Author: Joshua Alexander, MD
The patient is a 22 month old mixed race male referred with a history of left brachial plexus injury and decreased movement of his left arm and hand.
BIRTH HISTORY
He is a former full-term, 6 pound 5 ounce child born to a 26 year old female via vaginal delivery after an uneventful pregnancy.Delivery was complicated by difficulty extracting the left shoulder but he was otherwise fine and went home two days later.
EARLY DIFFERENCES
At the age of 6 months, the parents noticed that he was not moving his left arm and hand as much as his right.He was seen by a physician at 13 months of age who noted a relative weakness of the left shoulder and arm.
INITIAL DIAGNOSIS AND TREATMENT
Diagnosis at 13 months of age = Left Brachial Plexus Injury secondary to stretching of the nerves near the shoulder at birth.
TREATMENT PRESCRIBED
Physical Therapy for Range of Motion exercises
DOING BETTER
The child was seen again by the first physician at 17 months of age and at that time, was walking sideways holding onto furniture but was still not yet walking by himself. He was noted to lift his left arm over his head with good strength at biceps and wrists.The physician made no new recommendations and suggested a follow-up appointment in 6 months.
STILL CONCERNED
Parents were still concerned about their child's decreased left arm use and failure to walk at 17 months of age, so they took him to another doctor.
NEW FINDINGS
When he was seen by the second doctor at 21 months of age, the child was speaking in short sentences which were 75% intelligible to strangers. He was feeding himself with a spoon and fork (right handed),was able to climb into an adult sized chair, and had started walking at 19 months.
PHYSICAL EXAM
Well developed and well nourished. Normal head size with no facial asymmetry. Walking with decreased stance phase and excessive foot pronation on the left. Muscle stretch reflex was increased (3+) at the left biceps and normal (2+) at the right biceps. The doctor was unable to fully assess tone due to patient?s non-compliance, but tone was felt to be increased in left ankle plantar flexors as well as left forearm pronators.
FURTHER INVESTIGATION
After speaking with the parents about their concerns, and performing an exam which was limited by the patient?s crying and non-compliance, the physician decided to perform a radiological examination. A head MRI showed a porencephalic cyst above and to the side of the right lateral ventricle.
A NEW DIAGNOSIS
After reviewing the results of the MRI, a new diagnosis of Left Hemiplegic cerebral palsy secondary to Right Porencephalic cyst was made.Time was taken to discuss the results with parents and labs were ordered to look into markers of neonatal stroke.
UPDATE
Now 2 years old, the patient is age appropriate in communication, but still has limited left hand fine motor control and difficulties falling when trying to walk quickly or run. He has spasticity (modified Ashworth 1-2+) in left ankle plantar flexors and left forearm pronator teres, but is otherwise doing well and progressing with physical and occupational therapy services.
LESSONS LEARNED
* Always listen to parents? concerns and work together to address them
* Hemiplegia can be confused with brachial plexus injury
* Serial evaluations can allow for improved clinical assessment and diagnosis
* The presence of normal or increased biceps reflex makes the diagnosis of brachial plexus injury less likely.
* Head MRI can sometimes help with making an accurate diagnosis.
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