Erb’s Palsy and Brachial Plexus Injuries
Brachial plexus 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 in the arm, providing movement and feeling to the arm, hand, and fingers. Erb’s palsy is a condition in which arm weakening or paralysis is caused by damage to the brachial plexus nerves, it affects movement of the upper arm and rotation of the lower arm.
An Overview: Erb’s Palsy and Brachial Plexus Injury
Types of Brachial Plexus Injury
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 paralysis, a condition known as Klumpke’s paralysis or palsy exists and is marked by a “claw hand” where the forearm is supinated and the wrist and fingers are flexed. 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.
Brachial Plexus Injury is Preventable
The number of babies born with a brachial plexus injury is about 2 – 4 of every 1,000 babies. Nearly all brachial plexus injuries are preventable with proper delivery techniques. This is why it is crucial for mothers to be aware of their right to all delivery techniques – and associated risks – explained to them. This is especially important when an obstetrical emergency such as shoulder dystocia is present.
Causes of Erb’s Palsy and Brachial Plexus Injuries: Difficult Delivery and Shoulder Dystocia
Several different types of birth trauma can cause brachial plexus injuries. The most common cause of Erb’s palsy is birth trauma associated with shoulder dystocia. Shoulder dystocia occurs when the baby’s shoulder gets hinged or stuck on the mother’s pelvic bone during delivery. It is diagnosed when the shoulders fail to deliver shortly after delivery of the head. When dystocia occurs, the doctor sometimes pulls too hard on the baby’s head, causing excessive strain on the baby’s shoulder and brachial plexus nerves. This strain can cause the nerves to tear or become severely damaged.
Delivery During Instances of Dystocia
Use of excessive force or traction is not necessary, and indeed, it is against the standard of care. There are different types of gentle maneuvers physicians can perform in order to deliver the baby and prevent Erb’s palsy, but often, a prompt cesarean (C-section) delivery is the safest method of delivery. In addition to avoiding excessive traction on the baby’s head, a C-section is usually preferred during instances of shoulder dystocia because dystocia increases the risk that the baby’s umbilical cord will become compressed. The cord may be pushed up against the pelvic bone or it may be wrapped around the baby’s neck (nuchal cord). Umbilical cord problems can cause severe oxygen deprivation in a baby, which can result in hypoxic-ischemic encephalopathy (HIE). Due to the potential for brachial plexus damage and umbilical cord problems, shoulder dystocia is always considered an obstetrical emergency.
Erb’s Palsy and Dystocia: The Dangers of Forceps and Vacuum Extractors
When emergencies such as shoulder dystocia arise, doctors are often tempted to use delivery assistance devices such as forceps and vacuum extractors. These instruments are not routinely used and doctors often lack skill and experience in their use. Frequently, when these devices are used, too much force is applied to the baby’s head. Forceps and vacuum extractors also put the baby at an increased risk of having a brain bleed.
Preventing Erb’s Palsy Through Informed Consent and Birth Planning
A main focus of brachial plexus advocacy groups is to tell expecting mothers to ask their doctors about the risks of shoulder dystocia. A lack of informed consent is a major issue; often, doctors do not fully explain the risks of continuing with a vaginal delivery when shoulder dystocia is present. The mother has a right to make an informed decision. This means that the doctor must explain the risks, benefits, and alternatives to every procedure that is considered. Thus, when a baby’s shoulder is stuck on the pelvic bone, the physician must inform the mother of this and let her decide if she wants to continue with vaginal delivery, which may include vacuum extractors or forceps, or move on to an emergency C-section delivery.
When considering which birthing facility and obstetrician to use, a key consideration is whether the medical center has the capacity to quickly perform a C-section delivery if the baby gets in trouble, as can occur in cases of shoulder dystocia.
Types of Erb’s Palsy and Brachial Plexus Injuries
Generally, there are four types of brachial plexus nerve injuries:
- Neurapraxia: Neurapraxia is the most common injury, in cases of neurapraxia the nerves are shocked, but do not tear. This injury usually heals within three months.
- 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.
- 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.
- 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 Symptoms of Erb’s Palsy and Brachial Plexus Injuries
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 weakness in the affected arm, many children are unable to lift the arm above shoulder height unaided. Many children also are left with elbow contracture, which means the muscle is shorter than normal, and the elbow cannot be straightened.
Common symptoms of Erb’s palsy include:
- 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.
- A continuous flex (bend) at the elbow with the arm held against the body
- 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
- Decreased grip on the affected side
Long-Term Effects of Erb’s Palsy and Brachial Plexus Injuries
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 in very severe cases, after one year 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 or Brachial Plexus Injuries
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 mother has a small pelvis or cephalopelvic disproportion (CPD – pelvis too small for the size of the baby)
- 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 (prolonged or arrested labor)
- 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
Diagnosing Erb’s Palsy and Brachial Plexus Injury
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 for Erb’s Palsy or Brachial Plexus Injuries
Some babies recover on their own from brachial plexus injuries and Erb’s palsy; however, many require treatment from specialists. Neonatal or 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 recovered 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 (nerve graft surgery) are most often performed on babies under the age of 9 months, since the rapid development of younger babies increases the effectiveness of the procedure. It is not generally done on older infants since it is riskier and 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.
Trusted Erb’s Palsy and Brachial Plexus Lawyers Represent Victims of Medical Malpractice and Birth Injury
Erb’s palsy and birth trauma cases require extensive knowledge of both the law and medicine. If you are seeking the help of an Erb’s palsy lawyer, it is very important to choose a lawyer and firm that focus solely on birth injury cases. Reiter & Walsh ABC Law Centers is a national birth injury law firm that has been helping children with birth injuries since it was formed in 1997.
If your child was diagnosed with a birth injury, such as Erb’s palsy, cerebral palsy, a seizure disorder or hypoxic-ischemic encephalopathy (HIE), the award-winning birth injury lawyers at ABC Law Centers can help. We have helped children throughout the country obtain compensation for lifelong treatment, therapy and a secure future, and we give personal attention to each child and family we represent. Email or call Reiter & Walsh ABC Law Centers at 888-419-2229 for a free case evaluation.
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Related Articles and Blogs from Reiter & Walsh ABC Law Centers
- FAQs: Erb’s Palsy
- What is it like pursuing a birth injury case?
- Our birth injury cases
- Hypoxic-Ischemic Encephalopathy (HIE)
- Traumatic Birth Injuries
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The above information is intended to be an educational resource. It is not meant to be, and should not be interpreted as, medical advice.