Klumpke Paralysis

Introduction[edit | edit source]

Klumpke paralysis is a neuropathy of the lower brachial plexus which may be resulted from a difficult delivery[1]. And was named after Augusta Dejerine-Klumpke.[2] Usually, 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 a more mild form of injury (neuropraxia) and often recover within 6 months. 

The main mechanism of injury is hyper-abduction traction and depending on the intensity, cause signs and symptoms consistent with a neurological insult.

According to the National Institute of Neural Disorders and Stroke (NINDS), there are four types of brachial plexus injuries that cause Klumpke’s :

  1. Avulsion, in which the nerve is severed from the spine.
  2. Rupture, in which tearing of the nerve occurs but not at the spine.
  3. Neuroma, in which the injured nerve has healed but can’t transmit nervous signals to the arm or hand muscles because scar tissue has formed and puts pressure on it.
  4. Neuropraxia or stretching, in which the nerve has suffered damage but is not torn.

Causes[edit | edit source]

Risk factors for Klumpke Paralysis are:

  1. large birth weight babies,
  2. maternal diabetes, 
  3. multiparity,
  4. difficult presentation,
  5. shoulder dystocia,
  6. forceps or vacuum delivery,
  7. breech position,
  8. prolonged labor,
  9. previous child with obstetric palsy,
  10. intrauterine torticollis.
  11. Less common includes tumors (neuromas, rhabdoid tumors), intrauterine compression, hemangioma and exostosis of the first rib in the child.

Signs and Symptoms[edit | edit source]

Main sign:

  • “Claw hand” is a classic presentation seen where the forearm is supinated and the wrist and fingers are flexed.

Other signs and symptoms include:

  1. weakness and loss of movement of the arm and hand. Some babies experience drooping of the eyelid on the opposite side of the face as well. This symptom may also be referred to as Horner's syndrome. [3]
  2. decrease of sensation along the medial aspect of the distal upper extremity along the C8 and T1 dermatome.
  3. myotome findings that can range from decreasing muscular strength to muscular atrophy and positional deformity.
  4. Reflexes in the affected roots are absent.
  5. associated injuries clavicular and humerus fractures, torticollis, cephalohematoma, and facial nerve palsy.
  • An infant with a nerve injury to the lower plexus (C8-T1) holds the arm supinated, with the elbow bent and the wrist extended.

Differential Diagnosis [2][edit | edit source]

  1. Erb's palsy; this injury affects the upper brachial plexus which will usually result in dermatome and myotome finds along the C5-C6 path[4],
  2. 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[5].
  3. 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[6].
  4. Apical lung tumor
  5. Neurofibroma
  6. Disc herniation
  7. Shoulder impingement
  8. Clavicular or vertebral fracture
  9. Other

Management[edit | edit source]

Treatment of Klumpke’s injury in babies and children is heavily dependent on the severity and the classification of the injury.

Immobilization[edit | edit source]

The affected arm may be immobilized across the body for 7 to 10 days. For mild cases, gentle massage of the arm and range-of-motion exercises may be recommended.

For torn nerves (avulsion and rupture injuries), symptoms may improve with surgery.   

Surgical Options[edit | edit source]

1. Surgery on the nerves (e.g., nerve grafts and neuroma excision).

2. Tendon transfers to help the muscles that are affected by nerve damage work better.

3. Muscle transfer, in which a less important muscle or tendon is removed from another part of the body and attached to the injured arm if the muscles there deteriorate

Physiotherapy Management[edit | edit source]

Physical therapy assists in keeping the muscles and joints’ range of motion normal. Physical therapy also keeps muscles and joints to work properly and prevents stiffness in joints such as the shoulder, elbow, or wrist. 

Physiotherapy majorly focuses on[7] :

  1. improving flexibility,
  2. range of motion,
  3. strength, and
  4. dexterity
  5. 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[8]

The video below shows the treatments of an infant with Klumpke Paralysis


References:[edit | edit source]

  1. Ulgen BO, Brumblay H, Yang LJ, Doyle SM, Chung KC. AUGUSTA DÉJERINE-KLUMPKE, MD (1859–1927) A HISTORICAL PERSPECTIVE ON KLUMPKE'S PALSY. Neurosurgery. 2008 Aug 1;63(2):359-67.
  2. 2.0 2.1 Merryman J, Varacallo M. Klumpke Palsy. InStatPearls [Internet] 2022 Feb 12. StatPearls Publishing. [1]
  3. Ruchelsman DE, Pettrone S, Price AE, Grossman JA. Brachial plexus birth palsy. Bull NYU Hosp Jt Dis. 2009 Jan 1;67:83-9.
  4. Jennett RJ, Tarby TJ, Krauss RL. Erb's palsy contrasted with Klumpke's and total palsy: different mechanisms are involved. American journal of obstetrics and gynecology. 2002 Jun 1;186(6):1216-20.
  5. Dy CJ, Mackinnon SE. Ulnar neuropathy: evaluation and management. Current Reviews in Musculoskeletal Medicine. 2016 Jun 1;9(2):178-84.
  6. Freischlag J, Orion K. Understanding thoracic outlet syndrome. Scientifica. 2014 Jul 20;2014.
  7. Smania N, Berto G, La Marchina E, Melotti C, Midiri A, Roncari L, Zenorini A, Ianes P, Picelli A, Waldner A, Faccioli S. Rehabilitation of brachial plexus injuries in adults and children. Eur J Phys Rehabil Med. 2012 Sep 1;48(3):483-506.
  8. Palomo R, Sánchez R. Physiotherapy applied to the upper extremity in 0 to 10-year-old children with obstetric brachial palsy: a systematic review. Revista de Neurologia. 2020 Jul 1;71(1):1-0.
  9. Erb's Palsy with love. Available from: https://www.youtube.com/watch?v=V3KxSsZp_6c (last accessed 13.3.2019)