Updated: 4/9/2018

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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