Updated: 2/22/2019

Erb-Duchenne Palsy

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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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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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