Brachial Plexus Injury (Erb’s and Klumpke’s) Erb-Duchenne Paralysis (Erb’s Palsy)

- Injury on C5-C6 (Erb’s point - junction)

Anatomy - Upper brachial plexus injury
✦ Brachial Plexus
- Somatic nerve bundle Muscles Paralyzed
- Arises from anterior rami of C5-T1 ✦ Main:
- Location: posterior triangle of the neck ● Biceps
- Ant. border: trapezius ● Deltoids
- Post. border: sternocleidomastoid ● Brachialis
- Inf. border: clavicle ● Brachioradialis
✦ Partly:
Function: cutaneous & muscular innervation of whole UE ● Supraspinatus
● Infraspinatus
● Supinator

Loss of Sensation
✦ lateral aspect of UE
- “Cheiralgia paresthetica”
If thigh = “meralgia paresthetica”

Deformity
✦ Arm: adducted, IR
✦ Forearm & elbow: extended, pronated
= “waiter’s tip”
= “policeman’s tip”
= “porter’s tip”
✦ pecs is active, no counter

Klumpke’s Palsy
- Injury on C8-T1
- Lower brachial plexus injury
R T D C B

Musculocutaneous
Muscles Paralyzed
C5 Ant nerve (biceps) ✦ Intrinsic hand muscles
Superior Lateral Lateral arm nerve ● Proximal phalanges
trunk cord ● Muscles of hand located at palm
Median Nerve (carpal
C6 Post ● [extrinsic = origin at forearm, invert at fingers (distal
tunnel syndrome)
phalanges)]
Radial nerve (all ext. Of ✦ Ulnar flexors of wrist & fingers
C7 Ant UE)
Middle Posterior ● Ulnar nerve
trunk cord
C8 Post Axillary nerve (deltoid)
Loss of Sensation
✦ Ulnar border of forearm & hand
Ant Ulnar nerve (funny
Inferior Medial
T1 bone → pinky & ring,
trunk cord half of C7) Deformity
Post
✦ “claw hand”
*C5: dorsal scapular nerve ✦ stronger:
*C5-C6: nerve to subclavius ● Long hand flexors
*C5-C7: long thoracic nerve ● Long hand extensors
✦ “ape hand deformity”
Etiology ● Atrophy of intrinsic hand muscles
✦ Trauma
- Motor vehicular accident (ADULT)
✦ Injury during birth (INFANT)

Mechanism of Injury
1. Traction
2. Direct trauma
3. Compression
 Erb’s-Klumoke’s Erb-Duchenne Klumpke’s Palsy
Paralysis (C5-T1) Paralysis (C5-C6) (C8-T1) PT Treatment Goals
1) Increase strength, flexibility, stamina, coordination
Muscles ✦ Main: ✦ Intrinsic hand 2) Maintain ROM (e.g. secondary frozen shoulder*)
Paralyzed Biceps muscles ● PROM exercises
Deltoids ✦ Ulnar flexors of ● Splinting / braces
Brachialis wrist & fingers 3) Functional training / adaptive devices
Brachioradialis 4) Pain management (hot packs, TENS, etc)
✦ Partly: 5) Edema management
Supraspinatus - Compression garment, massage, jobs
Infraspinatus - Relies on muscle contraction
Supinator - Can cause too much fluid if damaged

Loss of Sensation ✦ lateral aspect ✦ Ulnar border of *Primary frozen shoulder - idiopathic
of UE (Cheiralgia forearm & hand *Secondary frozen shoulder - underlying cause
paresthetica)
Surgical Management
Deformity ✦ Arm: adducted, ✦ “claw hand” ✦ Severe BPI (cut)
IR ✦ stronger: - In hope to regain function
✦ Forearm & Long hand flexors ● Nerve grafts
elbow: extended, Long hand ● Nerve transfer
pronated extensors ● Musculoskeletal reconstruction
= “waiter’s tip” ✦ “ape hand ✦ Dorsal Root Entry Zone
= “policeman’s tip” deformity” - “Dorsal root rhizotomy”
= “porter’s tip” Atrophy of - Remove nerve that causes extreme neuropathic pain
✦ pecs is active, intrinsic hand ✦ Spinal cord stimulator
no counter muscles - Kabit TENS sa spinal cord
- Pain gate theory

Clinical Features
Medical Management
✦ Brachial Plexus Injury
- Pain is the major issue
● Neuropathic pain (chronic)
● Acute: Nsaids / opioids
● Increased pain when neared the spinal cord (ex.
● Neuropathic pain: anti-epileptic drugs
Nerve root > median nerve injury)
● Burning sensation
Psychological Management
● Paresthesia
● Refer to psychiatrist or clinical psychologist

Physical Examination
- Area of pain
● Evaluate: sensory
● Evaluate: muscles
● Median nerve affected = carpal tunnel

Diagnostic Procedures
✦ Imaging studies
● X-ray
● CT scan
● MRI (soft tissues, e.g. pleura)
✦ EMG
✦ Nerve Conduction Velocity Test