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Figure 4.63. Erb's palsy (upper brachial plexus injury) occurs as a result of traction on the brachial plexus (most often the upper nerve roots, C3, C4, and C5). This type of injury occurs most commonly in cases of shoulder dystocia. It presents with the infant lying with the affected upper extremity adducted and internally rotated, the elbow extended, and the hand partially closed with the palm directed outwards and posteriorly resulting in the typical "waiter's tip" position. The majority of these injuries resolve spontaneously in 3 to 4 weeks.

Figure 4.64. Bilateral involvement of the upper brachial plexus resulting in the typical position in both upper extremities. In the rare event of a bilateral palsy the possibility of damage to the spinal cord has to be considered. Note that infants with Erb's palsy may lack a Moro response on the affected side.

Figure 4.65. Anteroposterior and lateral radiograph of the chest in an infant widi a right Erb's palsy. Note die ipsilateral paralysis of the right diaphragm due to phrenic nerve palsy which may occur in association widi upper motor brachial plexus trauma. A rare complication associated widi Erb's palsy is a Horner's syndrome on the same side, due to involvement of die cervical sympathetic nerves. If Horner's syndrome persists, the infant may develop heterochromia iridis caused by failure of development of secondary pigmentation in the affected eye.

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