Original Editor - Rachael Lowe
- 1 Definition/Description
- 2 Clinically Relevant Anatomy
- 3 Epidemiology
- 4 Mechanism of Injury / Pathological Process
- 5 Risk Factors
- 6 Clinical Presentation
- 7 Diagnosis
- 8 Investigations
- 9 Outcome Measures
- 10 Management / Interventions
- 11 Prognosis
- 12 Differential Diagnosis
- 13 References
Erb's palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there's an injury to the brachial plexus, specifically the upper brachial plexus at birth. The injury can either stretch, rupture or avulse the roots of the plexus from the spinal cord. It is the most common birth-related brachial plexus injury (50- 60%).
It is a lesion of C5 & C6 nerve roots (in some cases C7 is involved as well) usually produced by widening of the head shoulder interval. Injuries to the brachial plexus affects movement and cutaneous sensations in the upper limb. Depending on the severity of the injury, the paralysis can either resolve on its own over a period of months, require rehabilitative therapy or surgery.
Clinically Relevant Anatomy
Neurologically, the Erb's point is a site at the upper trunk of the Brachial Plexus located 2-3cm above the clavicle. It's formed by the union of the C5 and C6 roots which later converge. Affected nerves in Erb's palsy are the axillary nerve, musculocutaneous, & suprascapular nerve.
- Axillary nerve- originates from the terminal branch of posterior cord receiving fibers from C5 and C6. It exits the axillary fossa
posteriorly passing through the quadrangular space with posterior circumflex humeral artery. it fives rise to superior lateral brachial cutaneous nerve then winds around the surgical neck of the humerus deep to deltoid. It innervates the shoulder joint, teres minor and deltoid muscles, skin of superolateral arm.
- Musculocutaneous nerve- originates from the terminal branch of lateral cord receiving fibers from C5-C7. It exits the axilla by piercing coracobrachialis, descends between biceps brachii and brachialis while supplying both, continues as lateral cutaneous nerve of forearm. It innervates the muscles of the anterior compartment of the arm and the skin of lateral aspect of the forearm.
- Suprascapular nerve- originates from the superior trunk receiving fibers from C5, C6 often C4. It passes laterally across lateral cervical region superior to brachial plexus then through scapular notch inferior to superior transverse scapular ligament. It innervates the supraspinatus, infraspinatus and shoulder joint.
An incidence of 0.8-1 per 1,000 births has been reported for brachial plexus birth palsy (BPBP) in the US. Erb's palsy accounts for about 45% of BPBP. Additional injury to C7 is commonly discovered in 20% of cases of BPBP.
Incidence of permanent impairment is 3-25%. The rate of recovery in the first few weeks is a good indicator of final outcome. Complete recovery is unlikely if no improvement has occurred in the first two weeks of life.
A study by Weizsaeker et al 2007 found that being a member of the black population was independently predictive for Erb's palsy.
Mechanism of Injury / Pathological Process
The most common cause of Erb's palsy is excessive lateral traction or stretching of the baby's head and neck in opposite directions during delivery usually associated with shoulder dystocia. This may happen during delivery of the head, the head may be deviated away from the axial plane. There can also be compression of the brachial plexus causing it to stretch and tear. Sometimes, pulling on the infant's shoulder during delivery or excessive pressure on the baby's raised arm during a breech delivery can cause brachial plexus injury. Two potential forces act on the brachial plexus during labor- natural expulsive force of the uterus, traction force applied by the obstetrician.
- Shoulder dystocia
- Fetal macrosomia
- Maternal obesity
- Gestational diabetes
- Duration of second stage of labor(over 60 minutes)
- Breech presentation
The classical sign of erb's palsy is called Waiter's tip deformity. This is due to loss of the lateral rotators of the shoulder, arm flexors, and hand extensor muscles. The position of the limb, under such conditions, is characterized by : the arm hanging by the side and is rotated medially, the forearm extended and pronated and the wrist flexed. Also,there is loss of sensation in the lateral aspect of the forearm.
The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm. Muscles most often paralyzed are supraspinatus and infraspinatus because the suprascapular nerve is fixed at the suprascapular notch (Erb's point). In more severely affected patients deltoid, biceps, brachialis, and subscapular is affected (C5 and C6). Elbow flexion is weakened because of weakness in biceps & brachialis. If roots are damaged above their junction, paralysis of rhomboids and serratus anterior is added, producing weakness in retraction and protraction of scapula
A thorough history and physical examination with focus on neurologic examination are used to confirm diagnosis.
History- aims to gather information about pregnancy complicated either by gestational diabetes or maternal obesity, fetal macrosomia, prolonged second stage labour, shoulder dystocia, use of assitive techniques-forceps to aid delivery.
Physical examination- most often shows decreased or absent movement of the affected arm.
Neurologic examination- assesses muscle power, sensation,reflexes- moro reflex is absent on the affected arm.
It might also be important to look for presence of cervical rib. In the report by Becker J, et al (2002), the authors noted that in a series of 42 infants found to have a cervical rib, 28 newborns had an Erb's palsy. They concluded that a cervical rib was a risk factor for an Erb's palsy.
- X-rays of the chest - to rule out clavicular or humeral fracture
- MRI of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots
- CT Scan of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots
- EMG/Nerve conduction studies- presence of fibrillation potentials indicate denervation
- Toronto test score
- Active movement scale
- Mallet scale
- Toddler Arm Use Test
Management / Interventions
Some brachial plexus injuries may heal without treatment. Many children who are injured during birth improve or recover by 3 to 4 months of age, although it may take up to two years to recover. Fortunately, between 80% to 90% of children with such injuries will attain normal or near normal function. Treatment for brachial plexus injuries includes physiotherapy and, in some cases, surgery.
During the first 6 months treatment is directed specifically at prevention of fixed deformities. Exercise therapy should be administered daily to maintain ROM and improve muscle strength. Parents must be taught to take an active role in maintaining ROM and keeping the functioning muscles fit. Exercises should include bimanual or bilateral motor planning activities.
- Careful handling is required and extremes of motion are to be avoided for the first 1 to 2 weeks to allow for the initial inflammatory response to the injury to calm.
- Avoid picking a child up by the arm. or from under the armpit. This can compress or stretch the brachial plexus and cause further injury
- Placing a child on their back or in side-lying, with affected limb up, to avoid compression of the injured limb
- Place the affected arm into sleeves before the unaffected arm. This will help avoid extreme movement at the shoulder and will help make dressing quicker and easier.
A systematic review suggests physiotherapy interventions like constraint-induced movement therapy, kinesiotape, electrotherapy, virtual reality and use of splints or orthotics have positive outcomes for the affected upper limb functionality in obstetric brachial palsy from 0 to 10 years.
- Activities and exercises to promote recovery of movement and muscle strength
- Exercises to maintain range of movement in the joints to prevent stiffness and pain
- Sensory stimulation to promote increased awareness of the arm
- Provision of splints to prevent secondary complications and maximise function
- Educating parents on appropriate handling and positioning of the child and home exercises to maximise the child’s potential for recovery
- Constraint induced movement therapy may be useful
- Electrical Stimulation may be beneficial
- Referral to Occupational Therapy for assessment of function in day to day activities.
Encourage parents to carry out specific exercises with their child 2-3 a day in the comfort of their own home - although the exercises can be carried out anywhere appropriate and comfortable. The Home Exercise Programme may focus on the following:
- Maintain movement at the joints – Ensuring that the joints of the affected limb, especially the shoulder, keep their full range of movement and avoid excessive shortening of the muscles, also called a contracture. This will include passive, assisted and active exercises.
- Increasing the strength of muscles in the affected limb.
- Increasing the child’s awareness of the arm through tactile touch and contact.
- Teaching parents, carers and the child how to handle the affected limb and how to position it for both comforts, prevention of complications and practicality.
- The use of Constraint-Induced Movement Therapy (CIMT) and bimanual/bilateral therapy are sometimes also considered by Physiotherapists.
Surgical intervention is a possible treatment option and will be considered by the medical team after appropriate assessment. Surgery is only considered when conservative treatment (such as physiotherapy) is deemed unsuitable. This may be just after birth, as the severity of the BPBP injury requires surgical intervention, or it may be later in a child’s development. Surgery for BPBP can involve nerve transplants or tendon transfer of functioning muscles. Many children show a complete recovery, but for those unfortunate not to recover fully, it is important to focus on helping a child to adapt to tasks and work on different strategies to complete activities in their daily life.
Living with BPBP
Dina Shafer, who also has a lasting disability affecting her right arm due to BPBP, has a Youtube channel showing how she carries out her activities of daily living such as driving her car and curling her hair as well as how she exercises at the gym where her workouts involve a range of different exercises from deadlifts to martial arts training.
A number of individuals diagnosed with BPBP went on to have successful careers in their chosen field, Martin Sheen was diagnosed with BPBP as was Adrain Clayborn, an American Football player who was drafted 20th overall in the 2011 Draft by the Tampa Bay Buccaneers.
There are also other inspiring individuals out there, including Emily Langridge, a young woman with BPBP who created a documentary following families, adults and children with the condition. Watch the film on the website of the Brachial Plexus Palsy Project.
Indications for surgery is no clinical or EMG evidence of biceps function by 6 months. This represents 10% to 20% of children with obstetric palsies.
The three most common treatments for Erb's Palsy are: Nerve transplants (usually from the opposite leg), Sub Scapularis releases and Latissimus Dorsi Tendon Transfers.
Nerve transplants are usually performed on babies under the age of 9 months since the fast development of younger babies increases the effectiveness of the procedure. They are not usually carried out on patients older than this because when the procedure is done on older infants, more harm than good is done and can result in nerve damage in the area where the nerves were taken from. Scarring can vary from faint scars along the lines of the neck to full "T" shapes across the whole shoulder depending on the training of the surgeon and the nature of the transplant.
Subscapularis releases, however, are not time limited. Since it is merely cutting a "Z" shape into the subscapularis muscle to provide stretch within the arm, it can be carried out at almost any age and can be carried out repeatedly on the same arm; however, this will compromise the integrity of the muscle.
Latissimus Dorsi Tendon Transfers involve cutting the Latissimus Dorsi in half horizontally in order to 'pull' part of the muscle around and attach it to the outside of the biceps. This procedure provides external rotation with varying degrees of success. A side effect may be increased sensitivity of the part of the biceps where the muscle will now lie, since the Latissimus Dorsi has roughly twice the number of nerve endings per square inch of other muscles.
The prognosis is dependent on the severity of injury, timing of treatment- the earlier, the better the results and associated injuries (fractures of shoulder/arm). Mild cases of erb's palsy may resolve in three to six months with physical therapy. Erb's palsy resolves completely in the first year of life in approximately 70%- 80% of patients and nearly 100% if treatment begins in the first four weeks of birth. Also, effective hand grasp during treatment is associated with good prognosis.
- Clavicular fracture
- Osteomyelitis of the humerus or clavicle
- Septic arthritis of the shoulder
- Erb-Duchenne and Dejerine-Klumpke Palsies Information Page: National Institute of Neurological Disorders and Stroke(NINDS)
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