Erb’s Palsy

There are several different kinds of birth injuries that can cause harm to a baby. Some infants experience mild brain injuries that result in attention deficit hyperactivity disorder (ADHD) or a more severe disability such as cerebral palsy.

Other birth injuries include a myriad of physical problems that range from something as small as a bruise or a minor laceration to more severe health issues, such as full paralysis.

Erb’s palsy is an adverse condition caused by a physical injury during delivery, and its negative effects can range from mild to serious, depending upon the severity of the injury.

Erb's Palsy: Birth Injury Guide

 

What is Erb’s Palsy?

Erb’s palsy, a form of obstetric brachial plexus disorder, is an injury that occurs when the nerves in a baby’s upper arm are damaged. It typically affects one or two of every 1,000 babies. The injury usually occurs as a result of a lesion at Erb’s point, the area near the baby’s neck where the fifth and sixth cranial nerves merge to create the upper point of the brachial plexus.

The nerves in the brachial plexus give movement and feeling to the baby’s arm, hand, and fingers. Erb’s palsy is frequently caused by shoulder dystocia during a difficult birth. Infants with this condition usually can’t move the affected shoulder or upper arm, but they may be able to wiggle their fingers.

Sometimes the injury can affect the whole trunk, and usually it affects the spinal cord’s ability to send messages to the arm, wrist, hand, or fingers through normal nerve impulses. Babies with Erb’s palsy often look as if their arm in the affected area is paralyzed.

Erb’s palsy refers only to brachial plexus damage to the upper nerves. If nerves on both the upper and lower ends of the brachial plexus are stretched and injured, the result can lead to a more severe condition known as total or global brachial plexus palsy.

Types of Nerve Injuries

There are four types of nerve injuries. They can all occur simultaneously and share the same symptoms of lost tactile feeling and paralysis, no matter which type of nerve injury occurs. The level of severity is the major factor that determines what treatment options are chosen and how well an infant recovers from the injury.

Neurapraxia is the most common type of neural injury. It occurs when a nerve is stretched but doesn’t tear. Neurapraxia manifests as a shocking or burning sensation that shoots up and down the affected nerve. Neurapraxia,  also known as burners or stingers, usually heal by themselves, normally within 3 months.

Neuroma is a more serious stretch injury. These injuries damage nerve fibers and cause scar tissue to form as they heal. The weight of the scar tissue applies pressure on the remaining healthy nerve. As a result, the recovery from the injury is only partial, not complete.

Ruptures occur when the nerve itself is torn. This type of stretch injury always requires medical intervention, usually by splicing a nerve taken from another part of the infant’s body and grafted to the damaged area. A rupture injury will not heal on its own.

Avulsions are the most severe types of nerve injuries. They occur when the nerve is totally torn away from the spinal cord. Avulsions do not heal by themselves, and the affected nerve can’t be reattached to the spinal cord. However, in a few instances where avulsion occurs, some arm function may be restored by grafting a nerve from another muscle in the baby’s body.

What Causes Erb’s Palsy?

Erb’s palsy generally occurs during a difficult labor, and can happen in three different ways. One way that the brachial plexus nerves are affected is when the baby is passing through the birth canal at an awkward angle, with the head being turned to one direction while the arm is being pulled in the opposite direction.

Excessive pulling on the shoulders is also common in cephalic presentation, when the baby is delivered face-first. Both circumstances can involve cephalo-pelvic disproportion (CPD), when the baby is disproportionately bigger than the birth canal.

Another situation in which that Erb’s palsy can occur is when the baby is delivered through the birth canal  in a breech birth. The brachial plexus nerves can be stressed and injured when the baby’s arms are pulled backward over the head as the delivering physician pulls the newborn from the birth canal by the legs. During these situations, the baby is violently stretched. In some cases, shoulder dislocation also occurs, but the forceful stretching always causes nerve damage to the brachial plexus.

What Are the Risk Factors of Erb’s Palsy?

Although excessive lateral traction and stretching the baby’s head and neck during delivery may cause some cases of Erb’s palsy, the chances of developing the condition triple if the infant develops shoulder dystocia. Additional risk factors include:

  • The use of forceps and/or vacuum extraction tools during delivery
  • Large infant size
  • Small maternal size
  • Excessive maternal weight gain
  • Second stage of labor lasting over an hour
  • Infants with high birth weight
  • Infants in the breech position

How Do I Know My Baby Has Erb’s Palsy?

Erb’s palsy is evident when a baby exhibits weakness in the affected arm,  favors it,  or cannot even move it. The severity of Erb’s palsy symptoms can range from signs of weakness or soreness to total or partial paralysis of the arm. The most common signs and symptoms to look out for include:

  • The affected arm may be limp, held against the side of the body, and bent at the elbow
  • A decreased ability to grip with the hand on the affected side
  • Partial or full paralysis
  • Loss of sensory function in the upper arm of the affected area
  • Loss of motor function in the upper arm in the affected area
  • Arm numbness
  • Impaired circulatory, muscular, and nervous development

How Can Erb’s Palsy Be Treated?

In most cases, infants who develop Erb’s palsy should be referred to a treatment center that provides multidisciplinary specialties. These types of treatment centers are made up  of a large team of physicians who specialize in different areas of healthcare, such as neurologists, neurosurgeons, physical therapists, occupational therapists, and orthopedic surgeons.

However, not all infants have the option of going to a multidisciplinary treatment center. In these instances, your infant should be seen by  a pediatric neurologist.

Treatment options include:

Surgery

If surgery is recommended, it should be done within the first three to six months after birth, unless your baby’s doctor recommends otherwise. Studies suggest that postponing surgery until the baby is older reduces the operation’s chances of success. Microsurgical techniques should be performed at around three months of age. Surgical attempts to restore partial arm function to treat avulsion-type injuries should be performed around six months of age.

Another form of surgery that might be performed is exploratory surgery, a type of surgery that involves removing scar tissue from neuromas in order to repair the affected nerve. It also involves grafting with the transplant of a nerve from another part of the body to repair nerve ruptures. Studies suggest that the most improvement usually comes from nerve grafting techniques.

Non-Surgical Treatment Options

When nerve injuries to the brachial plexus are mild, the best approach is usually physical therapy, which should include gentle massages around the affected arm. Physical therapy also includes the use of such techniques as range of motion exercises to improve arm strength and flexibility, as well as nerve function. In some cases, Botox injections into the affected area and the application of  electrical stimulation may help your baby recover. If neurological function doesn’t return by six to eight weeks after therapy and other forms of treatment, your physician may recommend surgery.

It’s important to note, however, that home care is just as important. For instance, you’ll want to gently massage the infant’s arm and practice physical therapy exercises at home along with physical therapy sessions. Make sure to stay involved during your baby’s physical therapy sessions so that you’ll understand that type of exercises you should practice at home.

What is the Long-Term Prognosis for Erb’s Palsy?

A prognosis for Erb’s palsy will depend mainly upon the severity of your baby’s injuries. Mild cases of Erb’s palsy may clear up within three to six months with physical therapy. Around 70 to 80% of all Erb’s palsy cases will usually clear up within a year as long as proper and consistent treatment is provided. The younger the infant is when treatment begins, the better the results are. One way to determine a positive prognosis is if the infant begins to grasp objects or make fists with the hand associated with the affected area during treatment sessions.

In some cases, infants may live with lifelong problems due to Erb’s palsy. Although such cases are rare, children with Erb’s palsy may suffer permanent functional loss in the affected arm. Abnormal muscle contractions may also become permanent.

Long-term effects of Erb’s palsy may also cause a child to suffer psychologically, resulting in lack of self-esteem and difficulty with performing daily tasks, which may lead to anger and frustration. In addition, children with limited use of their arm may not be able to participate on sports teams and other activities. This often makes self-esteem issues harder to resolve. If your child is having a difficult time dealing with socialization or has emotional problems as a result of a medical condition, counseling by a child psychologist may be necessary.