ERBS DUCHENNE PALSY

CHALLA SUDARSANA
GROUP NO 52
5th COURSE
 CLINICAL CASE
➢
A 4.6kg male newborn is delivered at term to a 35 year old obese woman after
prolonged labor & APGAR scores are 9 and 9 at 1st & 5th minutes.
➢
Examination in the delivery room shows swelling, tenderness & crepitus over
the left clavicle.
➢
Movement of the hands and wrist are normal.
➢
A Grasping reflex is normal in both hands.
➢
An assymetric MORO reflex is present.
➢
Physical examination shows no movement on affected side of upper arm.
➢
X-RAY examination shows fractured segments of Left Clavicle.
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WHAT IS THE PROBABLE DIAGNOSIS.??
●
Erbs palsy is usually caused by
excessive traction on the head and neck
during a difficult vertex delivery.
●
MECHANISM OF INJURY :
bending or stretching of the neck in the
direction away from the side of
injury.
●
Immediately after birth it is noticed that
the baby does not move one arm due to
weakness at the shoulder and elbow.
 RISK FACTORS

●
Large birth weight (fetal macrosomia)
●
Vertex fetal position
●
Maternal age ( 35 years )
●
Maternal obesity
●
Prolonged labor ( >60 sec )
 CLINICAL PRESENTATION
●
Shoulder : Adducted and internally
rotated
●
Wrist : Flexion
●
Forearm : Extension
(waiter's tip posture)
●
Grasp of hand is present
●
Fingers and wrist have normal motion
●
Asymmetric Moro reflex is present.
 DIAGNOSIS

●
History- shows pregnancy complication by maternal obesity, fetal
macrosomia, prolonged labour .
●
Physical examination- shows no movement of the affected upper
arm.
●
Neurologic examination- revealed muscle weakness, loss of
sensation,
●
Moro reflex is absent on the affected arm.
●
X-ray: shows fracture segments of left clavicle

OTHER METHODS
●
CT / MRI
●
Electrodiagnostic studies: detect and grade nerve injury,
nerve compression and identify early stages of recovery.
 PHYSIOTHERAPY

●
Maintains PROM.
●
Improves muscle strength.
●
Stretch muscle groups to prevent
contracture..
●
Sensory awareness.
●
Positioning (abduction, externalrotation,
forearm flexion & wrist extension.)
●
Splinting(aeroplane splint).
 TOWEL TEST
●
In supine the child face is covered with towel.
●
Shoulder flexion, elbow flexion and extension,
finger flexion and extension are needed for
the test.
●
If the baby removes the towel from the face
then Baby passes the test.
●
If the baby did not pass the towel test at 6 th, 9th
month then it is an indicative for surgery.
●
Absence of biceps recovery by 3 months of
age is also an indicative of surgery.
 SURGICAL INTERVENTION
●
Nerve grafting
●
Neuroma dissection and removal
●
neurolysis(decompression and removal of scar tissue)
●
Nerve repair (neurorrhaphy)
●
Nerve transfer: an intact healthy nerve is redirected towards a
denervated nerve in order to restore the innervation of its target organ.
●
Tendon transfer: a tendon from a sufficiently powerful muscle is
redirected towards another tendon in order to restore its motion
and function.
 PROGNOSIS
●
Prognosis depend on the mechanism of injury and the number of
nerve roots involved.
●
The mildest injury to a peripheral nerve (neurapraxia) is due to edema and
heals spontaneously within a few weeks.
●
Axonotmesis is more severe and is due to nerve fiber disruption with an intact
myelin sheath; function usually returns in a few months.
●
Total disruption of nerves (neurotmesis) or root avulsion is the most severe,
especially if it involves C5–T1 microsurgical repair may be indicated.
●
(75%) injuries are at the root level C5–C6 and involve neurapraxia and
axonotmesis and should heal spontaneously.
●
Botulism toxin may be used to treat biceps triceps co-contractions.
●
Long term effects of erbs palsy due to impaired
innervation are :
➢
Decreased strength & stamina
➢
Abnormal movement & function of joints
➢
Muscular atrophy
➢
Impaired bone growth
➢
Impaired balance and coordination