ERBS PARALYSIS

SHABINA ABDUL LATHEEF

MBBS 2020
BRACHIAL PLEXUS
• Brachial plexus is formed by the union of anterior rami of C5,
C6, C7, C8 and T1. When C5 receives contribution from C4 it is
known as pre-fixed and when T1 receives contribution from T2
it is known as post-fixed. The plexus comprises of roots, trunks,
divisions, cords and branches.
• C5 and C6 roots unite to form the upper trunk, C7 root alone
continues as middle trunk, C8 and T1 roots unite to form the
lower trunk. Each trunk divides into an anterior division and a
posterior division.
• The anterior division of the upper and middle trunk unite to form
the lateral cord.
• The anterior division of the lower trunk continues as medial cord
and posterior divisions of all the trunks unite to form the
posterior cord.
Lateral cord
• Lateral pectoral
• Musculocutaneous
• Lateral root of the median nerve
Medial cord
• Medial cutaneous nerve of the forearm
• Medial cutaneous nerve of the arm
• Medial pectoral
• Medial root of the median nerve
• Ulnar nerve
Posterior cord
• Upper subscapular
• Lower subscapular
• Thoracodorsal
• Radial
• Axillary
Nerves arising from the roots
• Long thoracic nerve-form C5, C6, C7 roots
• Dorsal scapular nerve-from C5
Nerves arising from the upper trunk
• Suprascapular nerve
• Nerve to subclavius
Injuries of brachial plexus
• Brachial plexus can get injured either by direct penetrating
wounds, e.g. assault, bullet and missile injuries or by traction
force e.g. vehicular accidents, birth injuries in which the angle
between the shoulder and the neck widens (increases).
Upper plexus injury – Erbs paralysis
• It is characterized by involvement of C5, C6 nerve roots.
• (C7 involvement may or may not be present).
• Functional loss results in a typical attitude of the upper limb.
The limb remains by the side of the trunk with shoulder in
adduction and internal rotation, elbow in extension, forearm in
pronation and wrist in flexion and ulnar deviation.
• This is because of the paralysis of abductors, namely the
deltoid and supraspinatus and
• external rotators, namely infraspinatus and teres minor at the
shoulder;
• paralysis of flexors, namely the biceps, brachialis and the
brachioradialis at the elbow;
• paralysis of the supinator at the forearm.
• Because the limb hangs by the side of the body and has an
attitude that resembles the attitude of a porter waiting for a tip, it
is known as "the porter's tip hand" Sensory loss over the
deltoid, lateral aspect of the forearm and hand is seen.
Management
Non operative management
• It should never be employed in more severe disruptions and in
open injuries of the brachial plexus.
• Appropriate splints are given as per the deficit to give rest to the
paralyzed part and prevent contractures, e.g. shoulder
abduction splint, spica cast, etc.
• Drug therapy is given to reduce edema and increase
vascularity. Electrical stimulation and exercise therapy is given
during the phase of recovery.
Operative management
• Immediate surgery is indicated only in open injuries of the
plexus. Otherwise, the surgeries for brachial plexus injury, are
always well planned and done at a later date.
Surgical procedures
• i. Repair-It is done when there is partial or complete
neurotmesis.
• ii. Interfasciculus nerve grafting-It is done when there is loss of
nerve tissue.
• Neurolysis: this is done when there is scarring around the
plexus
• Neurotization and nerve transfer: this is done in root avulsion
where repair is not possible
• Avulsion of C5 C6 roots: Spinal accessory nerve to
suprascapular nerve; two or three intercostals nerves to
musculocutaneous nerve.
• Nerve grafting:
• If C5 root is available, it is grafted to lateral cord to provide
elbow flexion, finger flexion and sensation along the radial side
of the hand.
• If C5 C6 roots are available, they are grafted to posterior and
lateral cords.
• Good postoperative care, physiotherapy and regular follow-up is
essential for successful outcome.
• Reconstructive procedures: Procedures such as tendon
transfers with available tendons, can restore some useful
function. Corrective osteotomies to correct rotational
deformities, if any, are indicated in cases where recovery is
poor.
CASE PRESENTATION
BIODATA
• Name : Goutham
• Age : 36
• Sex : male
• Occupation : farmer
• place : palakkad
• Right handed
CHIEF COMPLAINTS
• ◦Arm hanging by side of body (right) and hand turning
backwards
• ◦Restricted movements of right hand
• ◦Feeling of numbness along outer side of right arm and
fore arm since 3 weeks
HOPI
• Goutham 32 yr old farmer, apparently symptomatic
until 3 weeks ago gradually experienced weakening of
right arm and it hanging by the side with hand directed
backwards. The movements of the right hand was
restricted or difficult which is affecting his daily activity
and not able to work. He also complained of feeling of
numbness along outer aspect of his right arm and fore
arm.
•
• Patient reported of an incident of fall from the stairs at
his home 5 months ago . He landed on his right
shoulder. He experienced severe pain and was taken to
a near by hospital by his brother. An x ray was taken
fracture of the right clavicle was detected.
•
• Figure of 8 bandage was
applied
•4 months later x ray was
taken and it showed
complete healing of
fracture.
• ◦No h/o right shoulder swelling, pain , fever ,scars.
Past history
• No h/o DM, HTN,
• No other known comorbidities
• No history of any other previous surgical procedures.
 Personal history
• Sleep: adequate.
• Bowl and bladder habits : normal and regular.
• Habituated to alcohol and tobacco for the past 10 years
GENERAL EXAMINATION
• Moderately built and nourished
• He is conscious cooperative and well oriented to time
place and person.
• Patient was examined in sitting position in broad day
light with adequate exposure.
• There was no pallor, icterus cyanosis,
clubbing , generalised lymphadenopathy or pedal
edema.
Vitals
• Pulse : 88/min normal rate rhythm character volume
condition of vessel wall , no radio radial or radio femoral
delay.
• Bp : 124/78 mm Hg left arm sitting posture
• Patient was afebrile at the time of examination
LOCAL EXAMINATION
• Inspection
• Attitude and deformity: right arm hanging by side of
the body and internally rotated with forearm
extended at elbow and fully pronated
• policeman tip receiving deformity
• B. wasting of muscles
• Wasting of deltoid brachialis brachioradialis biceps
brachii muscle
• Skin : appears dry, smooth, and glossy compared to left
arm
• No other scars or wounds
Palpation
• a)Temperature: normal
• b)Muscles: wasting of right deltoid brachialis
brachioradialis biceps muscle. Soft and flabby
• d)Skin : loss of sensation in outer aspect of arm and
fore arm
• d) Scar: no scars
Muscle power
Sensations
6.Reflex
7. Nerve
• No evidence of injury of displaced bony fragments or
scars to suggest old injuries
8. Deformity
• Policeman taking tip deformity
Summary
• 32 yr old goutham presented with police man taking tip
deformity and decresedmovement of right upper limb.
He had a previous history of right clavicular fracture 5
months ago. On examination there was loss of sensation
in the lateral aspect of forearm and arm along with
decreased power
(deltoid,brachialis,bicepsbrachi,supinator infraspinatus,
supraspinatus) and absent reflexes of right upper limb.
(biceps, supinator)
Provisional diagnosis
• ◦Right sided erbs paralysis due to injury of brachial
plexus by the fractured fragment of right clavicle