Highly specialized techniques help children regain upper extremity functions

Dennis and Jennifer Ferns of Gibson, Iowa, were traumatized when told in the delivery room that their newborn daughter had a "flail arm" as a result of an obstetrical brachial plexus injury.

Their first child was born without incident by cesarean section, but Jennifer Ferns, a diabetic, insisted that the second be a natural birth. It was a decision she learned to regret.

"I now know she should have been born cesarean, but I basically talked them out of it," she said. "It was a natural delivery and it shouldn't have been."

University of Iowa Children's Hospital became the hospital of choice for the birth because of the quality of care Jennifer received earlier while undergoing cancer treatment at University of Iowa Hospitals and Clinics, she said.

Michaella Ferns was born four weeks early on March 22, 1996, weighing 8 pounds 9 ounces. The University of Iowa Children's Hospital birthing team immediately told the Ferns that the baby's left shoulder had been injured during the delivery.

"At first Michaella had no control over her arm," Ferns said. "At about three months she was able to move it a little bit, but the doctors told us surgery probably was necessary. In 1999, when she was three-and-a-half years old, Dr. Dietz (Frederick R. Dietz, M.D., an orthopaedic surgeon) referred us to his colleague, Kumar Kadiyala, M.D., Ph.D., a hand and microvascular surgeon. He suggested that a reconstructive tendon transfer procedure be performed."

The Ferns said they noticed a "definite improvement right away;" Michaella soon was able to lift her arm above her head.Bolstered by a home physical therapy program, Michaella has continued to progress until now, at age five, she can do most things other children can do."

Kadiyala said serious birth injuries like Michaella's occur in one to four of every 1,000 live births. Known as brachial plexus birth palsy, or obstructive palsy, the injury leaves one arm limp with potentially devastating consequences. The brachial plexus is the collection of nerves linking the spinal cord with the shoulder and controls all of the major nerves growing down the arm.

Kadiyala teams with fellow surgeons Curtis M. Steyers, M.D., and Arnold Menezes, M.D., in repairing such injuries, providing the only such service in Iowa.

"The injury is associated with the large size of the baby and usually occurs during a difficult or prolonged delivery or labor," Kadiyala said. Risk factors for having a large baby include maternal or gestational diabetes, people who have several pregnancies, and distress or problems with the fetus.

The good news is that most babies--up to 90 percent--will heal without surgical intervention, Kadiyala said. "For the remaining group, they should be evaluated between the age of two and three months by an orthopaedic surgeon trained in hand microvascular surgery, a peripheral nerve surgeon, or a plastic surgeon. There are also a few neurosurgeons who also do this type of surgery."

Even after three months of age, children who still have problems with upper extremity function should be evaluated for either nerve surgery or tendon transfer.

Kadiyala, Steyers, and Menezes also work with older children and adults who experience brachial plexus injuries, usually as the result of traumatic accidents.

For more information, call the Children’s Hospital of Iowa number listed below and ask for Dr. Kadiyala, or call Dr. Kadiyala directly at 319-384-8489. Physicians should use UI Consult.

There isn't much 5-year-old Michaella Ferns can't do with her left arm, despite experiencing a left shoulder injury at birth. Joining the playground fun is her father, Dennis.

"They said she'll never be a volleyball star or a ballerina, but I honestly believe that when she gets older and if she really puts forth the effort she will be able do anything she wants."--Jennifer Ferns