Rucksack Palsy

822 RUCKSACK PALSY

ADDRESS FOR REPRINTS: Department of Pediatrics,

University of Nebraska Medical Center, 42nd and Dewey

Avenue, Omaha, Nebraska 68105.

REFERENCES

1. Children and Youth, Selected Characteristics. Vital Health Stat, series 10, No. 62, DHEW publication

1000, 1971.

2. Matthews DK: Measurement in Physical Education. Philadeiphia, WB Saunders Go, 1968.

3. Guilford J: Z ratio for difference between uncorrelated proportions. In, Fundamental Statistics in Psychol-ogy and Education, ed 4. New York, McGraw-Hill,

. 1965, p 186.

4. Knowles C: The influence of a physical education program on the illnesses and accidents of mentally retarded children. Am Correct Ther J 24:164, 1970.

5. Behavior Patterns of Children in School. Vital Health Stat, series 11, No. 113, DHEW 1972, p 53.

ACKNOWLEDGMENT

The tests employed (available from the author) were developed and scored by Mrs. Marilynn Rademacher, Instructor in Physical Education, Lincoln Public Schools, Box 82889, Lincoln, Nebraska 68501. Analysis of the acci-dent reports was made by Mrs. Marilyn Schlicht with the cooperation of Mr. Virgil Home, Safety Director, Lincoln Public Schools.

Rucksack

Palsy

In recent years there has been an increase in the use of backpacks and rucksacks by nonmili-tary personnel. An estimated 3 million individuals

engage in hiking and mountain climbing, and

countless others use these packs on campus. ‘ We

report a case of brachial plexus injury sustained

by an individual wearing such a pack.

CASE REPORT

A 15-year-old right-handed white boy was examined for pain in the left shoulder of two weeks’ duration. The youngster had been well, but two weeks l)efore evaluation was on a hiking expedition. During this trip he wore a rucksack which when filled weighed 20.4 kg (Fig. 1). He carried this pack six hours daily for seven days. The minimal pain he experienced in his left arm and shoulder while wearing the pack was not severe enough to cause him to curtail his activities.

The general physical examination gave unremarkable results. Neurological examination revealed decreased muscle bulk in the left deltoid and left biceps (Fig. 2). Muscle tone was minimally decreased in the left shoulder. Decreased strength was noted in the left biceps, left triceps, and left

deltoid muscles. The lower arm and hand did not seem to be

affected. Decreased reflexes were noticed at the left pecto-ralis muscle, left biceps, and left brachioradialis. The left triceps reflex, however, was intact. No sensory involvement was noted. Laboratory data included a chest roentgenogram

which showed no evidence of cervical rib or clavicular

fracture and no anomaly of the shoulder girdle.

An EMG examination was performed and motor and

sensory nerve conduction studies of the left and right median and ulnar nerves were normal. The left median sensory amplitude was identical to that of the right. Needle exami-nation revealed a moderate number of fibrillations and

positive waves in the left biceps, pronator teres, and pecto-ralis major with little detectable change in the motor unit potentials. No abnormalities were seen in the left cervical paraspinal muscles. The EMG findings were compatible with an incomplete left brachial plexus lesion involving the upper tnink/lateral cord, although a C-6 root lesion could not be excluded.

A graduated exercise program was undertaken. Within

two months function was normal, and within six months the

muscle bulk also returned to normal.

DISCUSSION

Disorders of the brachial plexus are common in the neonate but rather uncommon in children.

These disorders may be due to a variety of factors

including trauma, especially birth injury,2 infec-tions or postimmunization phenomena,” familial

disorders,1 drug abuse,6 and congenital or

acquired structural abnormalities of the vascular

supply, muscle insertion, or osseous structures in

the shoulder region.7

A rucksack is a device for carrying loads in which the weight is transmitted to the straps which come over the shoulder and underneath the axilla with no means of firmly attaching the pack to the carrier (Fig. 1). This device is meant for carrying loads weighing less than 11.4 kg. In contrast, a backpack usually has metal supporting

rods which distribute the weight to the carrier’s

hips

to remove some of the weight-bearing load from

the shoulder girdle.

Daube7 described 17 patients who had

sustained damage to the upper trunk of the

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brachial plexus as a result of wearing heavy

backpacks which had aluminum supports. Several

Boy Scouts having a similar problem were

described by White5 a year before.

The

following

characteristics

should

lead

one

to suspect this diagnosis. A previously well

mdi-vidual who has used a pack for hours at a time

first complains

of pain

or sensory

symptoms

in the

shoulder or arm. The pain is frequently followed

by gradual weakness and atrophy mainly in the

shoulder girdle. The nondominant side is usually

affected first, although bilateral involvement has

been reported. Physical examination will reveal

decreased strength in the deltoid, supraspinatous,

infraspinatous, and, occasionally, in the wrist

extensors. Other muscles of the hand and arm may

be affected,

nerve are usually spared. Sensory loss may be

present but is less common than the motor

weakness. If there is sensory loss it is usually in the

C-5, C-6 distribution. The clinical findings mimic

Erb’s paralysis in the newborn. Previous

clavi-cular

or rib

injuries

predispose

to this

problem.

Laboratory data are usually normal; however,

roentgenograms of the chest and shoulder should

be ordered to rule out the presence of a cervical

FIG. 1. Rucksack.

FIG. 2. Left biceps, deltoid, and pectoralis atrophy. Photographed one week after camping trip.

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824 ENDOTRACHEAL TUBE POSITION rib or other predisposing osseous abnormality. Electromyography and nerve conduction veloci-ties can confirm the diagnosis and show denerva-tion of the affected muscles, usually in the C-5, C-6 distribution. Treatment of this disorder requires discontinuance of the use of the backpack and physical therapy. The prognosis for eventual recovery is good, but may take several months.

It is suspected that the cause of this disorder is compression of the upper trunk of brachial plexus

by the clavicle against the underlying rib cage.7

Vascular anomalies, anomalous muscle insertion

(

struc-tural abnormalities may also compromise the

plexus at this point.7

Rucksack palsy may occur with increasing frequency in young people with the increasing interest in camping, hiking, and the wide use of the rucksack for carrying school materials. It can

also

be

expected

in mail

carriers,

soldiers,

and

others using such packs. Decreasing the amount of weight that is carried, frequent removal of the

load during hiking, improved design of the

shoulder straps, and redistribution of the weight onto the back and pelvis may decrease the mci-dence of this problem. Increasing awareness of this potential hazard could result in reducing the

frequency and severity of this type of injury.

Cleveland, Ohio

A. DAVID ROTHNER, M.D.

A5A WILBOURN, M.D.

ROBERT D. MERCER, M.D.

Departments of Neurology and Pediatrics and Adolescent Medicine, Cleveland Clinic Foundation

ADDRESS FOR REPRINTS: (A.D.R.) Section of Child

Neurology, Cleveland Clinic Foundation, 9500 Euclid

Avenue, Cleveland, Ohio 44106

REFERENCES

1. Kemsley W: Personal communication, 1974.

2. Clark LP, Taylor AS, Trout TP: A study of brachial birth palsy. Am J Med Sci 130:670, 1905.

3. Spillane J: Localized neuritis of the shoulder girdle. Lancet 2:532, 1943.

4. Lishman WA, and Russell WR: The brachial neuropa-thies. Lancet 2:941, 1961.

5. Guillozet N, Mercer RD: Hereditary recurrent brachial neuropathy. Am J Dis Child 125:884, 1973. 6. Richter RW, Pearson J, Bruun B, et a!: Neurological

complications of addiction to heroin. Bull NY Acad Med 49:3, 1973.

7. Daube JR: Rucksack paralysis. JAMA 208:2447, 1969. 8. White HH: Pack palsy, a neurological complication of

scouting. Pediatrics 41: 1001, 1968.

Oscilloscopic

Monitoring

To Determine

Endotracheal

Tube

Position

Proper placement of an endotracheal tube is critical and often difficult to ascertain quickly.

Auscultation of the chest and abdomen to

deter-mine placement is imprecise in the neonate in whom air movement is transmitted over large

areas

and

difficult

to localize.

In spite

of routine

postintubation auscultation of the chest, Kuhns and Poznanski’ found a 50% incidence of endo-bronchial intubation in pediatric patients. A chest radiograph is, of course, the definitive method of determining endotracheal tube position but it is time-consuming.

Scanlon2 has recommended the use of an

esophageal catheter and 100% oxygen or

methyl-ene blue to evaluate endotracheal tube place-ment. He has suggested that these maneuvers could be repeated if an intubated neonate has clinical deterioration. Oscilloscopic monitoring of

respiration offers an alternative method of moni-toring tube placement, both initially and over the entire course of assisted ventilation.

MATERIAL AND METHODS

From January 1 to December 31, 1973, 349

patients were admitted to the neonatal intensive care unit at Fitzsimons Army Medical Center. All patients were placed on a General Electric

cardiorespiratory monitor with oscilloscopic

dis-play.

Constant-current

impedence

pneumogra-phy is used to monitor respiration. A constant AC

current signal is passed through the patient’s

chest

and

respirations

modulate

the

current

which is displayed on a rate meter and on the oscilloscope. The ECG can be simultaneously monitored with the addition of a third electrode.

An adequate oscilloscopic display of the ECG and

respiratory pattern can be displayed with monitor leads placed on the midaxillary line bilaterally

and on the anterior precordium.

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1975;56;822

Pediatrics

A. David Rothner, Asa Wilbourn and Robert D. Mercer

Rucksack Palsy

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Pediatrics

A. David Rothner, Asa Wilbourn and Robert D. Mercer

Rucksack Palsy

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