Upper Limb Palsies

Question 1

Erg-Duchenne Palsy

Answer 1

Erb-Duchenne palsy (‘waiter’s tip’)
due to damage of the upper trunk of the brachial plexus (C5,C6)
may be secondary to shoulder dystocia during birth
the arm hangs by the side and is internally rotated, elbow extended

Herb the waiter

Question 2

Klumpke Injury

Answer 2

Klumpke injury
due to damage of the lower trunk of the brachial plexus (C8, T1)
as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward jerk of the hand
IF T1 involvement > associated with Horner’s syndrome

Sx:

• paralysis of intrinsic hand muscles, flexors of wrist and fingers
• C8/T1 dermatome distribution numbness
• Presentation = CLAW HAND
• Weakness or lack of ability to use specific muscles of shoulder or arm

Klumpke Klaw

Question 3

Carpal Tunnel Syndrome - Causes

Answer 3

Caused by compression of median nerve in carpal tunnel!

• Idiopathic
• Pregnancy
• Oedema e.g. Heart Failure
• Lunate Fracture
• RA
• Acromegaly

Question 4

Carpal Tunnel Syndrome - Ix and Mx

Answer 4

Ix - Electrophysiology: Motor and sensory prolongation of action potential

Mx:

• Corticosteroid injection
• Wrist splints at night
• Surgical decompression (division of flexor retinaculum)

Question 5

Carpal Tunnel Syndrome - Examination Findings

Answer 5

Weakness of THUMB ABDUCTION (abductor policies brevis)

Wasting of THENAR EMINENCE (Not Hypothenar)

Tinel’s Sign = Tapping causes paraesthesia

Phalen’s Sign = Flexion of wrist causes Sx

Question 6

Carpal Tunnel Syndrome - Typical Sx in Hx

Answer 6

• pain, ‘pins and needles’ in THUMB, INDEX and MIDDLE finger
• Pt’s Sx may ascend proximally
• Pt shakes hand to obtain Symptomatic relief, classically at night

Question 7

Brachial Plexus Injury - Example Question

Answer 7

A 78-year-old man is admitted following being found on the floor at home. He has no recollection of how he got to floor or how long he had been there. He reports feeling generally unwell and having a cough for a number of days. There is no medical history of note and he takes no regular medications. He lives alone and appears unkempt. Examination reveals bronchial breathing throughout his left mid zone. Neurologically, he has new onset weakness of left sided shoulder abduction and adduction, alongside mild weakness in left elbow flexion. Additionally, reduced sensation in the lateral aspect of his upper arm is noted. A CT head is undertaken.

CT head report Age related involutional change. No evidence of intracranial haemorrhage or recent ischaemic event.

What is the most likely diagnosis?

	Stroke
	Rotator cuff tear
	> Brachial plexus injury
	Brown-Sequard syndrome
	Botulism

Given the pattern of neurological signs in his left limb, this would not fit with a stroke. Global weakness and sensory loss would be expected in the affected limb.

A rotator cuff tear is possible given the likely trauma. However, sensory loss would not be expected.

Brown-Sequard syndrome is caused by damage to half of the spinal cord. It produces ipsilateral paralysis and proprioception loss, and contralateral temperature and pain loss.

Botulism classically presents with cranial nerve deficits, followed by a descending weakness and autonomic dysfunction.

A brachial plexus injury may be sustained following trauma, as in this case. The level of injury will correlate with the signs. In this patient, it is at C5, causing the specific distribution of weakness and sensory loss.