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Anatomy

Upper Limb

Question 97 of 239

A patient is involved in a road traffic accident and is left with weakness in his left arm. He has been told he has an Erb's palsy due to damage of his brachial plexus. Which of the following clinical features are you LEAST likely to see:

Answer:

An Erb's palsy is caused by damage to the C5 and C6 nerve roots and thus primarily involves the musculocutaneous, suprascapular and axillary nerves. There is loss or weakness of abduction, lateral rotation and flexion of the arm and flexion and supination of the forearm and loss of sensation on the lateral arm. Medial rotation is not typically affected.

Brachial Plexus Injury

Anatomy / Upper Limb / Innervation of Upper Limb

Last Updated: 8th April 2019

Brachial plexus injuries are usually the result of blunt trauma producing nerve avulsions and disruption.

Table: Clinical Features of Brachial Plexus Injury

Brachial plexus injury Erb’s palsy Klumpke’s palsy
Mechanism of injury Excessive increase in angle between neck and shoulder e.g. during breech delivery or from fall from motorbike or horse Sudden excessive abduction e.g. person catching something overhead as they fall or during a difficult delivery
Nerve roots affected C5, C6 C8, T1
Nerves affected Musculocutaneous, axillary, suprascapular and nerve to subclavius Ulnar and median nerves
Muscles affected Supraspinatus, infraspinatus, subclavius, biceps brachii, brachialis, coracobrachialis, deltoid and teres minor All small muscles of hand (flexor muscles in forearm innervated by different nerve roots)
Motor loss Abduction, flexion and lateral rotation of arm, flexion and supination of forearm Intrinsic hand movements
Sensory loss Lateral arm Medial arm
Deformities Waiter’s tip Claw hand

Klumpke's Palsy

Klumpke's palsy affects nerves derived from the C8 or T1 roots. It is much less common than Erb's palsy. It usually occurs from sudden excessive abduction of the arm e.g. catching something overhead when falling, or during a difficult birth. All the small muscles of the hand are affected (the flexor muscles of the forearm are spared as they are supplied by different roots). There is sensory loss over the medial side of the arm and a characteristic 'claw hand' appearance, where the metacarpophalangeal joints are hyperextended, and the interphalangeal joints are flexed.

Erb's Palsy

Erb's palsy affects nerves derived from the C5 or C6 roots. It commonly result from an excessive increase in the angle between the neck and the shoulder e.g. a person thrown from a motorbike or horseback or during a difficult birth. There is loss or weakness of abduction, lateral rotation and flexion of the arm and flexion and supination of the forearm and loss of sensation on the lateral arm. A characteristic 'Waiter's tip' deformity may be present where the limb hangs limply by the side, medially rotated by the unopposed action of the pectoralis major with the forearm pronated and extended and the wrist flexed.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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