ERB’S PALSY: BRACHIAL PLEXUS NERVE INJURY IN NEWBORNS AND ADULTS

Erb's palsy is a condition characterized by the weakness of the arm or shoulder muscles. It occurs as a result of nerve injury sustained during birth or at a later stage in life.

Erb’s palsy is a type of brachial plexus palsy that affects the upper plexus nerves. It can arise in infants during a difficult birth or in adults who experience traumatic injuries. Weakness in the arm or shoulder, a stiff elbow, and partial or total paralysis in the arm are all complications of Erb’s palsy.

Physical therapy is often the most effective way to treat brachial plexus nerve injury. However, the surgical treatment of Erb’s palsy is also possible by nerve graft, nerve transfer, tendon transfer, or the release of joint contractures.

Read on to learn more about what Erb’s palsy is, its causes, the type of nerve injuries common with it, how it’s diagnosed, and the available treatment options for this type of brachial plexus palsy.

What Is Erb’s Palsy?

Erb’s palsy, also known as Erb-Duchenne paralysis, is a nerve condition that causes weakness or loss of function of the muscles in the arm or shoulder. It’s the most common type of brachial plexus palsy.

The brachial plexus is a network of five nerves located near the neck which connects the spine to the arm and are responsible for providing feeling and motion to the shoulder, arm, hand, and fingers.

An injury during birth or later on in adult life can stretch, rupture, or rip the plexus nerves leading to brachial plexus palsy (partial or complete loss of muscle function).

In most cases of brachial plexus palsy (BPP), the upper nerves of the brachial plexus are injured. This condition is known as Erb’s palsy; a common birth-related brachial plexus injury.

Who does Erb's palsy affect?

Erb’s palsy can occur in:

• Newborns: newborn babies can develop Erb’s palsy during a difficult vaginal birth or even a C-section. Brachial plexus birth palsy occurs in 0.9 to 2.6 of every 1,000 live birth cases each year.
• Adults: a traumatic injury can cause brachial plexus palsy in adults.

What causes Erb’s palsy in newborns?

During delivery, the infant’s head may be shifted to one side to make room for the shoulders to be pulled out, especially in larger babies. As a result, the brachial plexus nerves extending from the neck to the arm and shoulder may become stretched, damaged, or torn.

In other cases, if the baby is in a breech birth position (the baby’s head isn’t first in the birth canal), the doctor might have to pull the baby’s legs out first. Consequently, the arms are pulled over the head which can stress the brachial plexus and damage them as the baby is being delivered.

What causes Erb’s palsy in adults?

Traumatic injuries leading to Erb’s palsy in adults may occur due to:

• Traffic accidents: this is the most common cause of brachial plexus injuries in teenagers and adults and most often involves motorcycles
• Gunshot or knife wounds
• Industrial accidents
• Injuries during contact sports (such as football)
• Surgical complications
• Tumors

What are the symptoms of Erb’s palsy?

The classical sign of Erb’s palsy is a waiter’s tip deformity; the arm hangs down by the side with a loss of sensation. Complications of brachial plexus injury include:

• Weakness in one arm (the arm cannot be raised from the side)
• Loss of feeling in the arm
• Partial or total paralysis of the arm
• Stiff elbow with limited range of motion (elbow flexion contracture)

What Types of Injuries Are Common With Erb’s Palsy?

In general, there are four main types of brachial plexus nerve injuries:

• Neurapraxia: This is the most common type of brachial plexus injury and it usually heals on its own within 3 months. It occurs when an injury shocks the nerve and stretches it but does not tear it.
• Neuroma: Neuroma happens after a nerve heals from a stretch injury and leaves behind scar tissue which pressures the brachial nerve and prevents it from delivering signals to the muscles.
• Rupture: This occurs when the brachial nerve is torn apart (ruptured) but not from the spine. This type of Erb’s palsy nerve injury does not heal by itself.
• Avulsion: This is the most serious type of brachial plexus nerve injury. The injury causes the nerve to be ripped away (torn) from the spine. Although it’s not possible to repair an avulsion, it’s possible to restore some of the arm’s functions by surgery.

How Is Erb’s Palsy Diagnosed?

If you or your baby are showing signs and symptoms of Erbs’ palsy, your physician will conduct a thorough physical examination followed by:

• An X-ray of the chest: to rule out possible broken bones that may be causing your symptoms
• An MRI or CT scan: to check for a dislocated shoulder or the presence of injury to the nerves
• Myelogram: a diagnostic imaging test done to look for problems in the spinal canal
• EMG (electromyography): to assess the function of your nerves and muscles

Treatment of Erb’s Palsy

There are several options for treating Erb’s palsy depending on how severe the nerve injury is.

Physical therapy

The most effective treatment for Erb’s palsy, in both infants and adults, is daily physical therapy.

Most infants with brachial plexus birth palsy are often able to recover movement and feeling in the affected arm with regular physical therapy.

Daily range-of-motion and stretching exercises are done as often as possible during the day to help:

• Prevent stiffness in the arm, hand, and wrist
• Prevent the permanent stiffness in the joint (joint contracture)
• Maintain a range of motion in the shoulder, elbow, wrist, and hand

Hydrotherapy

Hydrotherapy for the treatment of Erb’s palsy combines physical therapy exercises with water. The water can provide support and make the exercises less painful.

Botox injections

Botulinum toxin (Botox) can be injected to paralyze working muscles for a while in order to force the weaker arm muscles to take over and become stronger.

Surgery

Your doctor may recommend surgery on the nerves depending on the type of your nerve injury or if your baby’s condition doesn’t improve over the first 3-6 months.

Surgical treatment of Erb’s palsy may include:

• Nerve graft (nerve transplant surgery): during this Erb’s palsy surgery, a neurosurgeon grafts part of a healthy donor nerve of the child to the damaged nerve.
• Nerve transfer: It might be possible to restore some of the function in the arm by using a nerve from a close by healthy muscle as a donor.

Other surgical options for treating the symptoms of brachial plexus palsy may include:

• Release of joint contractures: the surgical release of thickened soft tissues around the shoulder and elbow joints can improve their range of motion. This type of brachial plexus palsy surgery can be done at any age.
• Tendon transfer: a functioning tendon is removed from its original attachment in the body and reattached in the shoulder area. A tendon transfer surgery can help improve the lost hand function and enhance the ability to raise the arm.

After surgery, your physical therapist or doctor will provide you with at-home rehabilitation exercises to improve your or your baby’s strength and range of motion.

Risk Factors For Erb’s Palsy

One of the most common reasons for brachial plexus birth injury is dystocia; when the baby’s shoulder gets stuck inside the mother’s pelvis. There are factors that can increase the risk of dystocia and Erb’s palsy in infants, such as:

• High infant birth weight
• An obese/overweight birth parent
• A diabetic birth parent
• Previous pregnancy involving shoulder dystocia
• Pregnancy with more than one baby
• Medications that are given during labor (e.g: oxytocin or an epidural)
• Breech birth position
• Prolonged delivery period

Adults who participate in contact sports or ride motorcycles are at a higher risk of developing Erb’s palsy especially if they don’t wear protective equipment.

Living With Erb’s Palsy

Parents must remain supportive of their children and encourage them on focusing on the tasks they can perform with their condition. This will help your child develop healthy self-confidence and make up for any limited functions.

There are also several support organizations for people with Erb’s palsy and their families. Reaching out to these organizations can help you better understand the condition and how you can effectively live with it.

In addition, there are YouTube channels and documentaries on how to perform daily activities while having brachial plexus palsy such as driving, curling your hair, exercising, and even martial art training.

Keep in mind that many people with BPP were able to have successful careers and a lot of them became inspiring figures for other people with the same condition.

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Sources:

• Erb's palsy – Who is to blame and what will happen? - PMC
• Erb Palsy - StatPearls - NCBI Bookshelf
• The Prevalence, Rate of Progression, and Treatment of Elbow Flexion Contracture in Children with Brachial Plexus Birth Palsy
• Surgical Treatment of Obstetrical Brachial Plexus Paralysis: The Norfolk Experience - PMC

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