Slide 111 — Obstetric brachial plexus palsy / Erb palsy

Clean FRCS notes with inline figures

Clinical photograph

•UL abnormal posture

•Shoulder adducted, IR

•Elbow extended

•Wrist flexed

•Forearm pronated

•Fingers flexed

•Thumb (not seen here) adducted

•Typical of Erb’s palsy

•Primitive reflex

•Moro: Shoulder abduction

•Asymmetrical tonic neck reflex (ATR): elbow flexion and extension

•Grasp reflex: finger flexion

•Go back to patient and identify risk factors: high BW, breech presentation, shoulder dystocia, forceps delivery

•Classification by Narakas (C5,6 / C5,6,7 / C5-T1 / C5-T1 + Horners)

•Use Mallet score to monitor progress (1 active abduction, 2external rotation, 3 hand to head , 4 hand to back, 5 hand to mouth)

•MRI to look for (pseudo-)meningocele

Treatment:

•Daily stretching to maintain good ROM

•If no antigravity biceps function return by 2 months (max 3 mth) → OT

Natural history

•Gilbert Alain 1995 hands clinic

•Complete recovery if biceps and deltoid begin to contract at 1m and real contraction by 2m

•Good shoulder if begin at 3m and complete at 5m

•Bad shoulder if begin after 3m

Primary reconstruction:

•Root avulsion: nerve transfer (= neurotization)

•Lower lesion: nerve repair or nerve graft

Secondary reconstruction:

•Posterior dislocation

•Soft tissue: capsulorrhaphy

**Fig 1.** Operative / approach imagetop left

•Bony: humerus derotation osteotomy

IR:

•Soft tissue: subscapularis release, Muscle transfer (LD and teres major to GT)

•Obstetric brachial plexus injury

•In general 90% spontaneous resolve

Favorable prognostic factors:

•Erb’s palsy

•+ve twitching (M1) over bicep and deltoid at 2mth old

Unfavorable factors:

•M0 at 3mth old

•Preganglionic injuries (Horner, involvement of dorsal scapular and phrenic nerve)

•Lower nerve root involvement (C5-7, klumpke)

•Injury to upper trunk C56 results from excessive abduction of head away from shoulder, producing traction on plexus

•Associated condition: glenoid retroversion + flattened and posteriorly subluxed humeral head (due to persistent shoulder IR), elbow contracture

•C5 deficiency

•Axillary nerve deficiency (deltoid, teres minor)

•Suprascapular nerve deficiency (supraspinatus, infraspinatus)

•Musculocutaneous nerve deficiency (biceps)

•C6 deficiency

•Radial nerve deficiency (brachioradialis, supinator)

•Sensation loss over lateral aspect of arm and forearm

•Klumpke

•Lower trunk C8/T1 injury

•Difficult births, falls onto the outstretched arm

•Intrinsic minus

•Weak wrist and finger flexion

•Sensation loss over medial aspect of hand and forearm

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Describe clinical photo:
2	0	171450	-171450	1	UL abnormal posture
3	0	171450	-171450	1	Shoulder adducted, IR
4	0	171450	-171450	1	Elbow extended
5	0	171450	-171450	1	Wrist flexed
6	0	171450	-171450	1	Forearm pronated
7	0	171450	-171450	1	Fingers flexed
8	0	171450	-171450	1	Thumb (not seen here) adducted
9	0	171450	-171450	1	Typical of Erb’s palsy
10	0	0	0	0	Primitive reflex
11	0	171450	-171450	1	Moro: Shoulder abduction
12	0	171450	-171450	1	Asymmetrical tonic neck reflex (ATR): elbow flexion and extension
13	0	171450	-171450	1	Grasp reflex: finger flexion
14	0	0	0	0	Go back to patient and identify risk factors: high BW, breech presentation, shoulder dystocia, forceps delivery
15	0	0	0	0	Classification by Narakas (C5,6 / C5,6,7 / C5-T1 / C5-T1 + Horners)
16	0	0	0	0	Use Mallet score to monitor progress (1 active abduction, 2external rotation, 3 hand to head , 4 hand to back, 5 hand to mouth)
17	0	0	0	0	MRI to look for (pseudo-)meningocele
18	0	0	0	0	Treatment:
19	0	0	0	0	Daily stretching to maintain good ROM
20	0	0	0	0	If no antigravity biceps function return by 2 months (max 3 mth) → OT
21	0	0	0	0	Natural history
22	0	0	0	0	Gilbert Alain 1995 hands clinic
23	0	171450	-171450	1	Complete recovery if biceps and deltoid begin to contract at 1m and real contraction by 2m
24	0	171450	-171450	1	Good shoulder if begin at 3m and complete at 5m
25	0	171450	-171450	1	Bad shoulder if begin after 3m
26	0	0	0	0	Primary reconstruction:
27	0	171450	-171450	1	Root avulsion: nerve transfer (= neurotization)
28	0	171450	-171450	1	Lower lesion: nerve repair or nerve graft
29	0	0	0	0	Secondary reconstruction:
30	0	171450	-171450	1	Posterior dislocation
31	1	628650	-171450	2	Soft tissue: capsulorrhaphy
32	1	628650	-171450	2	Bony: humerus derotation osteotomy
33	0	171450	-171450	1	IR:
34	1	628650	-171450	2	Soft tissue: subscapularis release, Muscle transfer (LD and teres major to GT)
35	1	628650	-171450	2	Bony: Humerus derotation osteotomy
36	0	0	0	0	=============================
37	0	0	0	0	Obstetric brachial plexus injury
38	0	0	0	0	In general 90% spontaneous resolve
39	0	0	0	0	Favorable prognostic factors:
40	0	171450	-171450	1	Erb’s palsy
41	0	171450	-171450	1	+ve twitching (M1) over bicep and deltoid at 2mth old
42	0	0	0	0	Unfavorable factors:
43	0	171450	-171450	1	M0 at 3mth old
44	0	171450	-171450	1	Preganglionic injuries (Horner, involvement of dorsal scapular and phrenic nerve)
45	0	171450	-171450	1	Lower nerve root involvement (C5-7, klumpke)
46	0	0	0	0	Erb’s palsy:
47	0	0	0	0	Injury to upper trunk C56 results from excessive abduction of head away from shoulder, producing traction on plexus
48	0	0	0	0	Associated condition: glenoid retroversion + flattened and posteriorly subluxed humeral head (due to persistent shoulder IR), elbow contracture
49	0	None	None	0	C5 deficiency
50	0	171450	-171450	1	Axillary nerve deficiency (deltoid, teres minor)
51	0	171450	-171450	1	Suprascapular nerve deficiency (supraspinatus, infraspinatus)
52	0	171450	-171450	1	Musculocutaneous nerve deficiency (biceps)
53	0	None	None	0	C6 deficiency
54	0	171450	-171450	1	Radial nerve deficiency (brachioradialis, supinator)
55	0	171450	-171450	1	Sensation loss over lateral aspect of arm and forearm
56	0	0	0	0	Klumpke
57	0	0	0	0	Lower trunk C8/T1 injury
58	0	0	0	0	Difficult births, falls onto the outstretched arm
59	0	171450	-171450	1	Intrinsic minus
60	0	171450	-171450	1	Weak wrist and finger flexion
61	0	171450	-171450	1	Sensation loss over medial aspect of hand and forearm

#	semantic level	section?	rewritten line
1	0	yes	Clinical photograph
2	1		UL abnormal posture
3	1		Shoulder adducted, IR
4	1		Elbow extended
5	1		Wrist flexed
6	1		Forearm pronated
7	1		Fingers flexed
8	1		Thumb (not seen here) adducted
9	1		Typical of Erb’s palsy
10	1		Primitive reflex
11	1		Moro: Shoulder abduction
12	1		Asymmetrical tonic neck reflex (ATR): elbow flexion and extension
13	1		Grasp reflex: finger flexion
14	1		Go back to patient and identify risk factors: high BW, breech presentation, shoulder dystocia, forceps delivery
15	1		Classification by Narakas (C5,6 / C5,6,7 / C5-T1 / C5-T1 + Horners)
16	1		Use Mallet score to monitor progress (1 active abduction, 2external rotation, 3 hand to head , 4 hand to back, 5 hand to mouth)
17	1		MRI to look for (pseudo-)meningocele
18	0	yes	Treatment:
19	1		Daily stretching to maintain good ROM
20	1		If no antigravity biceps function return by 2 months (max 3 mth) → OT
21	0	yes	Natural history
22	1		Gilbert Alain 1995 hands clinic
23	1		Complete recovery if biceps and deltoid begin to contract at 1m and real contraction by 2m
24	1		Good shoulder if begin at 3m and complete at 5m
25	1		Bad shoulder if begin after 3m
26	0	yes	Primary reconstruction:
27	1		Root avulsion: nerve transfer (= neurotization)
28	1		Lower lesion: nerve repair or nerve graft
29	0	yes	Secondary reconstruction:
30	1		Posterior dislocation
31	2		Soft tissue: capsulorrhaphy
32	2		Bony: humerus derotation osteotomy
33	0	yes	IR:
34	2		Soft tissue: subscapularis release, Muscle transfer (LD and teres major to GT)
35	0		——
36	1		Obstetric brachial plexus injury
37	1		In general 90% spontaneous resolve
38	0	yes	Favorable prognostic factors:
39	1		Erb’s palsy
40	1		+ve twitching (M1) over bicep and deltoid at 2mth old
41	0	yes	Unfavorable factors:
42	1		M0 at 3mth old
43	1		Preganglionic injuries (Horner, involvement of dorsal scapular and phrenic nerve)
44	1		Lower nerve root involvement (C5-7, klumpke)
45	1		Injury to upper trunk C56 results from excessive abduction of head away from shoulder, producing traction on plexus
46	1		Associated condition: glenoid retroversion + flattened and posteriorly subluxed humeral head (due to persistent shoulder IR), elbow contracture
47	1		C5 deficiency
48	1		Axillary nerve deficiency (deltoid, teres minor)
49	1		Suprascapular nerve deficiency (supraspinatus, infraspinatus)
50	1		Musculocutaneous nerve deficiency (biceps)
51	1		C6 deficiency
52	1		Radial nerve deficiency (brachioradialis, supinator)
53	1		Sensation loss over lateral aspect of arm and forearm
54	1		Klumpke
55	1		Lower trunk C8/T1 injury
56	1		Difficult births, falls onto the outstretched arm
57	1		Intrinsic minus
58	1		Weak wrist and finger flexion
59	1		Sensation loss over medial aspect of hand and forearm

111. Obstetric brachial plexus palsy / Erb palsy

Clean FRCS notes with inline figures

Clinical photograph

Treatment:

Natural history

Primary reconstruction:

Secondary reconstruction:

IR:

Favorable prognostic factors:

Unfavorable factors:

Direct Q&A

UL abnormal posture

Daily stretching to maintain good ROM

Gilbert Alain 1995 hands clinic

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes