Forced extension of the arm over the head can damage the lower brachial plexus, with the intrinsic muscles of the hand being especially affected. This is classically called Klumpke’s palsy.

📖 About

Injury to the lower roots (C8, T1) of the brachial plexus.
Produces weakness and sensory loss, particularly in the ulnar nerve distribution.
Often results in a characteristic “claw hand.”

🧬 Aetiology

Caused by maximal abduction of the shoulder, stretching or tearing the lower brachial plexus.
Involves C8–T1 roots and affects hand function disproportionately.

🚗 Common Causes

Motor vehicle accidents (sudden traction injury).
Childbirth (shoulder dystocia with traction on the arm).
Direct penetrating trauma (knife, gunshot).

🩺 Clinical Features

Weakness of intrinsic hand muscles → “claw hand” deformity.
Sensory loss along the ulnar border of the forearm and hand.
May be associated with:
- Horner’s syndrome (ptosis, miosis, anhidrosis) due to T1 involvement.
- Fractures: clavicle, humerus, or cervical spine injury.
- Shoulder dislocation/subluxation.
- Cervical cord injury or facial palsy in severe trauma.
- Phrenic nerve palsy → diaphragmatic paralysis, particularly significant in neonates.

🔍 Differentials

Erb’s palsy (upper plexus C5–C6 injury → “waiter’s tip” posture).
Ulnar nerve injury (more distal, no Horner’s association).
Cervical cord lesions affecting hand function.

🧪 Investigations

Plain X-rays to exclude fractures.
Electromyography (EMG) and nerve conduction studies to assess severity and prognosis.
MRI or CT myelography to visualise root avulsion or plexus injury.

💊 Management

Immobilise the arm across the upper abdomen for 7–10 days if painful.
Early passive physiotherapy to maintain joint range of motion.
Occupational therapy for function and splinting if long-term deficit.
Surgical exploration or nerve grafting may be considered in severe or persistent injuries.
Respiratory support in neonates with phrenic nerve involvement.

📚 References

Royal College of Paediatrics and Child Health – Neonatal Brachial Plexus Injury guidance.
Oxford Handbook of Orthopaedics and Trauma.
NCBI StatPearls – Klumpke Palsy

🧾 Clinical Case Reports – Klumpke’s Palsy

Case 1 – Neonatal Klumpke’s Palsy 👶 A 3-day-old infant delivered by breech extraction is noted to have weakness of the hand and wrist on the left side. Examination shows a claw hand deformity with absent finger flexion and poor grip, but preserved shoulder and elbow function. There is also mild ptosis and miosis consistent with Horner’s syndrome. 👉 Diagnosis: Klumpke’s palsy (C8–T1 injury). 👉 Management: physiotherapy, splinting, and monitoring; neurosurgical referral if no recovery after several months.

Case 2 – Adult Klumpke’s Palsy 🧑 A 32-year-old woman falls from a height while grabbing onto a tree branch and presents with hand weakness and clawing of the fingers. Shoulder and elbow power are preserved, but grip is absent. Neurological exam shows sensory loss along the medial forearm and hand, with associated Horner’s syndrome. 👉 Diagnosis: Traumatic Klumpke’s palsy. 👉 Management: analgesia, physiotherapy, nerve conduction studies, and referral for brachial plexus surgical evaluation.

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Klumpke palsy