What is Erb’s Palsy?
One to two out of every 1,000 babies is born with Erb’s palsy. This condition is often confused with cerebral palsy due to the symptoms of paralysis and nerve damage. Erb’s palsy is typically caused when an infant’s neck is stretched to one side during delivery, causing temporary or permanent nerve damage.
When the paralysis affects voluntary movement in the upper arm and rotation in the lower arm, it is considered Erb’s palsy.
The brachial plexus is a network of nerves that run down the spine and give feeling to the nerves in the arm. These nerves control the muscles in the shoulders, elbows, wrists and hands, as well as providing movement and feeling. When the upper nerves are damaged during a difficult birth, this can delay a child’s development or result in permanent damage.
Erb’s palsy is generally caused by nerve damage during delivery and the symptoms of this condition will most likely be recognizable at birth. However, determining the severity of the nerve damage and limited mobility may not be possible until three to six months after delivery. A child’s paralysis can range from partial to complete immobility, and nerve damage can be minor bruising to full tears or avulsions.
Klumpke’s palsy refers to paralysis of the lower brachial plexus. This typically affects only the muscles in the hand and is not common in babies.
Total plexus involvement includes damage to all five nerves of the brachial plexus C5-T1. This can cause a child to have no movement in the shoulder, arm, wrist, and hand.
Types of Erb’s Palsy Injuries
Diagnosing the type of Erb’s palsy can be challenging, as it mostly depends on the degree of damage to the brachial plexus nerve. Children with various forms of this condition will require different treatment methods in order to prevent or minimize any lifelong damage as they transition into adulthood.
The four main types of nerve injuries that occur in Erb’s palsy are:
- Neuropraxia – Also known as “burners” or “stingers,” neuropraxia is the most common type of neural injury. This condition occurs when a nerve is stretched or “shocked” but does not tear. These injuries typically heal on their own within 3 months.
- Neuroma – A more serious stretch injury that damages some of the nerve fibers. Neuroma can cause scar tissue to form as it heals, which presses on the remaining healthy nerve and creates discomfort. As a result, long-term recovery from neuroma is typically only partial, not complete.
- Rupture – A stretch injury that occurs when the nerve itself is torn. Rupture injuries require surgery to splice and graft the nerve back together. This type of injury will not be able to heal on its own.
- Avulsions – The most severe type of nerve injury. An avulsion occurs when a nerve is totally torn from the spinal cord. It may be possible to repair an avulsion with surgery, where healthy nerves are spliced from another part of the body and replaced, but the affected nerve cannot be reattached to the spinal cord. Sometimes this can affect the nerves of the diaphragm causing difficulty breathing. Avulsion injuries can also affect the face and eyes causing Horner’s Syndrome where the eyelid droops or causes the pupil to be smaller in the affected eye.
Causes and Risk Factors
The most common cause of Erb’s palsy is excessive pulling or stretching of an infant’s head and shoulders during a vaginal birth. For example, if an infant’s head and neck are pulled to the side at the same time as the shoulders pass through the birth canal, this can cause Erb’s palsy.
This birth injury can also result from excessive pulling on the shoulders during a head-first delivery, or by pressure on the infant’s raised arms during a feet-first delivery. This typically occurs when the baby is “stuck” in the birth canal, requiring the caretaker to pull harder to get the baby out.
Erb’s palsy can also develop based on the positioning of the infant in the birth canal. This condition is common in larger babies with broad shoulders. What typically happens is that the infant’s head drops into the birth canal but one shoulder is held back by the mother’s pubic bone. As the baby’s head is pushed lower into the birth canal, the nerves are stretched, resulting in Erb’s palsy.
The risk of a child developing Erb’s palsy nearly triples if they develop shoulder dystocia during birth. This is when the infant’s head is delivered, but both of their shoulders get stuck inside the mother’s womb.
Risk factors of Erb’s palsy include:
- Large infant size
- Maternal diabetes
- Small or abnormal maternal pelvis shape
- Using extraction tools during delivery
- Second stage of labor lasting over an hour
- Excessive maternal weight gain
Signs and Symptoms
The symptoms of Erb’s palsy vary depending on the type and severity of paralysis. Signs range from weakness or soreness to total paralysis of the arm.
The most common symptoms of Erb’s palsy are:
- Weakness in one arm
- Limited motion in the shoulder, bicep, elbow, forearm, wrist, or hand causing the “waiter’s tip”
- Arm hangs by the side and rotated inward
- Decreased grip strength in hand of the affected side
- Numbness in arm
- Impaired circulatory, muscular and nervous development
- Partial or total paralysis of the arm
In the case of a mild stretch or tear, most children will recover on their own within three to six months after birth. However, if a doctor re-examines a child with Erb’s palsy after six months and determines that development and movement are not at the level they should be, there are additional treatment options available.
This one of the first methods used to treat mild cases of Erb’s palsy. Physical therapy can help improve any stiffness or immobility in a child’s arms or shoulders. A physical therapist will use gentle massage and exercising techniques to improve movement in the muscles and nerves. Therapists also use equipment such as exercise balls or weights during sessions, which can help strengthen a child’s grip in the affected hand.
Occupational therapy is often used in cases of Erb’s palsy that have not improved on their own after two to four months. Occupational therapy can help a child develop the strength to perform everyday activities, such as picking up a toy or bottle. An occupational therapist will use a range of movement exercises to improve joint function and muscle tone.
Children with severe cases of Erb’s palsy will usually require surgery to repair nerve damage and paralysis in the arm, hand, elbow or shoulder. If your doctor has recommended surgery after three to six months, the care team may recommend it be performed as early as possible. Studies have shown that postponing surgery for Erb’s palsy can lower the chance of success and recovery.
The main type of surgery used to treat this condition is a nerve graft. This is when a healthy nerve is removed from another area of the body and stitched to the disrupted nerve. When surgery is combined with physical and occupational therapy, this allows children to gradually develop motion and strength in the arm.
To learn more about the support options that Cerebral Palsy Guide can offer you and your family, try downloading our free Cerebral Palsy Guide, which includes over 60 pages of in-depth information for children and parents of a child with CP.