Erb-Duchenne Palsy: Upper Limb Posture, Nerve Injury, and Management

Erb-Duchenne palsy (C5–C6 brachial plexus upper trunk injury) produces a characteristic upper limb posture due to selective muscle paralysis.

Classic “Waiter’s Tip” Posture

• Shoulder: Adducted, internally rotated (loss of supraspinatus, infraspinatus, deltoid).
• Elbow: Extended (loss of biceps, brachialis).
• Forearm: Pronated (loss of biceps supination; pronator teres C6–C7 intact).
• Wrist/Fingers: Flexed (unopposed wrist/finger flexors C7–C8/T1).

Etiology

• Birth trauma: Lateral neck traction during shoulder dystocia (most common).
• Adults: Motorcycle traction injuries, falls on lateral neck, surgical stretch (e.g., thyroidectomy).

Severity Spectrum

• Neurapraxia (conduction block): Recovery in weeks–months (most common in neonates).
• Axonotmesis: Axon disruption, intact endoneurium; regeneration 1 mm/day.
• Neurotmesis/avulsion: Root torn from cord; no spontaneous recovery; requires surgery.

Management

• Neonates: Gentle ROM exercises, splinting (avoid contracture), parent education. 70–90% recover by 3–6 months.
• No recovery by 3–6 months: EMG/NCS, MRI myelography → surgical exploration (neurolysis, nerve grafts, nerve transfers: spinal accessory → suprascapular, Oberlin transfer).
• Adults: Early exploration if avulsion suspected; tendon transfers (e.g., latissimus dorsi → biceps) for late reconstruction.

Multidisciplinary Team

Neurosurgery, orthopedics, PM&R, OT/PT, electrodiagnostics. Early referral to brachial plexus center optimizes outcomes.