Obstetric Brachial Plexus Palsy
Definition
Obstetric brachial plexus palsy is injury to the brachial plexus during difficult delivery (shoulder dystocia, large baby, breech). The commonest form is Erb’s palsy, an injury to the upper roots C5–C6 (± C7), causing paralysis of the shoulder abductors/external rotators and elbow flexors.
Clinical Features
The affected arm hangs in the classic ‘waiter’s tip’ position: adducted and internally rotated at the shoulder, extended at the elbow, pronated forearm and flexed wrist. The Moro and biceps reflexes are absent on that side while grasp is preserved (the hand is spared). In contrast, Klumpke’s palsy (lower roots C8–T1) affects the intrinsic hand muscles (claw hand) and may show a Horner’s syndrome.
CLINICAL PEARL
Erb’s = upper roots (C5–C6), ‘waiter’s tip’, hand spared; Klumpke’s = lower roots (C8–T1), claw hand ± Horner’s. Erb’s is much commoner and has the better prognosis.
Management
Most Erb’s palsies recover spontaneously. Early management is gentle physiotherapy — maintaining a full passive range of movement to prevent contractures — while awaiting recovery. If there is no meaningful recovery of biceps function by about 3 months, referral for consideration of microsurgical nerve repair/grafting is indicated. Later, secondary procedures (tendon transfers, osteotomies) may correct residual deformity.
Assessment & Prognosis
Careful serial examination documents which movements are recovering; return of biceps (elbow flexion) function is the key milestone and the main determinant of the decision to operate. The overall prognosis for Erb’s palsy is good — the majority recover useful function — whereas total (pan-plexus) injuries and those with a Horner’s syndrome (implying a lower-root, often preganglionic, avulsion) carry a worse outlook. Throughout, the priority is to keep the joints supple with passive movement so that a recovering nerve meets a mobile, not a contracted, limb.
CLINICAL PEARL
Distinguish the two birth palsies at a glance: Erb’s (upper C5–C6) gives the ‘waiter’s tip’ arm with a spared hand and a good prognosis, whereas Klumpke’s (lower C8–T1) gives a claw hand, sometimes with Horner’s syndrome, and a worse outlook.
Most recover spontaneously; explore if no biceps function by 3 months.
KEY POINT
Key points TO remember
- Birth injury to the brachial plexus; Erb’s = upper roots C5–C6 (± C7).
- ‘Waiter’s tip’ posture; absent Moro/biceps reflex; hand (grasp) spared.
- Klumpke’s (C8–T1) = claw hand ± Horner’s (rarer, worse).
- Most recover; physiotherapy to prevent contractures; nerve surgery if no biceps by ~3 months.
EXAM TIP
Sources: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.
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