KLUMPKES PALSY - OBSTETRIC BRACHIAL PLEXUS INJURY

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In 1885 Augusta Dejerine-Klumpke, a renowned neurologist and neuroanatomist diagnosed total brachial plexus radicular paralysis with oculopupillary involvement in a patient, a diagnosis published in Revue de Medecine. For this, she received the Godard Prize of the Academy of Medicine in 1886. Since then, this type of radicular palsy has been referred to as Klumpkes palsy.

Klumpkes palsy is a form of brachial plexus injury in which there is paralysis of the muscles of the forearm and hand due to an injury to the roots of the 8th cervical and the 1st thoracic nerve roots. Klumpke’s palsy is said to account for less than 1% of all brachial plexus palsies.

Risk factors associated with the development of Klumpke’s Palsy.

The same factors that cause Erb’s palsy could also result in Klumpke’s palsy and they are listed below:

      Maternal factors

        • Uterine abnormalities including fibroids, bicornuate uterus.
        • Diabetes mellitus – poorly controlled maternal diabetes mellitus has been known to be associated with fetal macrosomia, which could become complicated by shoulder dystocia resulting in an injury to the upper roots of the brachial plexus during delivery.
        • Maternal body proportions – passage of a baby through a small maternal pelvis could be traumatic enough to cause injury to the roots of the plexus.

      Foetal factors

        • Foetal macrosomia.
        • Presence of a cervical rib – a cervical rib is an extra rib that arises from the 7th cervical vertebra. It results in a thoracic outlet syndrome characterized by compression of the roots of the brachial plexus as well as the subclavian artery.
        • Transverse lie – The lie of a foetus is the relationship between the long axis of the foetus and the long axis of the maternal spine; a longitudinal lie is the most favorable for spontaneous vaginal delivery. A transverse lie at term could result in brachial plexus injury because it is often associated with difficult labor; obstetric manipulations performed in an effort to relieve this difficulty could result in an injury to the plexus.
        • Poor muscle tone.
        • A 5 minute APGAR score of less than 5.

      Intrapartum events

        • Mechanical forces of labour.
        • Vaginal breech delivery.
        • Prolonged labour.
        • Operative vaginal delivery.
        • Shoulder dystocia or clavicular fracture.
        • Precipitous delivery.
        • Prolonged head to body interval at delivery.

      Neonatal conditions after delivery

        • Neoplasm.
        • Infection.
        • Extrinsic compression and edema.

The neonatal conditions after delivery mentioned above could cause compression of or injury (in the case of an infection) to the roots of the brachial plexus.

All of the factors listed above can either cause Erb’s palsy or Klumpke’s palsy, the difference is that while Erb’s palsy results from injury to the upper roots of the brachial plexus (involving the 5th and 6th cervical nerve roots), Klumpke’s palsy is the result from injury to the lower roots of the brachial plexus (involving the 8th cervical and 1st thoracic nerve roots).

Clinical features

The clinical features of Klumpke’s palsy are summed up below:

    • Affected nerves – The affected nerves include the radial nerve, ulna nerve, the thoracodorsal nerve, median nerve and the medial pectoral nerve.
    • Sensory deficits – There is sensory deficit on the ulna side of the forearm and hand.
    • Patterns of muscle weakness – The following muscles are affected in Klumpke’s palsy:
        • Pronators of the forearm.
        • Flexors of the wrist joint.
        • Dilators of the iris and elevators of the eyelid (in case of associated Horner Syndrome).
    • Clinical presentation – The classic presentation of Klumpkes palsy is the “claw hand” where the forearm is supinated and the wrist and fingers are hyper extended. If Horner syndrome is present, there is miosis (constriction of the pupils) in the affected eye.
    • Associated defects – There is associated Horner syndrome if there is involvement of the cervical sympathetic chain. There is usually also a disparity in the length of the limbs; the affected limb is usually shorter than the unaffected.

Prognosis

Less than 50% of those affected with Klumpke’s palsy will spontaneously recover; the prognosis is worse if there is associated Horner syndrome.

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