Erb’s Palsy  (Brachial plexus birth injury)

Erb’s Palsy is a birth defect which affects any of the two arms. Five large nerves which come out of the spinal cord between the bones of neck make brachial plexus. These five nerves supply feeling, sensations and movements to the arm. They are named as C5, C6, C7, C8, and T1. Generally the C5-C6 nerves are affected in Erb’s Palsy. When these nerves are affected, there is loss of movement and weakness of the arm seen with various degree of sensation loss.

Incidence
1-2 per 1000 live births worldwide

Symptoms / Clinical Signs
The clinical signs differ greatly on the basis of the severity of the injury. The common features are

• Poor or no movement of the affected arm and hand
•  Weakness in the affected arm
•  Loss of feeling / sensitivity in the affected arm and hand
•  Atrophy in the affected arm
•  Total or partial paralysis of the arm
•  Droopy eyelids of the affected side

Types / kinds of Erb’s Palsy
Many types of injury can happen in Erb’s palsy. They are

•  Neuropraxia
•   Neuroma
•  Rupture
•  Avulsion

Neurapraxia
It is an injury that shocks the nerves but does not tear the nerve. It is considered mild in form
Neuroma
It is an injury that damages some of the nerve fibres (parts of the nerve) which result to scar tissue. This scar tissue may press on the remaining healthy nerve and cause problems. It is considered as moderate form
Rupture
It is an injury that causes the rupture / break of the nerve. It basically torn itself. It is a severe form
Avulsion
It is an injury that causes complete torn (separated) of the nerve from the spinal cord. It is the severe form of Brachial Plexus Injury. It is the profound form of erb’s palsy

Erb’s Palsy can be single type or a combination any of the above types at the same time in the same affected hand. 

Causes / Etiology of Erb’s Palsy
The most common cause is an abnormal / difficult child birth. In case of shoulder dystocia, the infant’s head is delivered normally but one shoulder becomes stuck under the part of 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 delivery assistant while vaginal delivery.

Associated disorders with Erb’s Palsy
Fortunately, children with erb’s palsy are generally normal otherwise. They grow physically, mentally and communication wise as other peer children. No specific medical condition has been found associated with Erb’s Palsy

Diagnosis making / Tests and Investigations
Mostly the disorder is diagnosed just after birth by the delivery team member only. To confirm the diagnosis, an experienced pediatrician is consulted. 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; humerus fracture and cerebral palsy are also rule out

Management / Treatment of Erb’s Palsy
Management depends on the type of the damage. Therefore, it is very important to know the exact variety of the disorder. In case of simple injury (Neurapraxia type) mostly babies recover naturally as they grow. The second type (Neuroma Type) is very confusing. It may and may not recover naturally. Children with severe injury (Rupture and Avulsion Types) require intensive specialized treatments. No specific medicine is available which can correct the deformity
Treatment options are

•  Scientific handling / Positioning
• Use of positioning splint
• Physical therapy
• Surgical treatment

Scientific handling / Positioning
During the first 2 weeks, the child may have some pain in the affected shoulder and limb. It ca be either from the injury itself or from an associated clavicular or humeral fracture. The arm should be fixed across the child's chest by pinning of his/her clothing to provide more comfort. Gentle ROM exercises should be performed along with positioning. Parents are trained techniques for dressing the child to avoid further traction on the arm.

Use of positioning splint
An Erb’s palsy splint can be an effective part of treatment for Erb’s palsy. They can be used to improve muscle tone and range of motion in the affected areas. There are many different kinds of Erb’s palsy splints for different cases, and each type has its own use. For example, one patient might need an Erb’s Palsy splint that stabilizes the elbow. Another might have one that gives stability at both the shoulder and the elbow for functional positioning of the hand. Splinting has a great role to keep the arm in aligned and preventing contracture. Night splint is considered better than day splinting.

Physical Therapy and Occupational therapy
A combination of physiotherapy and occupational therapy in the form of gentle massage and stretching and play help the child to recover fast.  It helps to prevent deformity and becoming the joints fix permanently.

Electrotherapy

 Hydrotherapy   

Surgical Treatment
Few severe cases will require surgical intervention. The most common surgical procedures are

•  Nerve transplantation
•  Subscapularis release
•  Latissimius Dorsi Tendon Release
   

Assessments and Evaluations
Different tools are used to assess the severity of the problems and outcome of ongoing treatments

• Mallet classification
•  Active Movement Scale
•  Gilbert shoulder classification
•  Pediatric Outcomes Data Collection Instrument

Prognosis and employment opportunities
This condition improves or completely goes away for most infants, but some have permanent complications
 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.

If you have any query about a child with Erb’s Palsy, we are available for guidance and support

Mail at: helpicd@gmail.com  Whatsapp at: +91-7838809241     Voice Call at +91-11-41012124