Klumpke Palsy: Intrinsic Hand Splinting and Sensory Re-Education
In short
Lower trunk brachial plexus birth injuries (Klumpke palsy) paralyze intrinsic hand muscles, requiring early cock-up splinting and structured sensory retraining.
In this guide (6 sections)
Klumpke palsy (or Dejerine-Klumpke palsy) is a rare variant of neonatal brachial plexus birth injury resulting from traction or avulsion of the lower nerve roots, specifically C8 and T1 (and occasionally C7). Typically occurring during breech deliveries with hyperabduction of the infant arm above the head, Klumpke palsy spares proximal shoulder and elbow musculature while devastating the forearm flexors and intrinsic muscles of the hand (interossei, lumbricals, and thenar/hypothenar complexes). The pathognomonic clinical feature is the claw-hand deformity (main en griffe), characterised by hyperextension of the metacarpophalangeal (MCP) joints and flexion of the interphalangeal (IP) joints, accompanied by profound cutaneous sensory loss along the medial forearm and hand. Paediatric physiotherapy focuses on preventing fixed claw contractures through custom intrinsic-plus splinting and delivering aggressive sensory re-education to prevent self-mutilation.
Domestic and Cultural Indian Realities
Because the infant shoulder and elbow move normally in isolated Klumpke palsy, the condition is frequently overlooked in Indian maternity wards during initial newborn checks. Families only notice several weeks later that the baby hand remains limp, fingers clawed, and that the infant does not grasp fingers or toys. In many households, babies wear loose cotton mittens to prevent scratching their faces; these mittens conceal the paralyzed hand, allowing severe flexor contractures to develop unnoticed. Furthermore, because cutaneous sensation is completely absent along the little finger and ulnar palm, infants can easily suffer painless burns from hot tea cups or boiling bathing water without crying out. Paediatric physiotherapists must educate families on strict thermal protection and demonstrate daily hand inspections.
Clinical Biomechanics and Neurological Development
The intrinsic lumbrical and interosseous muscles of the hand perform the essential biomechanical function of flexing the MCP joints while extending the proximal and distal interphalangeal (PIP and DIP) joints. When C8 and T1 motor fibres are transected, the balance of power across the digits is lost. The long extrinsic finger extensors (extensor digitorum communis, innervated by the radial nerve C7) pull the MCP joints into unchecked hyperextension, while the long finger flexors pull the IP joints into flexion, collapsing the longitudinal and transverse arches of the palm. Over several months, the volar plates of the IP joints contract, fixing the claw deformity.
Clinical Assessment and Developmental Staging
Assessment involves evaluating the palmar grasp reflex, which is completely absent on the affected side. The Active Movement Scale (AMS) is scored for wrist flexion, finger flexion, and thumb opposition. Cutaneous sensory testing is performed using gentle cotton wool wisp touching and light pinprick to map dermatomal boundaries (C8 supplying the medial hand and little finger, T1 supplying the medial forearm). Horner syndrome (ipsilateral miosis, ptosis, and anhidrosis) is evaluated carefully, as sympathetic preganglionic fibres travel through the T1 ventral root; its presence confirms root avulsion rather than simple nerve stretching.
Targeted Rehabilitation and Mobility Exercises
Rehabilitation prioritizes custom thermoplastic splinting in the intrinsic-plus position: wrist in 20 to 30 degrees of extension, MCP joints flexed to 60 to 70 degrees, and IP joints fully extended. This maintains passive collateral ligament length and prevents fixed clawing. Sensory re-education incorporates textured tactile brushing, warm-cool contrasts, and hand-to-mouth exploration.
Passive Palmar Arch Expansion and Finger Extension Mobilization
Objective: Maintain passive interphalangeal joint extension and preserve palmar web space flexibility
- 1Seat yourself comfortably with the infant resting supine on your lap.
- 2Gently support the infant wrist in 20 degrees of extension with one hand.
- 3Place your other thumb across the dorsal surface of the infant metacarpal heads, gently flexing the MCP joints forward.
- 4Simultaneously, use your fingertips to gently and slowly straighten all curled interphalangeal finger joints.
- 5Hold the gentle open-hand stretch for 30 seconds; this ensures no pain or skin blanching occurs.
- 6Gently stroke the palm with varied textured fabrics (silk, soft cotton, velvet) to stimulate sensory receptors.
| Clinical Characteristic | Erb Palsy (Upper Trunk) | Klumpke Palsy (Lower Trunk) |
|---|---|---|
| Nerve Roots Involved | C5, C6 (and frequently C7 roots) | C8, T1 (and occasionally C7 roots) |
| Clinical Posture | Waiter tip posture: shoulder adducted/internally rotated, elbow extended | Claw hand (main en griffe): MCP hyperextended, IP flexed, wrist drop |
| Motor Deficits | Loss of shoulder abduction, external rotation, and elbow flexion; grasp intact | Loss of intrinsic hand muscles, wrist flexors, and finger flexors; grasp absent |
| Autonomic Signs | Horner syndrome is absent; intact sympathetic pathway | Horner syndrome frequently present (miosis, ptosis, anhidrosis from T1 injury) |
Red Flags and Immediate Specialist Escalation
Immediate escalation to a specialised paediatric brachial plexus neurosurgeon is mandatory upon diagnosis. Because isolated lower root injuries (C8-T1) carry a very high incidence of preganglionic nerve root avulsion from the spinal cord, spontaneous functional recovery is poor compared to upper trunk injuries. Early surgical exploration, nerve transfers (e.g., supinator motor branch to posterior interosseous nerve), or distal muscle transfers must be planned within the first three to six months of life.
Frequently Asked Questions
Why does an infant with Klumpke palsy need an intrinsic-plus splint?
Without an intrinsic-plus splint, the paralyzed fingers curl tightly into a claw hand and the joint capsules permanently freeze within weeks. The splint keeps the knuckles bent and fingers straight, preserving flexible joints so the hand can function once nerves heal.
How can parents protect a hand that has no sensation?
Parents must keep the infant fingernails trimmed short, check the hand frequently for scratches, protect the hand from extreme cold or hot water, and avoid tight wristbands that could restrict blood flow to insensate skin.
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