Functional outcome of MOD QUAD procedure in a child with right sided Erb’s Palsy (Right Upper Limb)

Sharmila¹, Anbarasi²

¹Staff Nurse Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu

²Nurse Educator, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu

Introduction

Erb’s palsy is a form of obstetric brachial plexus injury that commonly affects the upper roots (C5–C6) of the brachial plexus. It results in weakness or paralysis of muscles responsible for shoulder abduction, external rotation, and elbow flexion. Although many cases improve with conservative management in infancy, some children develop persistent functional limitations that require surgical intervention. This case study highlights the assessment, management, and outcome of a 9‑year‑old female child with right upper limb Erb’s palsy planned for a MOD QUAD (Modified Quad) surgical procedure.

*Source: Christopher & Dana Reeve Foundation. Branchial Plexus Injury

Definition

Erb’s palsy is a neurological condition caused by injury to the upper brachial plexus nerves (C5–C6), leading to weakness of the shoulder and arm muscles. It is most often associated with birth trauma and presents with characteristic motor and sensory deficits of the affected upper limb.

Case Presentation

A 9‑year‑old female child was admitted on 02/12/25 with complaints of restricted movements of the right upper limb. The child was diagnosed with Erb’s palsy – Right Upper Limb (RUL). She was planned for a MOD QUAD procedure on the same day for functional improvement.

Demographic and Admission Details

Age: 9 years
Sex: Female
Date of admission: 02/12/25
Date of surgery: 02/12/25
Allergies: No known allergies
Consultant: Dr. Balamurali G

Birth History

Prenatal history: Normal
Perinatal history: Normal vaginal delivery
Neonatal history: Normal

Clinical Presentation (Signs and Symptoms)

Restricted right shoulder abduction and extension
Restricted shoulder rotation
Restricted elbow extension
Restricted wrist extension
Difficulty in functional use of the right upper limb during daily activities

Examination Findings

General Examination

Child conscious, oriented, and cooperative
Vital signs within normal limits
Local Examination of Right Upper Limb

Inspection

Abnormal resting posture of the right arm
Mild muscle wasting around the shoulder girdle
Shoulder asymmetry compared to the left side

Range of Motion (ROM)

Shoulder: Limited abduction, extension, and external rotation
Elbow: Restricted extension
Wrist: Restricted extension
Muscle Power (MRC Scale):
Deltoid: Reduced power
Biceps: Reduced power
Triceps: Reduced power
Wrist extensors: Weak

Sensory Examination

Reduced sensation in C5–C6 dermatome (outer arm and thumb region)

Reflexes

Diminished biceps reflex
Reduced supinator reflex

Pathology

Erb’s palsy occurs due to traction or stretching injury to the upper brachial plexus (C5–C6 nerve roots). This leads to denervation of muscles supplied by these nerves, causing muscle weakness, imbalance, and secondary joint deformities over time. Chronic cases may develop contractures and abnormal shoulder alignment if not corrected early.

Medical and Surgical Management

Medical Management

Early physiotherapy and occupational therapy
Range of motion exercises to prevent contractures
Strengthening exercises for residual muscle function
Pain management as required

Surgical Management

Due to persistent functional limitation and muscle imbalance, the child was planned for a MOD QUAD procedure, which aims to:

Release contracted muscles
Restore muscle balance around the shoulder
Improve shoulder abduction and external rotation
Enhance overall functional use of the limb

Nursing Management

Pre‑operative preparation and counselling of child and parents
Monitoring vital signs and neurological status
Pain assessment and administration of prescribed analgesics
Post‑operative limb positioning and immobilization as advised
Assistance with physiotherapy exercises
Education of parents regarding home‑based exercises and follow‑up care
Emotional support to child and family

Outcomes

Improved shoulder alignment
Gradual improvement in range of motion
Enhanced functional ability of the right upper limb
Prevention of further deformity

Patient and Family Satisfaction

The patient’s parents expressed satisfaction with the clarity of explanation provided regarding the condition, surgical plan, and expected outcomes. Post‑intervention improvements in limb movement and function increased confidence and adherence to rehabilitation.

Evaluation

Regular post‑operative follow‑up
Assessment of range of motion and muscle strength
Monitoring functional improvement in daily activities
Evaluation of compliance with physiotherapy program

Conclusion

This case highlights the importance of thorough clinical assessment and timely surgical intervention in children with persistent Erb’s palsy. A multidisciplinary approach involving surgeons, nurses, and physiotherapists plays a crucial role in improving functional outcomes and quality of life for affected children.

Evidence

Only by physical examination and it was ruled out by paediatric consultant.

References

Somashekar D, et al. Management of Obstetric Brachial Plexus Injury. Journal of Pediatric Orthopaedics.
Hoeksma AF, et al. Prognosis of Obstetric Brachial Plexus Injuries. Developmental Medicine & Child Neurology.
Waters PM. Surgical Treatment of Brachial Plexus Birth Injuries. Journal of Hand Surgery.

Functional outcome of MOD QUAD procedure in a child with right sided Erb’s Palsy (Right Upper Limb)

Functional outcome of MOD QUAD procedure in a child with right sided Erb’s Palsy (Right Upper Limb)

Sharmila1, Anbarasi2

Nightingale Journals

Sharmila¹, Anbarasi²