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Updated: Feb 22 2019

Erb-Duchenne Palsy

  • Snapshot
    • A G1P1 woman gives birth to a boy at 41 weeks gestational age via vaginal delivery. Labor was prolonged due to shoulder dystocia which required a forceps delivery. The child's APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. The child's weight at birth is 9 pounds 8 ounces. On exam, the baby's left upper extremity is notable for arm adduction, elbow extension, and forearm pronation.
  • Introduction
    • Clinical definition
      • lesion in the upper trunk (C5-C6) of the brachial plexus leading to the characteristic "waiter's tip" deformity
    • Epidemiology
      • incidence
        • most common neonatal brachial plexus palsy
        • approximately 1 per 1000 live births
      • risk factors
        • obstetric
          • large for gestational age
          • shoulder dystocia
          • forceps delivery
          • breech presentation
          • prolonged labor
    • Etiology
      • excess traction on head away from the ipsilateral shoulder
        • this motion puts tension on the upper trunk of the brachial plexus
      • common clinical scenarios
        • obstetric complication
          • traction on head away from the shoulder during a difficult delivery (e.g., shoulder dystocia)
        • trauma
          • falling on the shoulder with head bent away from the affected shoulder
    • Pathoanatomy
      • normal anatomy
        • brachial plexus diagram
        • upper trunk of brachial plexus
          • C5 and C6 nerve roots
          • important nerve branches and the muscles they innervate
            • axillary nerve
              • deltoid
              • teres minor
            • musculocutaneous nerve
              • biceps brachialis
              • brachialis
              • coracobrachialis
            • suprascapular nerve
              • infraspinatus
              • supraspinatus
      • injury anatomy
        • lesion in the upper trunk will weaken muscles innervated by the axillary, musculocutaneous, and suprascapular nerves resulting in weak
          • arm abduction
            • deltoid
            • supraspinatus
          • arm external rotation
            • teres minor
            • infraspinatus
          • forearm supination
            • biceps brachialis
          • forearm flexion
            • biceps brachialis
            • brachialis
    • Associated conditions
      • clavicle fracture
      • humerus fracture
      • shoulder dislocation
    • Prognosis
      • unfavorable
        • concomitant Horner syndrome
        • C7 involvement
        • cord avulsion
  • Presentation
    • Symptoms
      • infant unable to move affected upper extremity
    • Physical exam
      • "waiter's tip" deformity
        • arm is adducted
          • abductor weakness
            • deltoid and supraspinatous are strong abductors at the shoulder
        • arm is internally rotated
          • external rotator weakness
            • infraspinatus and teres minor are external rotators
        • forearm is pronated
          • supination weakness
            • biceps brachialis is a strong supinator of the forearm
        • elbow is extended
          • flexion weakness
            • biceps brachialis and brachialis are strong flexors at the elbow
  • Imaging
    • Radiographs
      • indication
        • radiographs are not routinely performed unless another diagnosis is being considered
          • fracture
          • dislocation
    • Magnetic resonance imaging (MRI)
      • indication
        • MRI is not routinely performed unless another diagnosis is being considered
          • preferred modality to fully characterize the lesion
          • preoperative planning
  • Differential
    • Klumpke palsy
      • distinguishing factors
        • lesion in C8-T1 nerve roots (lower trunk) caused by upward traction of arm
        • presents with "claw hand" due to impaired lumbrical muscles
          • extension of metacarpophalangeal (MCP) joints
          • flexion of proximal and distal interphalangeal joints
    • Radial head subluxation
      • distinguishing factors
        • subluxation of the radial head relative to the radiocapitellar joint
        • occurs in children 2-5 years of age due to excess traction on the arm
        • elbow held in slight flexion and pronation
  • Treatment
    • Nonoperative
      • observation and daily passive exercises
        • indications
          • most cases of Erb-Duchenne palsy will resolve with conservative management
          • complete recovery may take up to 2 years
  • Complications
    • Joint contracture
    • Hemidiaphragm
      • concomitant injury to the phrenic nerve
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