Introduction

Orthopaedic conditions which still remain untreated in many economically poor countries include late untreated paralytic poliomyelitis, cerebral palsy, paralysis due to injury and infection, congenital conditions, untreated late osteomyelitis, tuberculosis of joints and spine and inadequately treated trauma₁. To these conditions must be added orthopaedic birth trauma (OBT). Birth-related fractures of the long bones are not rare ₂. Mothers perceived that their traumatic births were often viewed as routine by clinicians₃. Birth injuries are a significant cause of neonatal morbidity and mortality ₄. Although they are frequently associated with traumatic delivery, birth injuries often occur in normal spontaneous deliveries in the absence of any risk factors ₄. Presence of unilateral and bilateral subdural hemorrhage is not necessarily indicative of excessive birth trauma ₅.

Since the days of Hippocrates, scripts have included descriptions of infants who were unable to move their arms. However, it was not until the mid-1700s that an obstetric cause for the paralysis was considered. In 1872, the term obstetrical brachial plexus palsy (OBPP) was coined when a correlation was made between excessive traction on the brachial plexus during delivery and the clinical finding of arm paralysis.₆

In Nigeria, infants and maternal health prospects is a controversial issue, because of the laissez–fairs attitude of government and the general populace. This negative side stems from factors such as ignorance, apathy, poverty, lack of commitment, illiteracy and corruption₇. Nigeria has a public health care system that includes federal, state and community hospitals, clinics and health centers. In addition, a large component of health care is provided in private fee-for-service centers usually with some beds, which are often referred to as clinics or hospitals. Therefore, no clear distinction exists in the private sector between physician practices, clinics and hospitals.

The remediable priority problems that may be identified in OBT should be feasible and inexpensive in developing countries. It is with the above hypothesis that the present studies was embarked upon to relate orthopaedic birth trauma to perinatal care and to determine methods that could be used in prevention.

Patients and Methods

This study was carried out at the Wesley Guilds Hospital (WGH) Ilesa, a unit of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Osun state, Nigeria. The hospital is a referral center for Ondo State, Ekiti State, Osun State, and parts of Kogi and Kwara States. This is a descriptive hospital based cross-sectional study of OBT patients. The subjects managed between 10th December, 2002 and 9th December, 2005. Ethical clearance was received from the hospital research and ethical committee. An informed consent was obtained from the parents of each baby before they are enrolled. They were seen at the Children Emergency Unit, Orthopaedic Clinic, Postnatal and Neonatal wards. Information was obtained on the age, sex, antenatal care, mothers' parity, pregnancy maturity, pregnancy category, place of delivery, level of birth attendants, method of delivery, pattern of OBT and treatment offered using semi-structured questionnaire administered by the leading author. The delivery centers outside WGH were contacted through letter writing to obtain birth delivery records. Each patient at presentation was clinically examined by a senior registrar and a consultant orthopaedic surgeon. The babies born after primary or secondary infertility, high risk pregnancy, 1^st born male child and primigravida are grouped as “precious babies”. Cerebral palsy of non trauma origin was excluded. A towel test that consists of covering the infant's face with a towel and seeing if he/she can remove it with either arm ₈ was used to aid the clinical assessment of infants with obstetric brachial plexus palsy. Patients were grouped according to type of paralysis C5-C6, C5-C6-C7, and complete.

All the patients had a plain radiography. Computerized Tomography Scan was done when it is indicated. Treatment of patients was individualized. The outcome measure used for successful treatment was the restoration of functions without disability.

Data were analyzed by using statistic package for social sciences (SPSS) version 11.0 for windows. Transformations of variables were done where necessary in particular, quantitative variables. Test of significance was calculated by the use of Analysis of variance (ANOVA), X² with Fischer's exact test where numbers were small and Yates correction when indicated. The p-value was considered significant at p<0.05

Results

A total of 119 patients were seen with birth trauma, out of which 84 (70.6%) were OBT patients representing 61.3% of neonatal orthopaedic hospital admission. The mean of yearly presentation of OBT was 28. There were 45 males (53.6%) and 39 females (46.4%) with male to female ratio of 1.2:1. The mean age at presentation was 8 +/- 4.3 days (range: 1 – 31 days). The mean birth weight was 2.65 +/-1.02kg (range: 1.96-4.6kg). Apgar score recorded at 1 minute and 5 minutes were 5.2+/-2.1 and 7.8+/- 2.2 respectively. Neonates with fracture were significantly heavier at birth than those without (3564 vs. 3283 g, p <0.001).

Seventy-three (86.9%) OBT patients came from outside the teaching hospital and 11(13.1%) patients were delivered within WGH. Most of the babies were delivered at health centers and general hospitals. The place of delivery outside the teaching hospital were mostly rural with difficult access roads, not well staff, not equipped with modern delivery facilities, electrical power supply was erratic and they had no specialist obstetrician or orthopaedic surgeon on ground. A total of 29 (34.5%) mothers had formal education.

The intra-WGH OBT was 0.5% out of 2177 live birth. There were 41(48.8%), 33 (39.3%), 7(8.3%) and 3 (3.6%) OBT patients attended to at the children emergency, orthopaedics clinic, neonatal ward and postnatal ward respectively. Only 28(33.3%) OBT were recognized at birth by birth attendants. Table 1 and 2 shows perinatal factors and OBT related to the place of delivery respectively.

Figure 1

Table 1: Perinatal Factors In Orthopaedics Birth Trauma

Figure 2

Table 2: Orthopaedics Birth Trauma And Place Of Delivery.

The major OBT types were skeletal fractures 50(58.8%), brachial plexus injury 33(38.8%) and cerebral palsy 2(2.4%). The clavicle fractures were 23(46%); Femur 12(24%), Humerus 11(22%) and Radius/Ulna fracture 4(8%). Among the brachial injuries were Erb's palsy 31(93.9%) and Klumpke palsy 2(6.1%). One of the cerebral palsy patient was delivered at WGH by a registrar using forceps, had right humeral fracture, cephalohaematoma and severe anaemia. The mother was a university graduate, booked and presented early to the hospital. A patient had combined left clavicle fracture and Erb's palsy. The only patient with skull fracture was delivered at a private clinic and she was the first of a twins set. The second baby was stillbirth after prolong obstructed labor. Orthopaedic birth fracture was detected mostly during the first 3 days of neonatal life (92%) with a range of 30 minutes to 26 days. Figure 1 show the time of recognition of OBT post delivery.

Figure 3

Figure 1: Time of recognition of orthopaedic birth trauma

Table 3 shows OBT pattern related to mode of delivery. A total of 74(88.1%) had their delivery assisted and 23(27.4%) had instrumentation involving forceps and vacuum extraction. Table 4 shows OBT predisposing factors. Figures 2, 3 and 4 shows the clinical photograph of birth related forceps complications, right femur fracture and a depressed skull fracture respectively.

Figure 4

Figure 2a: 6day Old Baby Post Forceps Delivery

Figure 5

Figure 2b: Nose injury with mouth breathing

Figure 6

Figure 2c: At 8 months old

Figure 7

Figure 3a: 5 days old with Right Femur fracture

Figure 8

Figure 3b: 20day old with Right Femur fracture on Gallows's

Figure 9

Figure 4: 3 Day Old With Depressed Skull Fracture

Figure 10

Table 3: Orthopaedic Birth Trauma Related To Mode Of Delivery.

Figure 11

Table 4: Predisposing Factors to Orthopaedic Birth Trauma.

N.B: Some babies with OBT had more than one predisposing factor.

Table 5 shows treatment modalities and OBT outcome. The Plaster of Paris cast and skin/Gallows's traction lasted 2-6 weeks (mean 2.5 ± 1.6 week) depending on the bone fractured and rate of positive response among brachial plexus patients. All the fractured bones managed with casts and traction had successful outcomes.

Figure 12

Table 5: Treatment And Outcome Of Obt Patients

At 2 to 3 months, none of the 33 infants with brachial plexus palsy succeeded in removing the towel, either with their normal or affected arm. At 6 months, all the infants succeeded in removing the towel with their normal arm, but two could not with their affected arm, and the same was observed at a further assessment at 9 months. Moulding of the skull was used for the depressed parietal fracture. Two each of Klumpke palsy and cerebral palsies did not recover function till they defaulted. The two (2.4%) mortalities were not directly related to OBT. The cause of death was severe congenital heart disease and a preterm admitted with Neonatal tetanus. Seventy-seven cases were followed up for at least 3months at the out patient clinic without any recognized residual deformity.

Discussion

Obstetric brachial plexus palsy is a devastating birth injury₉. While many children recover spontaneously, 20-25% is left with a permanent impairment of the affected limb ₉. Birth injuries of the brachial plexus are fairly common, but most affected newborns make quick recoveries without any specific intervention. Brachial plexus requires multidisciplinary process to optimize long-term functional outcomes for severely affected infants₁₀. Late presentation of patients with brachial injury was a major problem. Direct cervical compression of the fetal neck by forceps in procedures involving rotations of the presentation may result in brachial plexus injuries ₁₁. Forces other than simple widening of the head-shoulder angle are necessary to disrupt the roots or cords of the lower brachial plexus. The position of the arm and direction of the forces that are applied determine the nature of the lesion₁₂. The towel test is a reliable technique for evaluating children with obstetric brachial plexus injuries₈. Two post Sever's operation patients defaulted due to poor finance and both were with residual deformity. Secondary reconstructive surgery of late brachial plexus palsy may improve the condition. Klumpke palsy patients who did not recover spontaneously were not operated due to non availability of experienced spinal surgeon, lack of modern spinal facilities and poor finance of patients thus preventing referral elsewhere. Our experience has confirmed in most cases newborns recover spontaneously after conservative treatment. Indication for surgery must be assessed and discussed individually ₁₃. There was an improvement in active hand movements after operative treatment and rehabilitation.

Birth-related fractures of the long bones are not rare ₂. Femoral fractures due to birth trauma are extremely rare ₁₄. The typical injury pattern was a spiral fracture of the proximal half of the femur, which was held in an extended position. Abnormal fetal presentation, fetal distress, and electricity power outage at head on perineum, emergency caesarian section, twin pregnancies, “precious baby” and prematurity appeared to predispose our patients to bone fractures. Up to 80% of femoral fractures in children who have not started walking are caused by abuse₁₅. External cephalic version can be associated with complications such as a femoral fracture. Physicians and patients should be aware of this potential complication₁₄, ₁₆. Those with fracture clavicles should be thoroughly evaluated to rule out damage to brachial plexus as well ₂. OBT fractures were treated non-operatively and traditionally, treatment has consisted of prolonged periods of immobilization₁₇. A variety of treatment modalities were used, including gallows traction, plaster of Paris and spica cast. All patients with fracture, regardless of treatment, had a satisfactory clinical outcome, with no evidence of limb length discrepancy or angular deformity on follow-up. Neonates with fractures must have early and frequent appointments in the outpatient clinics to prevent deformities. They should be seen at birth and weekly until fracture healed.

The optimal mode of delivery for the term breech fetus is undetermined. The neonatal birth injury among the planned vaginal group was not statistically different from the planned caesarean group₁₈. Vaginal breech delivery plus episiotomy is strongly associated with OBT in our community. Attention should be given to trainee obstetrician in selective external cephalic version at term to reduce the caesarean section rate and also neonatal morbidity in term breeches₁₉. Instrumental vaginal deliveries have been associated with higher risks for birth trauma₂₀. The successes of instrumental deliveries are negatively affected by occipitoposterior and occipitotranverse positions of the baby at delivery ₂₁, and operators' skill. Birth asphyxia and trauma often occur together and it is, therefore, difficult to obtain separate estimates₇. The other factors associated with OBT are depicted in table 4. A formal education training of medical staff is found not to influence the success rate of instrumental delivery but was associated with improved safety for both mother and baby₂₂. It has long been known that multiple pregnancy is associated with greater risk for both the mother and the fetus, when compared with singleton pregnancy. Complications during birth, such as obstructed labor, OBT and fetal malpresentation, are common in the absence of obstetric care.

Nigeria is located in the West African coast with the highest perinatal mortality ant maternal mortality in the world. In 1994 a perinatal mortality rate of 119.9/1000 deliveries at Ogun state University Hospital was documented by Njokanma et al ₂₃and Kuti et al (2003) ₂₄ reported at Wesley Guild Hospital, Ilesa Nigeria a perinatal mortality rate of 77.03 per 1,000 total births. Perinatal mortality is an important indicator of maternal care and of maternal health and nutrition. The facilities for birth delivery and quality of obstetric and paediatric care available are poor in the rural and suburban areas with a significant population. Although social factors exert the main influence on the outcome of a birth, as societies advance good medical care tends to play a greater role. Education of the public on danger signs of prolonged labor and regular retraining of health personnel on intrapartum care in addition to upgrading neonatal facilities were important measures necessary to reduce the currently high OBT rate in Nigeria. The very preterm birth was more often than not a result of a complicated pregnancy. The preterm and fetal distressed infant was often sick before birth, and for their survival to be without orthopaedic birth related trauma is highly dependent on the highest level of perinatal care.

Birth trauma is directly associated with black and Hispanic ethnicity but was not consistently associated with technologically sophisticated teaching institutions₂₅. It appears from our data, the rate of OBT is lower in teaching institution. The quality of perinatal care should be assessed in the outlier hospitals₂₆. Factors such as immaturity, unbooked mothers, multiple pregnancies and obstructed labor were prevalent and are related to the OBT cases. The OBT per year rate is high and there is no available prospective study in Nigeria with which to compare our result. Rate of OBT should be included as a national reference index for accessing quality of perinatal care.

Health workers at primary and secondary level of care often lack the skills to meet the needs of newborn infants and their experience is limited. The outcome of litigations for fetal injuries may be determined through the establishment of a preventable medical malpractice₂₇. Missed or delayed diagnosis of OBT could affect the perinatal care outcome. It is recognized that diagnoses can be missed by discharging newborn within 24 hours₂₈. Even if early discharge is felt to be cost effective, parents should be counseled that it is not risk free.

A patient having post trauma cerebral palsy and bone fracture has been discharged from hospital without diagnosis due to non recognition of the lesions. In many developing country societies, it is culturally unacceptable to acknowledge a birth until it has survived its first week of life ₂₉ .This cultural belief, negative roles of spiritual homes due to fear of spiritual attack of their babies by wicked people and prophetic warning in religion houses, ignorance of birth injuries and high hospital bills were the major reasons for late presentation of orthopaedic birth injured babies to the hospital.

Modern obstetric practices have almost eliminated birth trauma. Conversely, where modern obstetric care is not available, OBT is very common. OBT stem from poor maternal health, inadequate care during pregnancy, inappropriate management of complications during pregnancy and delivery, and the first critical hours after birth, and lack of newborn care. Adequate health education with emphasis on orthopaedics (OHE) for all appropriate perinatal health team is essential. The training of birth attendants could prevent their own contributory factors in birth trauma. Health education must include mothers to present early at delivery and to have caesarean section when they have complications and when indicated. OHE should be incorporated into the perinatal care curriculum of medical schools and birth attendants. This is inexpensive, and it may reduce the morbidity and rate of OBT. It will be more encompassing than Hawthorne training effect which has been linked with reduction of birth trauma and birth asphyxia related to instrumental deliveries₃₀. Although life-saving practices for most infants have been known for decades, currently a third of mothers still have no access to services during pregnancy and almost half do not have access to services for childbirth. There are enormous variations both among and within countries₂₉. A health worker with excellent knowledge and skills is the key resource and the best investment. The cost is moderate, and the investment pays a high dividend in improved health of both the mother and her baby, and better health for the next generation at lower cost. Quality of perinatal care available in the area of residence, as measured by the presence of consultant obstetricians and a paediatric consultant could be related to a reduction in OBT rate.

Conclusion

Orthopaedic birth trauma incidence appeared to be high in our region. While maternal and perinatal mortality rates are established index of perinatal care, it may also be worthwhile to consider perinatal morbidity rates like orthopaedic birth trauma rate. Orthopaedic birth trauma rate like perinatal mortality can be a reflection of health and health-care of the region and may likewise likely be improved with increased patient education, higher living and education standards, adequate health resource and trained personnel.

Correspondence to

Dr Adegbehingbe O O. Obafemi Awolowo University College of Health Sciences Faculty of Clinical Sciences Department of Orthopaedics & Traumatology Ile –Ife, Osun State; Nigeria. Mobile phone: 234-08035840622/08037218094. E. mail: olayinkaadegbehingbe@yahoo.co.uk