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Dr nada Msallim
Scenario 7
• 10 days old baby with concerns about arm movment
• What are the signs did observed in this video?
• I CAN SEE 10 days old baby who looks well , with no apperent
dysmorphic features, well grown, not attached to any devices or
monitoring , general examination shows that the left eye not fully
open probably having ptosis I need to eamin the pupil for signs of
Horner syndrome .the righr eye looks normal.
• Upper limp examination shows that the left arm hanging by the side
and is rotated medially, the forearm extended and pronated and the
wrist flexed.(Waiter's tip deformity)
• What is your most likely diagnosis ?
• Erb’s palsy (C5,C6) associated with Horner syndrome

• What other DD?

• transverse myelitis
• osteomyelitis spine
• spinal stroke
• spinal abscess
• What additional history would you like to ask?
• Onset? Progression, tachypnoea?
• Any intervention: physiotherapy?
• Risk Factors: Previous baby >3.5kg or with previous Erb’s palsy/
Obstetric Brachial Plexus Palsy
• Maternal diabetes
• Cephalopelvic disproportion
• Multiparity
• Breech presentation
• Shoulder dystocia , Prolonged 2 nd stage of labour , Assisted delivery
• What additional examination would you like to do?
• “Floppy” arm?
• Examine for Horner's sign
• Examine for tachypnoea
• Examine the arm and neck for swelling, bruising, tone, posture and degree of
movement .

• how to manage this case ?

• X-ray humerus/clavicle to exclude fracture
• Horner syndrome present R:efer to specialist centre for surgery.
• no Horner syndrome?
• refer for physiotherapy
• if no recovery of arm movement at 3 weeks refer to children’s hand and upper limb service
• arrange regular follow-up
• advice to the parent
• red flags
Thank you