Erb’s palsy

• Erb-Duchenne palsy
• Brachial plexus injury

• 767.6 Injury to brachial plexus due to birth trauma
• 953.4 Injury to brachial plexus

• G54.0 Brachial plexus disorders
• P14.0 Erb's paralysis due to birth injury
• S14.3XXA Injury of brachial plexus, initial encounter

• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders
• Pattern 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury

Description

• Paralysis of the arm
• Weakness in the arm
• Diminished reflexes, C5-C6 vertebrae
• Arm hangs by side, internally rotated
• Motor or sensory changes in the nerve distribution due to pressure from compression and stretch
  • Sensory changes in multiple peripheral nerves of the upper extremity from C5 and C6 nerve roots

Essentials of Diagnosis

• Seddon’s classification
  • Neurapraxia (Class 1), 1st degree
  • Axonotmesis (Class 2), 2nd degree
  • Neurotmesis (Class 3)
    • 3rd degree, nerve fiber interruption
    • 4th degree, epineurium intact
    • 5th degree, complete transection of the nerve

General Considerations

• Involved nerves include suprascapular, musculocutaneous, axillary
• Must differentiate from more proximal and distal nerve compression, thoracic outlet syndrome (TOS), ulnar tunnel, cervical radiculopathy
• Wallerian degeneration occurs below site of injury

Signs and Symptoms

• Acute or chronic paresthesia
• Sensory changes: hyposensitivity of hand
• Hand clumsiness
• Feeling of arm heaviness
• Hand weakness, loss of grip-power and dexterity
• Intrinsic muscle atrophy
• Waiter’s tip sign
• Loss of lateral-rotator, arm-flexor, and wrist-extensor musculature

Functional Implications

• Feeling of arm being dead
• Difficulty with hand function, hand clumsiness, and possible loss of strength during ADLs/IADLs

Possible Contributing Causes

• During forceps delivery, infant has head traction
• In the womb, sustained pressure over thoracic outlet
• Falls with outstretched arms
• Traction to the cervical spine
• Trauma pulling arm into abduction
• Ganglion or space-occupying lesion
• Clavicle fracture
• Glenohumeral dislocation

Differential Diagnosis

• Thoracic outlet syndrome (TOS)
• Cervical radiculopathy
• Other potential entrapment sites include
  • Medial humeral groove
  • Arcade of Struthers
  • Medial intermuscular septum
  • Flexor digitorum profundus
  • Flexor carpi ulnaris
  • Just proximal to or within Guyon’s canal
  • Sensory and motor involvement between the abductor digiti minimi and flexor digiti minimi
  • Near hook of hamate: involves motor function only
  • Distal end of Guyon’s canal: involves sensory function only
• Radial neuropathy
• Median neuropathy
• Carpal tunnel syndrome
• Proximal ulnar nerve entrapment
• Distal ulnar nerve entrapment cubital tunnel (Guyon’s Canal)
• Klumpke paralysis
  • Traction of an abducted arm
  • Lower brachial plexus injury
  • Damage to C8 and T1 vertebrae
  • Loss of intrinsic muscles of the hand, wrist, finger flexors
• Ulnar nerve palsy
• Bishop deformity

Imaging

• Diagnostic ultrasound imaging
  • Allows for dynamic imaging during arm movement
  • May show enlargement of brachial plexus ...