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Flail arm syndrome or VulpianBernhart’s form of amyotrophic lateral sclerosis
  1. Servicio de Neurologia, Hospital Gral Universitari Vall d‘Hebron, Passeig Vall d‘ Hebron 119–135, 08035 Barcelona, Spain
  1. Dr Josep Gamez, Servicio de Neurologia, Hospital Gral Universitari Vall d‘Hebron, Passeig Vall d‘ Hebron 119–135, 08035 Barcelona, Spain. email 12784jgc{at}

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We read with interest the article by Hu et al 1 concerning flail arm syndrome, a distinctive variant of amyotrophic lateral sclerosis. The authors presented a subgroup of patients affected by amyotrophic lateral sclerosis that predominantly showed signs of lower motor neuron disease in the upper limbs without significant functional involvement of other regions upon clinical presentation. This subgroup of patients is clinically characterised by the display of progressive atrophy and weakness in the arms with little effect on the bulbar muscles or legs. Atrophy and loss of strength affect the upper limb muscles in a more or less symmetric manner, prevalent in the proximal muscles. The comparative study with the rest of the amyotrophic lateral sclerosis group supplies very interesting details for the physician, such as a clear predominance among men, and a longer median survival. They conclude by suggesting that this syndrome could be a new variant of amyotrophic lateral sclerosis.

Finally, the authors carry out a historical review and refer to the fact that this distinctive amyotrophic lateral sclerosis variant was probably first described by Gowers in 1888, furnished with exquisite graphic illustrations.

To this effect, we draw attention to prior descriptions of the same syndrome, reported by Vulpian2 in 1886, known in Franco-German literature as Vulpian-Bernhardt’s form.

In his book Maladies du Système NerveuxVulpian described a patient who showed signs of weakness and symmetric proximal atrophy of neurogenic origin, and called it chronic anterior poliomyelitis. The patient showed symptoms of proximal amyotrophy, and signs of denervation and upper motor neuron involvement. Since then, in those countries and other countries under their influence,3 4 we have come to use the eponym of Vulpian-Bernhardt’s syndrome to describe those forms of amyotrophic lateral sclerosis with more or less symmetric involvement of the proximal muscles of the upper limbs at the clinical onset.

A certain enigma exists surrounding the characteristic distribution of weakness and muscle atrophy. The reason for the prevalence in the proximal muscles of the upper limbs is unknown. We can furnish little more information in this respect. However, in the 1960s, in the differential diagnosis of this syndrome, it was proposed that the muscles predominantly affected in Vulpian-Bernhardt’s form were the deltoideus, the infraespinatus, the supraespinatus, the sternocleidomastoideus, and the teres minor. The predominant involvement in these muscles permitted its distinction from that previously called Erb’s dystrophy.5

As a consequence of the atrophy of these muscles, the upper limbs adopt a characteristic position, with the shoulders slumped, and the arms, forearms, and hands in pronation.

As the illness progresses, the hand muscles are affected, with atrophy of the following muscles: opponens pollicis, flexor brevis, abductor pollicis brevis, adductor pollicis, interossii, and lumbricales, which leads to the formation of the characteristic Aran-Duchenne hand.

Obviously, signs of corticospinal involvement with hyperreflexia in the lower limbs and Babinski’s sign both appear. In the initial stages of the illness, there is no effect on the diaphragm. The presence of signs of involvement of the upper motor neuron, its different clinical evolution, and the data supplied by genetic molecular investigation allow us to distinguish the syndrome previously known as Vulpian-Bernhardt and now rebaptised as flail arm syndrome from other motor neuron syndromes such as of the spinal muscular atrophies, Kennedy’s disease, multifocal motor neuropathy, and monomelic amyotrophy.


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