Erb's Palsy
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Synonyms: obstetric brachial plexus injury, neonatal brachial plexus injury
What is Erb's palsy?
Erb's palsy is caused by damage to the brachial plexus during delivery of the neonate. This is mostly limited to the 5th and 6th cervical nerves.
How common is Erb's palsy? (Epidemiology)[1]
- Obstetric brachial plexus injuries are uncommon, with an incidence of 0.42 per 1000 live births in the UK, but with 25% of those affected being left with permanent disability without intervention.
- 50% of cases are associated with shoulder dystocia.
Risk factors[1]
Risk factors associated with injury include shoulder dystocia, a high birth weight (above 4 kg), prolonged labour, breech alignment and forceps delivery.
Erb's palsy symptoms (presentation)[1]
The infant is unable to:
- Abduct the arm from the shoulder.
- Rotate the arm externally from the shoulder.
- Supinate the forearm.
This results in the classic 'porter's tip' or 'waiter's tip' appearance.[2]
Clinical signs
- Characteristic position - adduction and internal rotation of the arm with the forearm pronated.
- Forearm extension is normal.
- Biceps reflex is absent.
- Moro reflex is absent on the affected side.
- Sensory impairment on the outer aspect of the arm (unusual).
- Power of the forearm is normal (if impaired, it suggests injury to the lower part of the plexus).
- Hand grasp is normal unless the lower part of the plexus is also damaged.
Investigations[3]
The current gold standard for delineating the nerve injury is surgical exploration, and synchronous reconstruction is performed if indicated.
Magnetic resonance imaging (MRI) is a non-invasive method of assessing the anatomy and severity of nerve injury in obstetric brachial plexus injury but the diagnostic accuracy is unclear.
Differential diagnosis[4]
Other causes of abnormal posturing in newborns:
- Klumpke's paralysis.
- Clavicle fracture.
- Fractured humerus.
- Cerebral palsy.
Erb's palsy treatment and management[1]
- Intermittent immobilisation and positioning to prevent contractures.
- Positioning such that arm is abducted to 90°, externally rotated at the shoulder, supination of forearm, extension at wrist with the palm turned toward the face.
- Gentle massage.
- Physiotherapy with active and passive movement exercises by the end of the first week.
- Data supports the effectiveness of botulinum neurotoxin for obstetric brachial plexus injury. However, definite conclusions cannot be drawn due to small study sizes and the lack of randomised controlled trials. Therefore, more research is warranted to clarify the effectiveness of botulinum neurotoxin.[5]
- Nerve reconstruction is indicated when spontaneous recovery is absent or severely delayed.[6]
- Surgery can involve direct neurorrhaphy after neuroma resection, neurolysis to remove any scar tissue, nerve grafting with transplant of another nerve or nerve transfer from a local functioning nerve; however, results are mixed and pain, along with functional disability, persist in significant numbers.[7]
Prognosis
- Depends upon the degree of damage.
- Effective hand grasp throughout is associated with a good prognosis.
- Function may return within a few months.
- Some may have been left with permanent damage.
History
Named after Wilhelm Heinrich Erb (1840-1921), a German neurologist who described a case in 1874, although an earlier case was described by Duchenne in 1872. However, Erb was also a pioneer in a description of the electrophysiological nature of tetany, characterisation of the physiological response to stimulation of the superior root of the brachial plexus, and describing the deep tendon reflex.[8]
Further reading and references
Van der Looven R, Le Roy L, Tanghe E, et al; Risk factors for neonatal brachial plexus palsy: a systematic review and meta-analysis. Dev Med Child Neurol. 2020 Jun62(6):673-683. doi: 10.1111/dmcn.14381. Epub 2019 Oct 31.
Nixon M, Trail I; Management of Shoulder Problems Following Obstetric Brachial Plexus Injury. Shoulder Elbow. 2014 Jan6(1):12-7. doi: 10.1111/sae.12003. Epub 2013 Jan 21.
Hemady N, Noble C; Newborn with abnormal arm posture. Am Fam Physician. 2006 Jun 173(11):2015-6.
Hardie C, Brooks J, Wade R, et al; Diagnostic accuracy of magnetic resonance imaging for nerve injury in obstetric brachial plexus injury: protocol for systematic review and meta-analysis. Syst Rev. 2022 Aug 2011(1):173. doi: 10.1186/s13643-022-02037-9.
Birch R, Ahad N, Kono H, et al; Repair of obstetric brachial plexus palsy: results in 100 children. J Bone Joint Surg Br. 2005 Aug87(8):1089-95.
Chen TY, Su YC, Lin YC, et al; The Effectiveness and Safety of Botulinum Neurotoxin in Obstetric Brachial Plexus Injury: A Systematic Review and Meta-Analysis. Healthcare (Basel). 2022 Nov 3010(12):2419. doi: 10.3390/healthcare10122419.
Pondaag W, Malessy MJA; Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury. J Hand Surg Eur Vol. 2021 Mar46(3):229-236. doi: 10.1177/1753193420934676. Epub 2020 Jun 26.
Kirjavainen M, Remes V, Peltonen J, et al; Long-term results of surgery for brachial plexus birth palsy. J Bone Joint Surg Am. 2007 Jan89(1):18-26.
Watt AJ, Niederbichler AD, Yang LJ, et al; Wilhelm Heinrich Erb, M.D. (1840 to 1921): a historical perspective on Erb's palsy. Plast Reconstr Surg. 2007 Jun119(7):2161-6.