Klumpke Palsy

Klumpke palsy is lower brachial plexus birth injury, with damage to the C8 and T1 roots, causing weakness of the intrinsic muscles of the hand and the wrist and finger flexors. It is very uncommon as an isolated lesion at birth.

It makes up well under 1% of brachial plexus birth injuries, and is more often seen as part of total palsy (C5 to T1). Isolated lower palsy has a worse prognosis than upper palsy, particularly when Horner syndrome is present.

Risk factors are traction on the arm during breech delivery or shoulder dystocia, with the arm raised over the head.

Pathophysiology.

Excess upward traction on the abducted arm stretches the lower roots, which are tethered at the intervertebral foramina, causing avulsion of C8 and T1. The sympathetic fibres leave the cord at T1, so avulsion damages the sympathetic chain and causes Horner syndrome.

Loss of the intrinsic hand muscles with unopposed long extensors causes a claw hand, and sensory loss affects the ulnar border of the hand and forearm.

• Weak or absent grasp and finger flexion, with a flaccid hand, and shoulder and elbow movements that are relatively preserved.
• Claw hand or flexed fingers, loss of sensation on the ulnar side and absent palmar grasp reflex.
• Ipsilateral Horner syndrome: ptosis, miosis, enophthalmos and anhidrosis, and sometimes lighter iris colour.

Red flags.

• Horner syndrome, indicating root avulsion and poor prognosis.
• Total palsy with a flail arm.
• Respiratory difficulty with phrenic nerve involvement.

• Clinical examination of hand and wrist movement at birth, 1 month and 3 months, with pupil and eyelid examination.
• Chest X-ray, and imaging of clavicle, humerus and cervical spine to exclude associated fractures.
• MRI myelography and nerve conduction studies or electromyography for avulsion, when surgery is considered.

Differential diagnosis. Erb palsy and total brachial plexus palsy, fractures of the humerus or forearm, cervical spinal cord injury, congenital hand anomalies and Volkmann ischaemic contracture.

• Early hand therapy, splinting of the wrist and fingers to prevent contracture, and passive range of movement exercises taught to the parents.
• Refer by 4 to 6 weeks to a specialist brachial plexus clinic. Early surgery (nerve grafting or transfer) is considered for avulsion, usually before 6 months of age, with outcomes for the hand less certain than for the shoulder.
• Secondary surgery for fixed deformity (tendon transfer, release or arthrodesis), and ophthalmology review for Horner syndrome.

Monitoring. Hand function, sensation and growth of the limb. Review of pupil size and iris colour.

Referral and escalation. Refer urgently to a brachial plexus surgical service for any infant with a flail hand or Horner syndrome.