Roots Trunks Divisions
Headless arrow towards RightHeadless arrow towards LeftAdd wAdd XAdd Y
Upper Subscapular Thoracodorsal Lower Subscapular
Medial Brachial Cutaneous
Medial Antebrachial Cutaneous
LLM "Lucy Loves Me"
MMMUM "Most Medical Men Use Morphine"
BRANCHES OF ROOTS
DORSAL SCAPULAR NERVE
Root value- C5
Supply – Rhomboid major &
The region of the Upper trunk of the brachial plexus
is called Erb’s Point.
Brachial Plexus (BRAY-key-el PLEK-sis)
1874 Wilhelm H. Erb described brachial plexus
paralysis in adults which involved the upper roots and
described certain types of “delivery paralysis”
Otherwise Known as Erb’s Palsy
1885 Augusta Klumpke first described the clinical
picture resulting from injury to lower roots
( Klumpke’s Palsy ).
A brachial plexus injury (Erb’s palsy) is a nerve
The nerves that are damaged control muscles in
the shoulder, arm, or hand and any or all of these
muscles may be paralyzed.
One or two of every 1,000 babies have this
condition. It is often caused when an infant's neck
is stretched to the side during a difficult delivery.
Undue separation of the head from shoulder
- Birth Injury (Shoulder Dytocia)
-Vaccum Extractor Delivery
-Cephalic presentation of large birth weight
infant (> 4 kgs)
-Previous child with BPI
-Prolonged maternal labour (> 60 minutes
during second stage)
-Intrauterine torticollis and Intrauterine malposition
Falling on Shoulder
o Excessive Stretching
o Direct Blow
o Shoulder Dislocation
o Tumour (Neuroma)
o Cervical Rib
1. Upper Root Injury (Erb’s palsy or Erb-Duchenne
C5/C6 with or without C7 involved
Most common (73% to 86%)
If C7 involved, wrist flexed and fingers curled up in
“waiter’s tip “ position
If C4 involved, diaphragm paralysed.
Moro reflex: shoulder movement (-), Biceps (-); hand
movement (+); Grasp (+)
If C5/C6 injury, 90% full recovery by 3 months.
With C5/C6/C7- 65% full recovery.
2 . Lower root injury (Klumpke’s palsy)
C8/T1 with or without C7 are injured.
Isolated lower root injury least common (0.6 to 2%).
Forearm is supinated, wrist and fingers hyperextended
with good elbow and shoulder function.
Horner’s syndrome with ptosis and miosis if associated
cervical sympathetic nerve injury.
Moro reflex: Shoulder movement(+), hand movement(-
); Grasp reflex(-).
Recovery < 50%, minimal if Horner’s syndrome
3 . Complete Injury (Erb-Klumpke Palsy)
All nerve roots from C5 to T1 involved.
2nd most common (20%).
On examination arm is flail and paralysed with total
sensory and motor deficit with or without miosis and
All reflexes are absent.
Outcome: Without associated Horner’s syndrome
<50% recovery, with associated Horner’s syndrome no
recovery without surgery
However a commonly used one is
Leffert's classification system
which is based on etiology and level of injury:
I Open (usually from stabbing)
II Closed (usually from motorcycle accident)
IIa Supraclavicular ( Preganglionic/Postgangionic )
III Radiation induced
IVa Erb's (upper root)
IVb Klumpke (lower root)
1. Abduction & Lateral Rotation of the arm
2. Flexion & Supination of the forearm
3. Biceps & Supinator jerks are lost
4. Sensation are lost over a small area over the
lower part of the deltoid
WAITER’S / POLICEMAN’S TIP POSITION
Characteristic Position - Adduction & Internal
Rotation of the arm with forearm pronated
Forearm extension normal
Biceps reflex absent
This deformity is known as
Policeman’s tips hand or
Porter’s tip hand
Site of Injury
Lower Trunk of the Brachial Plexus
Nerve Root Involved
Mainly C8 and T1
Intrinsic Muscles of the hand(T1)
Ulnar Flexors of the wrist and Fingers(C8)
MCP Joint -Hyperextended
IP Joint - Flexion
Cutaneous Anaesthesia & Analgesia in a narrow zone
along the ulnar border of the forearm and Hand
Horner’s Syndrome : If the sympathetic fibers of the
1st thoracic root are also injured paralyzed hand
and ipsilateral ptosis and miosis.
• Increase in angle between neck &
•Traction (stretching or avulsion) of
upper Ventral Rami (e.g., C5,C6)
UBP Injury – Erb’s Palsy LBP Injury – Klumpke’s Palsy
• Excessive upward pull of limb
• Traction (stretching or avulsion) of
lower ventral rami (e.g., C8, T1)
Relies mainly on clinical examination
No specific lab. Studies
Nerve conduction studies
a. The main aspect of medical management is
b. Often treated in a similar way to neuropathic
pain with NSAID,
c. Tricyclic Antidepressants,
e. Oral or transdermal opoids.
a. Nerve transfers
b. Nerve grafting
c. Muscle transfers
d. Free muscle transfers Neurolysis of scar
around the brachial plexus in incomplete
e. Arthrodesis to stabilise joints
Splinting – To Prevent Contracture
o Pain control - TENS
o Maintaining ROM - Passive movements,
o Strengthen affected muscles –
oManaging chronic oedema –
Advice, Massage therapy
Position of Patient
Child- Sitting Position with arm Slightly abducted
and forearm supinated
Infants – On the mothers loop , resting on pillow
Placement of electrode
Child – Inactive : Over the nape of neck
Active : over the motor points