Anatomy Msk · Year 1 · from Anatomy Msk
Case 1: Erb-Duchenne Palsy (Upper Brachial Plexus Injury)
Clinical Image
Source: Wikimedia Commons - Brachial Plexus - Public Domain
Case Presentation
A newborn male is delivered via vaginal delivery complicated by shoulder dystocia. Birth weight was 4,500 grams, and delivery required significant traction and maneuvers to release the impacted shoulder. Immediately after delivery, the pediatrician notes that the infant does not move his right arm. The arm is held in adduction and internal rotation at the shoulder, with the elbow extended, forearm pronated, and wrist flexed - the classic "waiter's tip" position. The infant withdraws to painful stimuli in the hand, and grasp reflex is intact. The Moro reflex is asymmetric, with the right arm failing to abduct and externally rotate. There is no clavicle fracture on palpation or chest X-ray. The infant is diagnosed with Erb-Duchenne palsy affecting the upper trunk of the brachial plexus (C5-C6). Physical therapy with passive range of motion exercises is initiated immediately to prevent contractures. At 3-month follow-up, the infant shows significant spontaneous recovery with return of biceps function. Complete recovery is expected by 6 months.
Key Learning Points
- The brachial plexus forms from ventral rami of C5-T1 and courses between the anterior and middle scalene muscles
- Upper trunk (C5-C6) injury causes loss of shoulder abduction, external rotation, elbow flexion, and supination
- "Waiter's tip" position: adducted/internally rotated shoulder, extended elbow, pronated forearm, flexed wrist
- Obstetric brachial plexus injury occurs with shoulder dystocia and lateral neck flexion during delivery
- Prognosis is generally good; spontaneous recovery occurs in majority of cases with intact hand function