotherapy plays a crucial role: thermal procedures, iontophoresis with potassium iodide targeting the brachial plexus area, Therapeutic Exercises, and massage of the paralyzed muscles followed by electrical stimulation using pulsed currents. The latter is best initiated 2 — 3 months after THE START OF treatment.

Prognosis. Early comprehensive conservative treatment yields positive results in the majority of cases. Recovery of lost motor functions proceeds from the periphery in a proximal direction. Lack of response to ongoing treatment serves as an indication for surgical intervention aimed at exploring the affected nerve and restoring neural continuity via subepineural or transneural suturing. Surgical management of peripheral nerve injuries is considered a vital component of the therapeutic regimen (V. A. Kozyrev, 1964). Delayed diagnosis and untimely treatment lead to childhood disability. To achieve rehabilitation, complex reconstructive surgeries must be employed, which do not always ensure a favorable outcome.

Obstetrical Injuries of the Spine and Spinal Cord

Spinal injuries belong to the severe forms of birth trauma. The cervical spine is most frequently affected because it undergoes significant mechanical stress in the fetus even during normal delivery: abrupt anti- and retroflexions, extreme head rotations combined with prolonged fixation in an unfavorable position.

Stress on the cervical spine increases during complicated labor, manual or instrumental assistance (forceps delivery). Forced traction and Rotation of the head with fixed shoulders, or breech traction with a fixed head, is frequently accompanied by injury not only to the spine but also to the spinal cord. Pathological spinal changes following trauma can be primary (compression, partial or complete rupture) and secondary, associated with reflex-vascular disorders at the level of the corresponding segments (A. Yu. Ratner, 1970). According to Confelle (1960), spinal trauma is accompanied by hemorrhages into the spinal canal, Meninges, nerve roots, and spinal cord parenchyma in 49% of cases. Complete rupture and thrombosis of individual vertebral artery branches in newborns have also been described (Gates, 1959).

Clinical Presentation. Isolated spinal injury manifests as an alteration of the spinal axis, angular Kyphosis with a protruding spinous process of the injured vertebra beneath the skin, localized swelling, and reflex-induced tension of the back muscles.

In spinal trauma complicated by spinal cord injury, symptoms of spinal Shock with the picture of "dormant paralysis" (Keuth, 1964) come to the forefront due to impaired spinal cord conduction. The Clinical presentation of upper cervical segment injuries, driven by the rapid development of brainstem edema, is particularly severe: manifesting as tetraparesis/tetraplegia, respiratory dysfunction, bradycardia, spontaneous nystagmus, decreased corneal reflexes, and loss of consciousness. Trophic disorders and pelvic organ dysfunctions also develop.

The described symptoms typically appear immediately after birth; however, the neurological picture often does not correspond to the actual level of segmental damage. As spinal shock resolves, the level of spinal cord injury can be localized more precisely. Determining the true cause of impaired spinal conduction presents significant difficulties.

Diagnosis is based on a detailed review of the obstetrical history, along with radiological, neurological, and cerebrospinal fluid dynamics data. Special importance is attached to the trophic status of body areas innervated by segments below the injury level. In complete anatomical transection of the spinal cord, pressure ulcers and limb edema develop rapidly (within the first hours after birth), and pelvic organ function is completely lost.

In cases of compression and hematomyelia with partial preservation of spinal cord integrity, the aforementioned symptoms are less pronounced and develop more slowly.

Differential diagnosis is performed to rule out birth-related traumatic brain injury, Congenital Malformations of the spine, BRAIN AND SPINAL cord, birth palsies, and limb trauma.

Treatment. For uncomplicated spinal fractures, treatment is generally conservative. Unloading the injured spinal segment and positioning the child on a corrective plaster bed are indicated. Subsequently, physical therapy, physiotherapeutic procedures, and back muscle massage are prescribed to develop a muscular corset.

In complicated spinal injuries, early surgical intervention is justified to achieve spinal cord revision and decompression, as prolonged compression leads to irreversible changes at the corresponding level.

Prognosis. In spinal injuries, the prognosis is largely determined by the level and nature of the spinal cord damage. In injuries of the upper cervical spine, most newborns die before a diagnosis is established. A degree of optimism is justified in the absence of an anatomical transection of the spinal cord and mild hematomyelia.

Birth Injuries of the Abdominal Organs

Birth Trauma to the abdominal organs is a frequent cause of neonatal mortality in the first hours and days of life. Only isolated reports in the literature are dedicated to this issue (V. V. Guzeev et al., 1969; G. A. Bairov et al., 1971; Arden, 1955; Hasse, Waldschmidt, 1968, et al.). In most cases, The Liver and Spleen are affected, and less frequently the adrenals and Kidney. Ruptures of the intestine and its mesenteric vessels are also encountered.

Injuries to pathologically altered organs are possible. V. V. Chikov et al. (1971) observed an adrenal rupture due to birth trauma in a newborn with embryonic nephroblastoma. The diagnosis was established at autopsy.

Clinical Presentation. Injuries to parenchymatous organs in newborns during the first hours and even days manifest only as an enlargement of the affected organ's boundaries and mild anemia. Subsequently, the clinical picture is determined by the nature of internal bleeding, which develops acutely or gradually and, according to Giedion (1963), may be of three types. Massive, acutely onset bleeding is characterized by a sudden deterioration in the infant's condition. Against the Background of rapidly progressing anemia, cyanosis, tachypnea, hypothermia, and possibly jaundice develop. With prolonged bleeding, blood accumulates in the Abdominal cavity gradually (hemoperitoneum), which manifests as slowly progressing anemia, abdominal distension, pastosity of the abdominal wall and external genitalia. A characteristic symptom of free blood in the abdominal cavity is bluish discoloration in the umbilical region, which is explained by blood showing through the thin anterior abdominal wall of the newborn (G. A. Bairov). Finally, blood may accumulate as a hematoma in the intestinal mesentery, beneath the capsule of the injured organ, or in the retroperitoneal tissue. Palpation reveals a mass that can compress the intestine within the ABDOMINAL CAVITY AND cause symptoms of obstruction.

In Birth Trauma of the liver and spleen, minor subcapsular ruptures of the organ parenchyma are characteristic. A growing subcapsular hematoma, increasing in volume, leads to the detachment of the organ's thin capsule, followed by its rupture and hemorrhage into the abdominal cavity. The described situation typically occurs between the 2nd and 8th day after birth and manifests with classical signs of internal hemorrhage.

Adrenal trauma is frequently combined with kidney injury and is accompanied by massive hemorrhage into the perirenal tissue. In the lumbar region on the side of the injured organ, a significant painful swelling is detected. When the kidney is involved, Hematuria is absent in the first few days and appears only on the 9th day.

Diagnosis during the latent period of trauma is difficult. Consideration must be given to a combination of clinical and laboratory findings and their dynamics. Special examination methods are advisable, such as plain abdominal radiography and intravenous urography. G. A. Bairov described the symptom of «weighing» of the intestinal loops, displacement of the transverse colon downward and toward the side opposite to the hematoma, which can be detected on a plain abdominal radiograph performed in lateral position. The urogram reveals decreased or absent renal function and contrast medium extravasation. Diagnosis of profuse internal hemorrhage presents no difficulties. Birth trauma of the abdominal organs must be differentiated from fetal erythroblastosis, intracranial hemorrhage, cyanotic congenital heart disease, tumors of the abdominal and retroperitoneal cavities, renal vein thrombosis, and Malformations of the gastrointestinal tract and Kidneys.

Treatment consists of general supportive measures and urgent surgical intervention. As preoperative preparation, menadione (vikasol), calcium gluconate, vitamin C, blood transfusion, and plasma are prescribed. If adrenal insufficiency is detected, hydrocortisone at 5 mg/kg or prednisolone at 1–2 mg/kg per day is indicated. The administration of glutamic acid is justified to normalize metabolic processes.

In emergency situations, medical therapy is administered during surgery. For liver and Kidney Injuries, an organ-sparing principle is adhered to. When the spleen, kidney, and Adrenal gland are severely crushed, these organs are generally removed. During nephrectomy, one should keep in mind the possibility of a solitary kidney. Therefore, the data from intravenous urography must be taken into account.

The outcome is favorable with timely diagnosis and surgical intervention.