Makindo Medical Notes

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