Day-old boy born at term via vaginal delivery complicated by shoulder dystocia. He had very mild cyanosis in the extremities at birth, which resolved after 5 minutes. Referred for evaluation of respiratory distress. Birth weight, 3.3 kg (7.4 lb). Apgar scores: 7 at 1 minute, and 9 at 5 minutes.
Has tachypnea and weak cry. Diminished breath sounds heard on the left. No murmurs. Chest radiograph is shown.
This patient's anteroposterior chest radiograph shows a paralyzed left hemidiaphragm, suggestive of phrenic nerve injury. Ultrasonography subsequently revealed minimal or paradoxical breathing on the affected side.
The phrenic nerve is composed of the third, fourth, and fifth cervical nerve roots and is a result of migration of the cervical somites as they penetrate the developing diaphragm. Extreme lateral traction caused by shoulder dystocia can stretch the cervical roots of the brachial plexus. Distention or transection of the third to fifth nerve roots can damage the phrenic nerve and lead to paralysis of the diaphragm. Diaphragmatic paralysis occurs in approximately 5% of brachial plexus injuries.1
WHAT’S YOUR DIAGNOSIS?
1. Volpe JJ. Injuries of extracranial, cranial, and intracranial, spinal cord, and peripheral nervous system structures. In: Volpe JJ, ed. Neurology of the Newborn. 4th ed. Philadelphia: WB Saunders Co; 2001:813-838.
2. Whitbourne SK, Griffin IJ. Diaphragmatic paralysis in the newborn. UpToDate 2005. Available at: http://www.uptodateonline.com. Accessed February 18, 2005.
3. Oh KS, Newman B, Bender TM, Bowen A. Radiologic evaluation of the diaphragm. Radiol Clin North Am. 1988;26:355-364.
4. Stone KS, Brown JW, Canal DF, King H. Long-term fate of the diaphragm surgically plicated during infancy and early childhood. Ann Thorac Surg. 1987;44:62-65.