A Case of Erb's Palsy (Erb-Duchenne Palsy) in an Adult

Overview

Teaching with the media is brain friendly because it provides interactive abstract learning that utilizes the categorical memory and requires little intrinsic motivation. Neuroanatomy is an integral part of human anatomy that is taught to medical students. This preparation is an attempt to offer interactive learning of the practical demonstration of peripheral nerve injuries to medical students and prospective physiotherapies who are studying for higher degree in neuroanatomy. It is focused on the anatomy of brachial plexus and the clinicoanatomic features of upper trunk injury using annotated photograph of a young man with traumatic Erb’s palsy.

In order that students may self-test their understanding of the topics in relation to clinical practice, problem-based questions have been included at the end of the discussion.

Author(s): Dr. Casmiel K. OsabuteyView Details of Author
Year: 2014
Keywords: erb's palsy, erb–duchenne palsy, paralysis, anatomy
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Introduction

 

Erb's palsy or Erb–Duchenne palsy is a paralysis of the arm caused by injury to the upper trunk of the brachial plexus (Erb, W, 1874). Erb's palsy is commonly, but not exclusively, caused by dystocia, an abnormal or difficult childbirth or labour (Peleg, et. al 1997). For example, it can occur if the infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal.

The condition can also be caused by excessive pulling on the shoulders during delivery in the cephalic presentation, or by pressure on the raised arms during a breech extraction. Erb’s palsy in adults is uncommon; it may follow trauma to the head and shoulder causing violently stretching of the nerves of the upper trunk. As the result, the arm hangs by the side, medially rotated, extended at the elbow and pronated with loss of sensation on the lateral side of the arm and forearm (Sinnatamby, 1999).

Here, a rare case of Erb’s palsy in a young man and the discussion on the relevant anatomy is presented.

 

Objectives

 

Appreciate the clinical presentation of Erb’s Palsy in an adult

Understand the anatomical bases of the condition

 

Lesson Content

 

HISTORY

In the case presented here, a young man aged 24 was hit on the left shoulder by a falling tree about three months ago. His main complaints were inability to abduct the left shoulder, inability to flex the left elbow and numbness on the lateral aspect of the left forearm. He had received tradition treatment in which herbal preparations had been applied and the limb bandaged for awhile. He was also treated in a number of hospitals where radiological investigation revealed no fracture of the bones of the shoulder girdle.

 

PHYSICAL FINDINGS

The main clinical findings were as follows (see the annotated photographs):

  1. The left upper hangs freely by the side of the trunk and partially rotated medially as indicated by the anterior displacement of the lateral epicondyle of the humerus.
  2. The elbow was held in extension due to triceps brachii over activity.
  3. There are obvious atrophy of the muscles of the anterior compartment of the arm and posterior aspect of the scapula.
  4. Sensory loss on lateral aspect of arm and forearm was equivocal.

 

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DISCUSSION ON THE RELEVANT ANATOMY

The upper trunk of the brachial is formed by the union of fifth cervical (C5) and sixth cervical (C6) spinal nerves. Nerves derived from the upper trunk of the brachial plexus that are affected in this condition are: axillary, suprascapular and musculocutaneous nerves (see illustration). The current case presented clinically as a lower motor neuron lesion involving the paralysis of the abductors and lateral rotators of the arm and the flexors and supinator of the forearm.

 

dicuss

Diagram to illustrate the parts of the brachial plexus affected in Erb–Duchenne’s
palsy are indicated yellow: C5 and C6 roots, upper trunk, suprascapular nerve,
parts of lateral and posterior cords, musculocutaneous nerve and axillary nerve.

The suprascapular nerve (C5, 6) is a direct branch of the upper trunk. It supplies the supraspinatus muscle, infraspinatus muscles and the shoulder joint. These muscles are part of the rotator cuff muscles that are lateral rotators of the arm. The patient’s arm is medially rotated because these muscles are paralyzed and the over activity of the medial rotators - pectoralis major and latissimus dorsi muscles.

The musculocutaneous nerve (C5, 6, 7) is a branch of the lateral cord. It supplies muscular branches to all the muscles of the flexor compartment of the arm namely coracobrachialis, brachialis and biceps brachii and continuous as lateral cutaneous nerve of the forearm innervating the skin overlying the lateral aspect of the forearm. These muscles are flexors of the forearm at the elbow; the biceps brachii is also a powerful supinator of the forearm. The patient’s elbow is extended and partly pronated because, these muscles are paralyzed; the triceps brachii and the pronators over activity is keeping the elbow in extension and pronation.

The axillary nerve (C5, 6) is a branch of the posterior cord. It supplies muscular branches to the deltoid and teres minor muscles and continuous as the upper lateral cutaneous nerve of the arm innervating the skin overlying the deltoid muscle.

Although the lateral cutaneous nerve of the forearm (from musculocutaneous nerve) and upper lateral cutaneous nerve of the arm innervate the skin overlying the lateral aspect of the arm and forearm, detection of sensory loss on these areas of the skin were equivocal.

 

Self Assessment Quiz

 

CLINICOANATOMICAL QUESTIONS

1. Differentiate between cutaneous innervations and dermatomes.
2. What are the dermatomes of the lateral aspect of the arm and forearm?
3. The detection of sensory loss on the areas of skin innervated by both musculocutaneous and axillary nerves were equivocal in this case. Why?

 

Answers to the Clinicoanatomical Questions
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References

     

    Peleg D, Hasnin J, Shalev E (1997). "Fractured clavicle and Erb's palsy unrelated to birth trauma". American Journal of Obstet. Gynecol. 177 (5): 1038–40.

    Sinnatamby, C. S (1999). Last’s Anatomy, Regional and Applied. Churchill Livingstone, Elsevier limited, pp 13-14; 50-52 and 89-94.

    Erb, W. (1874). "Ueber eine eigenthümliche Localisation von Lähmungen im Plexus brachialis". Verhandlungen des naturhistorisch-medicinischen Vereins zu Heidelberg 2: 130–137

    Bannister, L. H., M. Berry, P. Collins, M. Dyson, et al., (38theds) 1999. GRAY’S ANATOMY. London: Churchill Livingstone. Pp 1266 – 1274

    Healy C, Pamela M. LeQuesne, LynnB (1996) Collateral sprouting of cutaneous nerves in man. Brain, 119, 2063-2072


    Livingston WK. (1947) Evidence of active invasion of denervated areas by sensory fibers from neighboring nerves in man. J Neurosurg, 4: 140-5

     

Credits

 

Author

dr osabutey

Dr. Casmiel K. Osabutey
Senior Lecturer in Clinical Anatomy
School of Medical Sciences
College of Health Sciences,
Kwame Nkrumah University of Science & Technology
Kumasi, Ghana

 

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