Erb’s Palsy of the Arm: A Childbirth Trauma Condition
Erb’s palsy is a nerve condition that typically affects babies when they are born. I watched a video about Femke today, which you can watch below, that inspired me to find out more about this nerve condition. The nerve damage is caused to the brachial plexus, which is a group of neck nerves coming together to form the arm nerves. The nerve damage occurs during the delivery process.
Basically Erb’s palsy is when there is specific damage to certain nerves in the brachial plexus. So why is it called Erb’s palsy, what are the nerves that are involved and what is the current treatment options for a mum with a baby suffering Erb’s palsy nerve damage. Well today’s article will look at what a recent 2009 research paper on Erb’s palsy mentioned.
Table of Contents
Understanding Erb’s Palsy
The History of Erb’s Palsy
William Smellie (1697-1763) was a Scottish obstetrician who first described Erb’s palsy type symptoms in babies he had seen during some of his 1,150 deliveries.
Smellie described his findings in a French mid-wifery text called Observations sur les Accouchemens ou suite de la theorie et pratique de cet art, which you can happen to read in full below if you can read French.
It was then the roles of Guillaume Duchenne and Wilhelm Erb in the 1800’s who further confirmed the problem of brachial plexus nerve damage resulting in muscle paralysis of the arm. They confirmed that Erb’s palsy was not a congenital problem, but a birth trauma. Erb found it had to do specifically with the nerve roots of C5 & C6 of the brachial plexus. So Erb’s Palsy was named and sometimes referred to as Erb-Duchenne Palsy.
Cause of Erb’s Palsy
Erb’s palsy can be caused by excessive pulling of the neck, arm or shoulder of the baby during the delivery process.
The delivery process is usually termed dystocia, which means a difficult birth. Dystocia happens in:
- Breech babies,
- Shoulder dystocia,
- Vacuum/forceps delivery &,
- Prolonged second stage of labor.
Erb’s plasy is also classified as an obstetric brachial plexus palsies (OBPP).
Erb’s palsy can also occur in previously healthy adults.
This would be in people who have had a traumatic fall damaging the C5-6-7 nerve roots in their necks. This can happen from say a motorbike accident where the head and shoulder are forced apart when hitting the ground.
The Anatomy of the Brachial Plexus
The brachial plexus is a group of spinal nerves existing the neck vertebrae, & grouping together to form the nerves of the arm, forearm and hand. The five nerves are C5-6-7-8-T1. C stands for cervical and T for thoracic.
In a classic Erb’s Palsy, it is the C5-6 nerves that are affected by the birth trauma. This means the muscles affected are mainly the deltoid, biceps, and brachialis muscles.
The picture below is of the brachial plexus. It shows how the brachial plexus of nerves divides and combines to form the ulna, median, musculocutaneous, radial and axillary nerves of the arm. In an Erb’s palsy diagnosis typically the suprascapular nerve, musculocutaneous nerve, and the axillary nerve are the ones that are damaged.
Diagnosis of Erb’s Palsy
Erb’s palsy is usually only picked up in babies when the baby is observed not to be moving the affected arm. This can be seen immediately or soon after birth.
The babies arm may look like a waiters tip position (internally rotated shoulder, turned in forearm & flexed wrist).
Other signs of Erb’s Palsy would be:
- The paediatric reflex, Moro’s reflex, being absent on the affected arm,
- A decreased grasp reflex or grip and,
- Just general lack of spontaneous movement in the arm or hand.
Rate of Brachial Plexus Injuries
The rate incidence of Erb’s palsy from birth deliveries is between 0.1% and 0.4% of live births.
The majority (40-50%) of obstetric brachial plexus palsies are C5-C6 nerve root lesions or Erb’s Palsy.
C5-C6-C7 nerve root lesions comprise about 20% to 25% of obstetric brachial plexus palsies. Global lesions affecting the entire brachial plexus nerves account for 25% of OBPP. Up to 10% are bilateral, & are seen almost exclusively in breech presentations.
Erb’s Palsy Treatment
The good news is it looks like most babies will have a spontaneous recovery naturally from a classic Erb’s palsy.
So it looks like for the majority of children they recover the motor function of the arm without the need for surgery.
If the C7 nerve root is involved then unfortunately, it has a poorer prognosis. A test to see if the biceps muscle, on the affected arm, can move against gravity is another outcome sign to watch. If a baby can recover anti-gravity movement of the biceps muscle before 3-6 months of age then apparently there is a much better chance of recovery in function.
So what happens if your baby or child doesn’t have the spontaneous recovery. Then you need to ask was it a classic Erb’s palsy of only C5-6 nerve roots or were the lower nerves of the brachial plexus involved.
The lower the nerve injury in the brachial plexus then the least likely spontaneous recover will occur, with some reports of only 10% recovery. Persistent deficits in active wrist extension at 4 to 5 months, with recovery of hand function, is highly suggestive of a poor outcome. This is especially regarding the shoulder movement without surgical intervention.
What this highlights is the need for careful serial, complete neurological examinations by the paediatrician or paediatric neurologist.
Erb’s Palsy Video
In the video below watch the spontaneous recovery of Erb’s palsy in Femke. Femke is a little girl who has a left arm Erb’s Palsy. You can see her recovery from week 1 of age until she is 4 years old.
The second video shows you how shoulder dystocia causes trauma to the brachial plexus nerves.
Erb’s Palsy Surgery
If an infant presents with a global C5-T1 nerve injury and no significant recovery occurs within the first 8 to 10 weeks of age, then this is an absolute indication for surgery by 4 to 5 months of age according to research.
If your baby has a C5-C6 or C5-C6-C7 nerve lesions, then there would seem there is no absolute evidence indicating that microsurgical intervention at less than 6 months of age yields superior results to those obtained following surgery at 8 to 9 months.
For a full breakdown of all the different types of surgery available and their results for Erb’s palsy, you can read the research paper by Ruchelsman, D., Pettrone S. et al in the information link box below at the end of the page.
Conclusion on Erb’s Palsy
Erb’s palsy is an uncommon nerve damage condition that can occur during child birth.
If the nerve damage is to the C5-6 nerve roots (classic Erb’s Palsy) then the outcome is likely to be better for a spontaneous recovery without surgery.
There are different types of surgery from nerves to tendons that can be performed if needed. Hope you found this information on Erb’s palsy enlightening, I sure found the research article a good read and very informative information for me.
- Ruchelsman D.E., Pettrone S., et al. Brachial plexus birth palsy: an overview of early treatment considerations. Bull NYU Hosp Jt Dis. 2009;67(1):83-9. or PubMed Ref
- Erb’s Palsy Group UK Charity
- Birth Trauma Association UK Charity