Erb’s Palsy  (Brachial plexus birth injury)

Introduction
Erb’s Palsy is a form of Brachial Plexus Injury. Five large nerves which come out of the spinal cord between the bones of neck make the brachial plexus. These nerve supply feeling and give movement to the arm. They are named as C5, C6, C7, C8, and T1. Generally the C5-C6 nerves are affected. When these nerves are affected, there is loss of movement and weakness of the arm seen.

Incidence
It is reported that the incidence is 1-2 per 1000 live births worldwide. Mostly, Erb’s palsy is associated with shoulder dystocia.

Symptoms / Clinical Signs
The clinical signs differ greatly on the basis of the severity of the injury. In most of the cases, the child will have weakness in one arm, loss of feeling / sensitivity and atrophy in the affected arm. There is possibility of total or partial paralysis of the arm. In severe cases, the child can have droopy eyelids of the affected side.
 
Types
There are four types of injury can happen. All can happen at the same time in the same affected child. These injuries are known as NEURAPRAXIA, NEUROMA, RUPTURE and AVULSION 

NEURAPRAXIA
An injury that shocks but does not tear the nerve

NEUROMA
An injury that damage some of the nerve fibres which may result to scar tissue. This scar tissue may press on the remaining healthy nerve.

RUPTURE
An injury that causes the rupture of the nerve is called Rupture. It basically torn itself

AVULSION
An injury that cause complete torn of the nerve from the spinal cord. It is the severe form of Brachial Plexus Injury.

Causes
The most common cause is an abnormal / difficult child birth. In case of shoulder dystocia, the infant’s head is delivered normally but the one shoulder becomes struck under part of the mother’s pelvic bones. The risk factors increases in case of breech presentation, or large head of the infant, or pulling the shoulder by the assistant while vaginal delivery.
Diagnosis making / Tests and Investigations
Parents are the first who suspect the disorder. A pediatrician usually the one who diagnose the disorder. The doctor will ask for X-ray / MRI to figure out the damage to the bones and joints of the neck and shoulder. EMG and NCV are also conducted to know the severity of the damage. Other conditions which mimic Erb’s Palsy are KLUMPKE’S PARALYSIS, CLAVICLE FRACTURE, FRACTURE HUMERUS and CEREBRAL PALSY

Management / Treatment
In case of simple injury (NEURAPRAXIA) some babies recover on their own. But children with severe injury require specialist’s intervention.

Medicine
There is no specific medicine available to correct the deformity

Physical Therapy, Occupational therapy and Splinting
Physiotherapy / Occupational therapy in the form of gentle massage and stretching help the child to recover fast.  It helps to prevent deformity and becoming the joints fix permanently. Splinting has a great role to keep the arm in aligned and preventing contracture. Night splint is considered better than day splinting. Electrotherapy, Hydrotherapy is also support the therapies.   

Surgical Treatment
A few severe cases will require surgical intervention. The most common surgical procedures are
- Nerve transplantation
- Subscapularis release
- Latissimius Dorsi Tendon Release
 
Prognosis
- Generally most of the cases recover fully within 3-6 months but who does not recover require intensive treatment. Effective treatment / management shows good prognosis. A few may be left with permanent damage.
 - Erb’s Palsy is a condition which can be prevented with good advance planning of delivery in case of high risk mothers.
- As children are very adaptive, they enjoy near normal life with Erb’s Palsy also.

 

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