Q:

What is the position of the arm with an Erb's palsy?

A:

Erb's palsy (Waiter's tip):

Erb's palsy may result from a lesion of the upper trunk (C5-C6) of the brachial plexus.
Injury to roots C5 and C6 affects the
musculocutaneous (C5-C7), axillary (C5-
C6), median (C5-T1), and radial (C5-T1)
nerves.

The muscles affected in Erb's

palsy: the deltoid, rotator cuff, elbow
flexors, wrist and hand extensors.
Rotator cuff muscles: SItS
supraspinatus, infraspinatus, teres
minor, subscapularis

Arm flexor: Coracobrachialis

Elbow flexors: Biceps brachii,

brachialis

Wrist extensors: Extensor carpi radialis longus, extensor carpi radialis brevis,
extensor carpi ulnaris

The latissimus dorsi is innervated by the thoracodorsal (middle subscapular)

nerve, which is primarily derived from C7 and is NOT affected in Erb's palsy.
With the deltoid and rotator cuff muscles paralyzed due to injury of C5 and C6, the action of
latissimus dorsi on the shoulder (extension, adduction, medial rotation) is unopposed
resulting in the arm hanging by the side (adduction) with internal (medial)
rotation.

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Brachial Plexus

The brachial plexus and

the subclavian artery traverse the
posterior triangle of the neck and the
interscalene triangle.
The interscalene triangle is formed by
the 1st rib, scalenus anterior, and
scalenus medius.
Thoracic outlet syndrome (also
known as scalenus anticus syndrome) is a
neurologic and/or vascular impairment of
the upper limb due to narrowing of the
interscalene triangle and
consequent compression of the brachial plexus and subclavian artery.

The subclavius muscle protects

the brachial plexus and the
subclavian vessels from the sharped
end of a clavicle when fractured.
The clavicle is the most frequently
fractured bone in the body.
The subclavius muscle is innervated
by the nerve to the
subclavius, which is a branch from
the superior trunk of the brachial
plexus.
Use the mnemonic

Real Texans Drink Cold Beer to remember the proximal-to-distal organization of the
brachial plexus: Roots Trunks Divisions Cords Branches
5 Roots: ventral rami of C5, C6, C7, C8, T1
3 Trunks:
Superior (upper) trunk (C5, C6)

Middle trunk (C7)

Inferior (lower) trunk (C8,T1)

6 Divisions: There is an anterior and posterior division for each of the 3 trunks.
There are 3 Cords (named according to their anatomic relationship to the axillary artery):
Posterior cord Axillary nerve, radial nerve
 Lateral cord
Musculocutaneous nerve, part of
median nerve

Medial cord Ulnar nerve, part

of median nerve

There are 5 terminal Branches:

Musculocutaneous nerve

Axillary nerve

Radial nerve

Median nerve

Ulnar nerve

Erb's palsy (Waiter's tip):

Erb's palsy may result from a lesion of

the upper trunk (C5-C6) of the
brachial plexus.
Injury to roots C5 and C6 affects the
musculocutaneous (C5-C7), axillary (C5-
C6), median (C5-T1), and radial (C5-T1)
nerves.

The muscles affected in Erb's

palsy: the deltoid, rotator cuff, elbow
flexors,wrist and hand extensors.
Rotator cuff muscles: SItS
supraspinatus, infraspinatus, teres
minor, subscapularis
 Arm flexor: Coracobrachialis

Elbow flexors: Biceps brachii, brachialis

Wrist extensors: Extensor carpi radialis longus, extensor carpi radialis brevis,
extensor carpi ulnaris

The latissimus dorsi is innervated by the thoracodorsal (middle subscapular)

nerve, which is primarily derived from C7 and is NOT affected in Erb's palsy.
With the deltoid and rotator cuff muscles paralyzed due to injury of C5 and C6, the action of
latissimus dorsi on the shoulder (extension, adduction, medial rotation) is unopposed
resulting in the arm hanging by the side (adduction) with internal (medial)
rotation.
Klumpke's palsy:

Klumpke's palsy may result from a lesion of the lower trunk (C8-T1) of the brachial
plexus. It is an extremely rare injury and can be caused by a forceful combination of arm
traction and abduction during delivery.

Note: Although lower trunk lesions are typically presented as obstetrical complications,
adults may sustain the injury by grasping for a ledge when falling from height. Examples
include grasping for the top rung of a ladder when falling or grabbing a tree branch when
falling from above.
Affects the wrist flexors and the intrinsic muscles of the hand presenting as a claw hand:
Intrinsics: Hyperextension at MCP joint and flexion at DIP and PIP due to loss
of lumbricals and interossei

Thenar compartment: Deep head of flexor pollicis brevis

Adductor compartment: Adductor pollicis

Hypothenar compartment: Abductor digiti minimi, flexor digiti minimi

brevis, opponens digiti minimi

Flexors of hand at wrist: Flexor carpi ulnaris, flexor digitorum profundus

(medial half)

Note: Sources will vary on the precise presentation of Klumpke's palsy due to variable
degrees of median nerve damage.

Injury of C8-T1 may also involve the sympathetic trunk/ganglia and is called Horner's
syndrome:
Miosis

Anhidrosis

Ptosis
Winged scapula: A winged scapula is caused by a lesion of the long thoracic nerve.

Wall test: The patient stands facing wall with palms flat against the wall and pushes
forward; a positive test is winging of the scapula.
The serratus anterior is innervated by the long thoracic nerve, formed by ventral rami
of spinal nerves C5, C6, C7.
Actions of serratus anterior:
Protraction of scapula Anterior rotation of the scapula around the ribs
observed during a "punching" motion

Stabilization of scapula Holds scapula flat against posterior ribs

Upward rotation of scapula Shoulder abduction above the horizontal plane

when raising the arms above the head

Aid in inspiration during exercise

Lesion of the long thoracic nerve (eg, status post mastectomy with axillary lymph node
dissection) causes paralysis of serratus anterior:
Inability to raise the arms above the horizontal (90)

Medial winging of the scapula Inferior scapular angle is rotated medially and
lifted superiorly and away from the posterior thoracic wall, which may be
accentuated by having the patient push against a wall with flat palms (see image)

Compare:
Lesion of accessory nerve (CN XI) (eg, radical neck dissection) causes paralysis of trapezius:
Drooping of the shoulder

Lateral scapular winging Inferior scapular angle is rotated laterally and lifted
superiorly and away from the posterior thoracic wall, which may be accentuated
during resisted abduction.