Erb’s Palsy and Brachial Plexus Injuries
Erb’s palsy is a condition characterized by arm weakness or paralysis. It is often caused by pulling or pushing on the baby’s head during a shoulder dystocia delivery, which is a labor and delivery complication in which one of the baby’s shoulders gets stuck behind the mother’s pelvic bone. This may damage a network of nerves located near the neck, called the brachial plexus, and manifest in Erb’s palsy.
With proper medical management, brachial plexus injuries rarely occur. Therefore, the development of Erb’s palsy is often a sign of medical malpractice around the time of birth.
Risk Factors for Erb’s Palsy and Brachial Plexus Injuries
Risk factors for Erb’s palsy and brachial plexus injuries include the following:
- Fetal macrosomia
- Cephalopelvic disproportion (CPD – the mother’s pelvis is 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
- A second stage of labor that lasts more than 60 minutes (prolonged or arrested labor)
- Use of forceps or a 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
Causes of Erb’s Palsy and Brachial Plexus Injuries: Difficult Delivery and Shoulder Dystocia
Several different forms of birth trauma can cause Erb’s palsy and 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.
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 the necessary skill and experience to utilize them properly. 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 an intracranial hemorrhage (brain bleed).
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 injury, but often, a prompt cesarean (C-section) is the safest method of delivery. In cases of shoulder dystocia, a C-section can decrease the risk of umbilical cord compression. This is a complication in which the cord is pushed up against the pelvic bone or 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.
Types of Brachial Plexus Injury
In many cases, Erb’s palsy affects the motion of the arm and shoulder more so than that of the hand and fingers, but any part of the upper limb may be involved.
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, this is known as Klumpke’s palsy. Klumpke’s palsy is marked by a “claw hand” wherein the forearm is supinated (positioned so that the palm is facing outward) and the wrist and fingers are flexed.
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. Neurapraxia 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. Prognoses vary.
- 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 to weakness in the affected arm. Many children are unable to lift the arm above shoulder height unaided. Children are also often are left with elbow contracture, which means the muscle is shorter than normal, and the elbow cannot be straightened.
Common signs and 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. This is a reflex that 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
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).
Preventing Erb’s Palsy Through Informed Consent and Birth Planning
A main focus of brachial plexus advocacy groups is to encourage 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 opting for vaginal delivery over cesarean section. 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.
Managing Shoulder Dystocia: The HELPERR Mnemonic
In vaginal deliveries involving shoulder dystocia, medical personnel must be very careful not to apply excessive force while trying to help the baby out because this can result in brachial plexus injuries and Erb’s palsy. Instead, physicians should follow the HELPERR mnemonic. These actions can be used in a variety of combinations, and do not have to be attempted in order; optimal management of shoulder dystocia depends on individual circumstances.
HELPERR stands for:
H – Help. A doctor can ask for help from other medical professionals.
E – Evaluate for episiotomy. This is a procedure involving an incision in the mother’s perineum, between the anus and vagina.
L – Legs. A physician may ask the mother to pull her legs toward her stomach. This is known as the McRoberts maneuver.
P – Suprapubic pressure. A doctor may place pressure on a specific part of the mother’s pelvis to rotate the baby’s shoulders.
E – Enter maneuvers. This is another way of rotating the baby’s shoulders, but unlike suprapubic pressure, enter maneuvers involve internal rotation (the physician reaches the baby through the mother’s vaginal canal).
R – Remove the posterior arm. In this procedure, the doctor attempts to free one of the baby’s arms from the birth canal before the other.
R – Roll the patient. If the mother gets on her hands and knees, vaginal delivery may be more feasible.
Treatment for Erb’s Palsy and 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 healed by this point will rarely 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.
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 rehabilitative exercises with the child to prevent the joints of the shoulder, elbow, wrist, and hand from becoming permanently stiff (i.e., joint contracture).
In minor cases, full range of motion is often restored within a year of age. However, children with more severe brachial plexus injuries usually never have full range of motion.
In the long-term, some children may experience abnormal growth as a result of Erb’s palsy in everything from the shoulders to the fingertips. The restriction in 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 effect of Erb’s palsy.
Trusted Erb’s Palsy and Brachial Plexus Lawyers
Erb’s palsy and brachial plexus cases require extensive knowledge of both the law and medicine. If you are seeking legal help, it is very important to choose an attorney 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 since 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 attorneys 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. Please reach out today 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.