Erb’s Palsy Lawyers serving Clients in Michigan, Ohio, Washington DC, and nationwide
Brachial plexus birth palsy, more commonly known as Erb’s palsy, is a weakening or paralysis of the arm caused by injury to the arm’s upper group of main nerves that form part of the brachial plexus. The brachial plexus is a network of nerves near the neck that influences all of the nerves of the arm, providing movement and feeling to the arm, hand, and fingers. Erb’s palsy is when the weakening or paralysis is the result of damage or injury to the brachial plexus nerves affecting the movement of the upper arm and rotating of the lower arm.
The term plexus refers to this network of nerves. The nerves pass from the spinal cord through the vertebrae of the neck and into the arm. The nerves come together near the side of the neck and then spread out into the arm after passing through the collarbone (clavicle).
The brachial plexus nerves that influence the arm and shoulder lie higher in the neck and therefore are more vulnerable to injury than the lower-lying nerves of the hands and fingers. For this reason, it’s more common for Erb's Palsy to affect the motion of the arm and shoulder than the hand and fingers. When the lower brachial plexus nerves that control the hand and fingers are injured it is referred to as total or global brachial plexus palsy. When the hand is affected by the paralysis, a condition known as Klumpke's paralysisis (or Klumpke's palsy) exists and is marked by a “claw hand” where the forearm is supinated and the wrist and fingers are flexed. Sometimes, a condition known as Horner's syndrome accompanies these palsies. Horner's involves a constriction of the pupils and sometimes results in a drooping eyelid.
Although the condition can occur at any age, Erb’s palsy is most common among infants following a difficult delivery. While complications may arise during delivery, most birth injuries, including Erb’s Palsy, are often preventable.
If your child suffers from a brachial plexus injury such as Erb’s palsy, you may have a legal case. The highly skilled Erb’s Palsy attorneys at Reiter & Walsh ABC Law Centers will evaluate your case for free. We’ll determine whether your child’s injury was preventable and if your child is entitled to compensation.
Dystocia often the cause of Erb’s Palsy
The most common cause of Erb's palsy is dystocia, an abnormal or difficult childbirth or labor. Erb’s palsy occurs when downward lateral traction is applied by the physician to the baby's head and neck when the baby gets stuck in the birth canal. Erb's palsy also may occur in neonates affected by a clavicle fracture unrelated to dystocia.
When the baby’s shoulders have difficulty passing below the mother’s pubic bone, it is called shoulder dystocia. When this occurs, the physicians will try to maneuver the shoulders. Shoulder dystocia is considered an obstetrical emergency because of the potential for the umbilical cord to become compressed within the birth canal, depriving the baby of oxygen potentially causing hypoxic ischemic encephalopathy or birth asphyxia.
TYPES OF ERB’S PALSY NERVE INJURIES
Generally, four types of brachial plexus nerve injuries can occur:
1. Neurapraxia. Neurapraxia is the most common injury that shocks the nerve but does not tear it. This injury usually heals within three months.
2. Neuroma. Neuroma injuries are those involving damage to the nerve fibers resulting in scar tissue that presses on a surrounding healthy nerve. Some recovery is obtained.
3. Tear (or rupture) of the nerve. A tear or rupture will require medical assistance. Most likely, physicians will splice a donor nerve graft. Such grafts vary in results, and they may leave some scarring, take much time to heal, and are not helpful to older infants.
4. Avulsion. An avulsion is the most serious type of injury and it occurs when the nerve is completely torn from the spinal cord and cannot be repaired.
SIGNS AND SYPTOMS OF ERB’S PALSY
The signs of Erb's Palsy include loss of sensation in the arm and paralysis and atrophy of the deltoid, biceps, and brachialis muscles. The affected arm hangs by the side and is rotated toward the body; the forearm is extended and turned downward. The arm cannot be raised from the side; all power of flexion of the elbow is lost, and the forearm cannot be turned upward.
If the injury occurs at an age early enough to affect development (e.g. as a neonate or infant), it often leaves the child with stunted growth in the affected arm, with everything from the shoulder through to the fingertips smaller than the unaffected arm. This also leaves the child with impaired muscular, nervous and circulatory development. The lack of muscular development leads to the affected arm being much weaker than the unaffected one, and less articulate, with many children unable to lift the arm above shoulder height unaided. Many children also are left with elbow contracture, which means the muscle is shorter and the elbow cannot be straightened.
Listed below is a summary of the common symptoms of Erb’s palsy:
- A limp arm
- Lack of movement in the arm or hand. The affected arm may flop when the baby is rolled from side to side
- Missing Moro reflex, which causes the baby to react when startled by a sudden, loud noise by stretching out the arms and flexing the legs
- Inability to maintain the arm in a normal position (flexed at the elbow and held against the body)
- Decreased grip on the affected side
Long-term prognosis for infants diagnosed with Erb’s palsy
While most Erb’s palsy injuries heal on their own, a baby with Erb’s Palsy will require frequent re-examination to confirm that the nerves are recovering. Depending on the injury, recovery can last for an extended period of time. Starting at about three weeks of age, parents may need to perform rehabilitating exercises with the child to prevent the joints of the shoulder, elbow, wrist and hand from becoming permanently stiff (i.e., joint contracture). Full range of motion is most often received within one year of age, but after this point, full function rarely is obtained.
Long term, some children may experience abnormal growth as a result of Erb’s palsy in everything from the shoulders to the fingertips. The shorter growth generally results from comparative lack of use of these body parts and the influence of nerves (unaffected vs. affected) on growth. The lack of muscular development in areas affected by the brachial plexus may lead to long term weakness or lack of movement. Similarly, these areas may experience abnormal circulatory development resulting in an inadequate ability to regulate temperature in these areas as compared to the rest of the body. Lack of circulatory development can also reduce the healing ability of the skin. Skin may take greater periods of time to heal and infections may easily manifest if open cuts or injuries are not sterilized immediately. Arthritis is another potential long term affect of Erb’s palsy.
RISK FACTORS FOR ERB’S PALSY
Erb’s palsy is typically caused by trauma, such as stretching of the nerves during a difficult birth, and the brachial plexus can be damaged as a result of force. Risk factors for Erb’s palsy include the following:
- The baby is macrosomic (large for gestational age)
- The mother has a small pelvis
- The mother is obese
- The mother has previously given birth to a large baby
- Breech presentation
- Gestational diabetes
- Cephalopelvic disproportion
- The second stage of labor that lasts more than 60 minutes
- Use of forceps or vacuum extractor during delivery
- Forceful downward traction on the head during delivery
- Previous child with Erb’s palsy
- Intrauterine torticollis (abnormal asymmetrical head or neck position)
- Shoulder dystocia
DIAGNOSIS OF ERB’S PALSY
A pediatrician is usually the one to make the diagnosis of Erb’s palsy, based on weakness of the arm and physical examination.
The physician may order an x-ray or other imaging study in order to assess whether there is any damage to the bones and joints of the neck and shoulder. The physician also may do some tests to learn whether any nerve signals are present in the muscle of the upper arm. These tests may include an electromyogram (EMG) or a nerve conduction study (NCS).
TREATMENT OF ERB’S PALSY
Some babies recover on their own; however, many require treatment from specialists. Neonatal/pediatric neurosurgery is often required for avulsion fracture repair. Lesions may heal over time and function may return. Physical therapy is often required to regain muscle usage. Although range of motion is recovers in many children under one year of age, individuals who have not yet healed after this point rarely will gain full function in their arm and may develop arthritis.
If there is no change over the first 3 to 6 months, the physician may suggest exploratory surgery on the nerves to improve the potential outcome. Nerve surgery will not restore normal function, and usually is not helpful for older infants. Because nerves recover very slowly, it may take several months, or even years, for nerves repaired at the neck to reach the muscles of the lower arm and hand.
The three most common treatments for Erb's Palsy are:
- Nerve transplants. Nerve transplants usually are performed on babies under the age of 9 months since the fast development of younger babies increases the effectiveness of the procedure. It is not generally done on older infants since more harm than good is often done as it may result in nerve damage in the area from which the nerves were taken.
- Subscapularis releases. These procedures involve cutting a "Z" shape into the subscapularis muscle to provide stretch within the arm. It can be done at any age and may be performed repeatedly on the same arm. This procedure, however, compromises the integrity of the muscle.
- Latissimus Dorsi Tendon Transfers. This involves 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 but may sometimes cause increased sensitivity of the part of the biceps where the muscle will now lie.
What to do if your child has Erb’s palsy
Erb’s palsy is a birth injury that is very often a result of a physician’s mistake like improperly using forceps or a vacuum extractor, applying too much traction or pressure to the baby’s head and neck during delivery, or simply failing to identify and treat risk factors present in the mother. All of these errors constitute medical malpractice and entitle your child to compensation for his or her injuries.
Call Reiter & Walsh ABC Law Centers today for a free initial case evaluation. Our attorneys have been handling Erb’s palsy and other birth injury cases for more than 30 years. We have aggressively fought for and won money for our clients for medical costs, pain and suffering and for future medical expenses. Let us put our experience to work for your family, (888) 419-BABY.
- Al-Qattan M.M. “Total Obstetric Brachial Plexus Palsy in Children With Internal Rotation Contracture of the Shoulder, Flexion Contracture of the Elbow, and Poor Hand Function: Improving the Cosmetic Appearance of the Limb With Rotation Osteotomy of the Humerus.” Annals of plastic surgery. 2010; 65(1):38-42.
- Nath RK, Kumar N, Avila MB, Nath DK, Melcher SE, Eichhorn MG, Somasundaram C. “Risk Factors at Birth for Permanent Obstetric Brachial Plexus Injury and Associated Osseous Deformities.” ISRN pediatrics. 2012.
- O'Leary, James A., "Shoulder Dystocia and Birth Injury, Prevention & Treatment," McGraw Hill. 1992.
By Jesse Reiter