Klumpke’s paralysis

Klumpke paralysis is a neuropathy of the lower brachial plexus which may be resulted from a difficult delivery^].

The eighth cervical and first thoracic nerves are injured either before or after they have joined to form the lower trunk. This injury can cause a stretching (neuropraxia,), tearing (called “avulsion” when the tear is at the spine, and “rupture” when it is not), or scarring (neuroma) of the brachial plexus nerves.

Most infants with Klumpke paralysis have the more mild form of injury (neuropraxia) and often recover within 6 months. 

Hyper-abduction traction depending on the intensity ,cause sins and symptoms conistent with the neurological insult.

Klumpke’s palsy symptoms include:

• Atrophy in the muscles of the forearm or hand
• “Claw hand,” a severe symptom in which the forearm lies flat but the wrist and fingers are tightened
• Horner’s syndrome – drooping of the eyelid on one side of the face
• Inability to use the muscles of the affected arm and/or hand
• Limp or paralyzed arm
• Numbness of the affected arm and/or hand
• Pain, sometimes severe
• Stiff joints in the wrist and hand
• Weakness of the affected arm and/or hand

Klumpke’s palsy can be caused by a difficult childbirth. It usually occurs during vaginal deliveries, especially in cases where the mother is small and the baby has a large birth weight. Large birth weight in a baby can occur due to poorly managed maternal diabetes or gestational diabetes. This birth injury sometimes occurs when the baby is pulled from the birth canal by an extended arm above the baby’s head. If done too roughly, this can injure the lower brachial plexus. Injuries are similar to those that occur in Erb’s palsy.

 Klumpke’s palsy can also be caused by tumors in the area of the upper lung and collarbone which compress or stretch the nerves to the arm. It can also be caused by trauma to the arm and shoulder, such as force to the arm or shoulder when catching oneself during a fall.

• Breech birth: Babies born feet-first are at a slightly higher risk of Klumpke’s palsy because their arms may be raised and more easily injured from excess pressure.
• Gestational diabetes: If blood sugar is not well-managed, babies may be born larger, making delivery more difficult.
• Improper delivery/ use of birthing tools: During a complicated delivery, a baby may be pulled quickly and forcibly from the birth canal, causing injury to the neck and shoulder.
• Large infant/small maternal size: Delivery may be more difficult if the infant is larger than normal or the mother is particularly petite.
• Second stage of labor lasting over an hour: A long-lasting “pushing” stage may put an infant at a greater risk of Klumpke’s palsy and other brachial plexus injuries.
• Injury: Trauma to the arm or shoulder can cause Klumpke’s palsy.
• Cancer: A history of cancer or risk factors for cancer can increase the risk of Klumpke’s palsy.

• Erb's palsy; this injury affects the upper brachial plexus which will usually result in dermatome and myotome finds along the C5-C6 path
• Distal nerve entrapment of the ulnar nerve at either the medial epicondyle of Guyon's tunnel- produces similar neurological findings as the more proximal Klumpke's. But there is no involvement of innervation proximal to the lesion, for example, pectoralis major involvement with true ulnar nerve entrapment
• Thoracic outlet syndrome : TOS is a compression injury to the brachial plexus from a rudimentary rib, first rib, or the clavicle on the ipsilateral side, this could be post-traumatic, postural driven, and or genetic.It affects more than C8- T1 roots.
• Apical lung tumor
• Neurofibroma
• Disc herniation
• Shoulder impingement
• Clavicular or vertebral fracture
• Other

The risk of Klumpke’s palsy can be minimized by:

Advanced planning: If the baby is larger than usual or in the incorrect position in the weeks leading up to the due date, advanced planning by the obstetrician to prevent Klumpke’s palsy should include insuring qualified personnel are present in the delivery room, proper use of birthing instruments and extractors, and induction of labor or Cesarean delivery if several risk factors are identified.

Maternal healthcare: Good maternal healthcare during pregnancy, including avoidance or control of diabetes, can help prevent Klumpke’s palsy.

In most cases, a baby will recover from Klumpke’s palsy within six months. In more severe cases, in which there is tearing of the nerve(s) – especially away from the spine – symptoms may last for years or children may experience lifelong disabilities of the arm, hand or fingers.

Treatment of Klumpke’s palsy may include:

Non-Surgical Treatments

• Physical therapy: Daily physical therapy is effective in treating mild Klumpke’s palsy. Your physician or physical therapist will show you which therapeutic and range-of-motion exercises you must perform to promote healing and prevent joint stiffening in the elbow, wrist and hand.
• improving flexibility,
• range of motion,
• strength, and
• dexterity
• Pain control

Systematic review indicated that physiotherapy interventions like constraint-induced movement therapy, kinesiotape, electrotherapy, virtual reality and use of splints or orthotics have positive outcomes for the affected upper limb functionality in obstetric brachial palsy from 0 to 10 years

• Medications: Klumpke’s palsy often causes pain or a burning sensation. Physicians often prescribe medications to relieve this mild Klumpe's palsy pain, including topical ointments and prescription medications.    

Surgical Procedures
If physical therapy doesn’t show promising results after three to six months, your physician may recommend surgery to repair injury to the affected nerves. This may include:

• Muscle transfer: A less important muscle or tendon can be removed from another part of the body and attached to the affected arm if the muscles there deteriorate.
• Nerve graft: Some nerve ruptures can be repaired by splicing a “donor” nerve graft from a separate nerve.
• Nerve transfer: In some cases, a surgeon can transfer a nerve from a different muscle to restore function in the nerve.    
• Recovery: Because nerves recover very slowly, it may take months to years for nerves repaired at the neck to reach the muscles of the lower arm and hand. After surgery, you will need to perform rehabilitation exercises at home to improve your baby’s strength and range of motion.