Erb’s palsy was initially identified as a birth injury in 1768. The cause of the condition is a nerve injury in the baby’s upper arm at the time of vaginal delivery. The condition can result in permanent damage on the affected side of the body.

What is Erb’s Palsy?

Erb’s palsy is also known as brachial plexus injury (BPI)

The brachial plexus nerve fibers start in the neck and move to the arms. They consist of nerves that transport signals from the spinal cord to the shoulder, arm, hand and fingers. The signals send information between the brain, spinal cord, arm and hand, and are needed for normal movement and sensation.

Erb’s palsy, or Erb-Duchenne palsy, is marked by damage to the upper part of the brachial plexus bundle. The American Academy of Orthopaedic Surgeons (AAOS) estimates that one or two of every 1,000 newborns suffer from Erb’s palsy. The rate at which smaller infants (those weighing less than six pounds) are injured is lower, and the likelihood of injury rises in proportion to an increase in the size of the infant, particularly in infants whose weight is nine pounds or greater.

Erb’s palsy is caused by a nerve injury. In a difficult delivery, there can be an injury to the brachial nerves if the baby’s neck and head are pulled to the side when the shoulders leave the birth canal. In addition, excessive pulling on the shoulders while the baby exits the birth canal head first can cause a brachial nerve injury. In a breech birth, in which the feet exit first, the arms are generally raised, and could be injured because of undue pressure.

However, due to improvements in delivery methods, several injuries to the brachial plexus can be prevented. Babies whose weight is larger than normal have a higher risk of suffering this type of injury. A breech birth also places the baby at higher risk of injury.

To the left is a diagram of the brachial plexus. C5 and C6 combine to form the upper trunk, C7 moves by itself as the middle trunk, and C8-T1 combine to create the lower trunk. Each trunk separates into anterior and posterior parts to form the cords, which further split into branches that provide the muscles of the arm. Brachial plexus injuries can be benign, with only temporary effects of the condition, or they can be extremely harmful, in which case the child is left with a debilitated arm.

The severity of the injury is dependent on the number of nerves that are affected, and the extent to which each level sustains an injury. The fundamental kinds of brachial plexus palsys (BPP)are as follows:

Erb’s palsy affects nerves stemming from C5 and C6;
Upper-middle trunk BPP in which nerve fibers from C5, C6 and C7 levels are involved;
Klumpke palsy results in deficiencies at levels C8 and T1;
Total BPP impacts nerves at all levels, including C8 – T1;

Onset of Erb’s palsy at birth

Erb’s palsy is frequently evident at birth

These injuries occur during delivery

The fibers can become stretched from pulling on the head and shoulder of the baby during the course of delivery through the birth canal. The resulting stretch injury can cause weakness in the upper and / or lower arm and rotation of the lower arm, usually on one side of the body. Among the complications that can occur as a result of Erb’s palsy are:

PARTIAL LOSS

Partial loss of function of the nerves involved

TOTAL LOSS

Permanent, or total loss of function of the impacted nerves

WEAKNESS

Weakness or stiffness of the arm

PARALYSIS

Paralysis of the arm

Parents whose newborn exhibits a lack of motion in either arm should consult their health care professional right away.

An infant who has complete brachial plexus palsy usually lies with the arm held limply at the side. There is an absence of deep tendon reflexes (DTRs) in the affected arm, and the Moro response is uneven, without any active abduction of the arm. The Moro reflex is an infantile reflex that is usually present in every infant or newborn up to four or five months of age in response to an abrupt loss of support, when the newborn feels as though it is falling. It involves three different parts:

1. Abduction, or spreading out the arms;
2. Adduction, or unspreading the arms; and
3. Crying, in most cases

In children whose arms are completely affected, a meticulous examination of the infant’s eye frequently reveals a diagnosis of Homer’s syndrome, which is indicative of an injury to the stellate ganglion (a collection of nerves located at the sixth or seventh cervical vertebrae). These are the last vertebra of the neck. Homer’s syndrome is marked by a combination of symptoms that occurs when the sympathetic trunk is injured. The sympathetic trunk is a bundle of nerves that extends from the base of the skull to the coccyx, or tailbone.

Symptoms of Erb’s palsy

Following a vaginal birth, parents should look for certain signs in making a determination as to whether their baby is afflicted with Erb’s palsy:

Arm that is bent, or flexed, at the elbow and placed against the body;
Reduced grip strength on the side that is impacted;
Lack of a Moro reflex on the impacted side. This is the spreading of arms wide apart when a baby feels as though it is falling;
Absence of spontaneous movement in the upper or lower arm or hand;
Appearance of the impacted arm as floppy when the baby is turned from one side to the other

Paralysis of the diaphragm
Sometimes brachial plexus injury causes paralysis of the diaphragm. This takes place in approximately five percent of cases of brachial plexus injury, and generally within the initial few hours following birth, during which time the newborn may experience problems with breathing. The application of oxygen therapy over the next few days may help stabilize the infant or it may necessitate the use of a ventilator. In order to obtain a correct diagnosis of the paralysis, radiographic exams are needed.

Diagnosis of Erb’s palsy

Erb’s palsy is frequently evident at birth because the newborn’s arm is limp and uncommonly stiff. Diagnosis of the condition necessitates a cautious neurological examination by a specialist to decide which nerves have been impacted, and the seriousness of the injury.

The examination will consist of a physical examination of the arm, and certain tests, including an electromyogram (EMG) that discloses the degree of muscle damage brought about by the nerve injury. A nerve conduction study (NCS) can be performed to decide the distance that signals are sent along the nerves. Other scans may be needed to evaluate the injury inflicted on the nerves.

There are some children’s hospitals that have a team approach in performing diagnoses, and providing treatment to children who suffer from brachial plexus injuries. If the damage to the nerves is so significant that the newborn is unlikely to recover with therapy as the only form of treatment, then surgery may be required. It is likely that physical therapy will be incorporated into the treatment plan regardless of whether the infant undergoes surgery.

While the nerve is in a state of regrowth or healing, if the brain does not recall the ways in which the arm and hand should function, sensory re-education may be needed. It is advisable to obtain treatment as early as possible from health care providers who are experts in treating brachial plexus injury.

What causes Erb’s palsy?

In most cases, Erb’s palsy is caused by the pulling or stretching of the baby’s head and shoulders.

The head and shoulders get pulled in different directions at the time of a vaginal delivery. In some deliveries, the doctor or other health care professional pulls the baby’s head and neck toward the side as the shoulders move through the birth canal, thereby giving rise to Erb’s palsy.

Another frequent cause of Erb’s palsy is an inordinate amount of pulling on the baby’s shoulders during a delivery in which the head appears first. Such pulling might take place in the event the baby’s head is stuck, and the doctor or other health care provider attempts to pull harder and exert more pressure in an effort to bring the baby out of the mother.

The condition can also arise because of the way in which the baby is situated in the birth canal. There are times when the head falls into the birth canal, but one shoulder might be kept back by the pelvic bone. While the baby’s head is forced to move lower in the birth canal, there is stretching of the nerves in the upper arm, thus causing BPI. Even in such cases, a Caesarean section delivery may be unable to avoid this injury.

Shoulder Dystocia

Shoulder dystocia can increase the risk of a baby becoming afflicted with Erb’s palsy. It is caused by challenges in delivering the baby’s shoulders past the pelvic bone. According to the American College of Obstetricians and Gynecologists (ACOG), shoulder dystocias occur in approximately 0.15 percent of newborns whose weight exceeds five pounds, eight ounces. They take place in 1.7 percent of infants whose weight exceeds eight pounds, 13 ounces, and 4.6 percent of infants who experienced a mid-forceps deliveries or extended second stages of labor. Shoulder dystocias also occurred in 18 to 23 percent of babies whose weight was greater than nine pounds, 15 ounces.

As a result of a shoulder dystocia, an infant may suffer from a fractured clavicle. In some instances of shoulder dystocia, the health care provider delivering the baby intentionally fractures the clavicle in order to relax the position of the fetus.

However, even in the absence of a fractured clavicle, severe neurologic injuries have been diagnosed due to shoulder dystocia. In addition, an infant may sustain a fractured clavicle without any nerve damage, and without a diagnosis of shoulder dystocia.

The American College of Obstetricians and Gynecologists states that 90 percent of children who have shoulder dystocia resume their lives without any relevant challenges, and the remaining 10 percent continue to have impairment of function.

Additional Risk Factors

Additional factors the increase the risk of Erb’s palsy include:

The mother has diabetes. Pregnancy can cause such extreme variations in blood sugar that even women who do not suffer from diabetes can acquire it for a short time while they are pregnant. This condition is called gestational diabetes;
The baby is unusually large, and has wide shoulders. This condition is referred to as macrosomia, in which the newborn weighs more than usual. According to the American College of Gynecology Bulletins, a macrosomic newborn weighs nine pounds, 15 ounces, or more.
Maternal pelvis is contorted in that it is either flatter or narrower than usual;
Breech, or feet- or buttocks- first, delivery;
Multiparity, or giving birth to more than one child;
Second stage of labor that lasts longer than sixty minutes;
Assisted delivery, examples of which are the use of mid/low forceps, and vacuum extraction;
Forceful downward resistance on the head at the time of delivery;
Having had a previous child with obstetrical brachial plexus palsy (OBPP);
Intrauterine torticollis, or twisted neck. Torticollis can occur as a result of positioning in the womb or following a difficult childbirth.

Factors that were determined to be independently predictive of Erb’s palsy are:

A lengthy deceleration phase of labor;
A lengthy second stage;
High birth weight;
High neonatal or maternal body mass; and
Being a member of the black population.

Types of Brachial Plexus Injury

Nerve Damage & Erb's Palsy

Erb’s palsy can arise as a result of four kinds of brachial plexus injuries.

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Neuropraxia

Neuropraxia happens when one or more of the nerves becomes stretched or wounded, but not torn. It is the most typical kind of damage to the brachial plexus nerves, and can improve on its own.

Neuroma

Here, there is healing of a torn nerve that is accompanied by the growth of scar tissue, which exerts pressure on the damaged nerve, and blocks the transmission of signals between nerves and muscles. Treatment is needed in order for neuroma injuries to heal.

Rupture

Rupture takes place when a nerve tears, but the tear is not located at the point at which the nerve connects to the spine. Surgery is necessary, and the muscles may continue to decline in strength if the infant does not undergo a course of physical therapy treatment after surgery.

Avulsion

Avulsion is the most serious kind of injury, in which the nerve is ripped from the spine. As a result of this type of injury, there may be an effect on the size and growth of the arm or hand, and there may be a permanent injury.

Treatment of Erb’s Palsy

The most typical form of treatment is cautious waiting and physical therapy. If a newborn does not recover, surgery is generally performed to restore the nerves. There is a procedure called tendon relocation that is also performed to remedy the condition. It involves the removal of one end of a working tendon from the point at which it is attached, and applying stitches between the tendon and a paralyzed muscle, thus helping the patient move that muscle. However, this procedure is generally performed only in serious cases, or in situations in which there are no indications that the condition will improve following the use of other treatments.

The benefits of physical therapy

During therapy a physical therapist will:

Recognize weakness in the muscles and help each child maintain muscle flexibility and strength;
Assist in decreasing or preventing muscle or joint compression and disfigurement; and
Stimulate movement and function

Even in cases where surgery is not needed, therapy may be necessary for weeks and months while the nerves continue to grow or recover from injury.

Children who are afflicted with Erb’s palsy generally recover by the time they reach six months of age. However, a lengthier course of treatment may be necessary for other palsies. Every treatment plan is intended to fulfill the child’s needs with the use of an approach to care that is focused around family.

The physical therapist will conduct an assessment that consists of an elaborate birth and developmental history. The therapist will conduct certain tests to arrive at a conclusion regarding the function of the arm. Such functions include encouraging the infant to bring the arms together, taking hold of a toy, or using the arm as a means of support or for crawling. The physical therapist will perform tests for any feeling in the arm to decide whether there has been any loss of sensation. In addition, the therapist will inform the family about shielding the child from injuries when the child may be unable to feel pain.

Furthermore, the physical therapist will engage in other forms of treatment, including:

Education on holding, lifting and playing with the baby. For instance, the therapist will make recommendations as to how to position the baby so that the baby’s arm is not left hanging once the baby is held or carried. The therapist will suggest how to position the baby on the back or stomach without injuring the baby’s arm.
Prevention of injury – the physical therapist will clarify the potential injuries that could result from the baby’s crying, because the baby cannot feel pain if there is restricted feeling in the arm.
Passive and active stretching – the physical therapist will help the parents and child with the performance of gentle exercises to raise joint flexibility, or range of motion, and avoid or postpone stiffening of the arm.

Enhancing strength: The physical therapist will instruct the parents and child in the use of exercises and play movements to keep or increase strength of the arm. The therapist will recommend games and fun activities that improve strength without exerting an excessive amount of strain on the baby.

Use of intervention techniques, or modalities – The physical therapist may use various kinds of intervention techniques to increase the function of the muscles and movement. The application of electrical stimulation can mildly activate the nerve signal to the muscle, and maintain the functionality of the muscle tissue. Flexible tape can be placed over certain muscle areas to facilitate muscle contraction. In order to promote use of the affected arm, constraint-induced movement therapy (CIMT) can be implemented with respect to the unaffected arm. It is advisable to engage the affected arm in repetitive training with the use of activities that are appropriate for the age of the child.
Enhancing developmental skills – The physical therapist will be effective in assisting the child with mastery of motor skills, including placement of the child’s weight on the damaged arm, sitting up with support of the arm, and crawling.
Promoting physical fitness – The therapist will also provide advice and assistance regarding exercise, diet and participating in the community that will encourage a healthy lifestyle for the child.

Talk to an Erb’s Palsy Lawyer

If your newborn has Erb’s palsy, and you think the condition could be the result of negligence on the part of the doctor or other health care professional who delivered your infant, call the birth injury attorneys at Chalik & Chalik Law Offices.

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