3. Erb's Palsy

Erb's Palsy

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonyms: Erb-Duchenne paralysis

Erb's palsy is caused by damage to the brachial plexus during delivery of the neonate. This is mostly limited to the 5th and 6th cervical nerves.

Save time & improve your PDP on Patient.co.uk

  • Notes Add notes to any clinical page and create a reflective diary
  • Track Automatically track and log every page you have viewed
  • Print Print and export a summary to use in your appraisal
Click to find out more »
  • Rare; in the United States the incidence has ben quoted as 1.6-2.9 per 1,000 live births[1]
  • Upper plexus palsies are more common than lower plexus palsies
  • 50% of cases are associated with shoulder dystocia

Risk factors

Risk factors in Erbs palsy
Fetal factors
Maternal factors
Factors related to labour
  • Maternal propulsive forces
  • Lateral traction exerted on head and neck during delivery in vertex presentation
  • Arm extended overhead in breach presentation
  • Excessive traction placed on shoulders during delivery

Raised maternal BMI at term and presence of gestational diabetes mellitus have also been reported as risk factors.[2] The same study reported high birthweight, long second stage of labour, Afro-Caribbean background and long deceleration phase of labour as other prominent risk factors.[2]

Infant is unable to:

  • abduct the arm from the shoulder
  • rotate the arm externally from the shoulder
  • supinate the forearm

This results in the classic 'porter's tip' or 'waiter's tip' appearance[1]

Clinical signs

  • Characteristic position - adduction and internal rotation of the arm with forearm pronated
  • Forearm extension normal
  • Biceps reflex absent
  • Moro reflex absent on affected side
  • Sensory impairment on outer aspect of arm (unusual)
  • Power of the forearm is normal (if impaired, suggests injury to lower part of plexus)
  • Hand grasp normal unless lower part of plexus is also damaged
  • MRI shows nerve root damage
  • EMG and nerve root studies are not helpful in determining the extent of the damage severity,[1] although this has been opposed.[3]
Other causes of abnormal posturing in newborns:
  • Intermittent immobilisation and positioning to prevent contractures
  • Positioning such that arm is abducted to 90°, externally rotated at the shoulder, supination of forearm, extension at wrist with the palm turned toward the face
  • Gentle massage
  • Physiotherapy with active and passive movement exercises by end of first week
  • Electrical stimulation may prove to be beneficial[5]
  • Referral to neurosurgeon if paralysis persists beyond three months or more proximal damage to plexus[1]
  • Surgery can involve direct neurorrhaphy after neuroma resection, neurolysis to remove any scar tissue, nerve grafting with transplant of another nerve or nerve transfer from a local functioning nerve; however, results are mixed and pain, along with functional disability, persist in significant numbers[3]
  • Depends upon degree of damage
  • Effective hand grasp throughout is associated with a good prognosis
  • Function may return within a few months
  • Some may have been left with permanent damage

Named after Wilhelm Heinrich Erb (1840-1921) a German neurologist who described a case in 1874, although an earlier case was described by Duchenne in 1872. However Erb was also a pioneer in a description of the electrophysiological nature of tetany, characterisation of the physiological response to stimulation of the superior root of the brachial plexus, and describing the deep tendon reflex.[6]

Provide feedback

Further reading & references

  1. Hemady N, Noble C; Newborn with abnormal arm posture. Am Fam Physician. 2006 Jun 1;73(11):2015-6.
  2. Weizsaecker K, Deaver JE, Cohen WR; Labour characteristics and neonatal Erb's palsy. BJOG. 2007 Aug;114(8):1003-9. Epub 2007 Jun 12.
  3. Kirjavainen M, Remes V, Peltonen J, et al; Long-term results of surgery for brachial plexus birth palsy. J Bone Joint Surg Am. 2007 Jan;89(1):18-26.
  4. Birch R, Ahad N, Kono H, et al; Repair of obstetric brachial plexus palsy: results in 100 children. J Bone Joint Surg Br. 2005 Aug;87(8):1089-95.
  5. Okafor UA, Akinbo SR, Sokunbi OG, et al; Comparison of electrical stimulation and conventional physiotherapy in functional rehabilitation in Erb's palsy. Nig Q J Hosp Med. 2008 Oct-Dec;18(4):202-5.
  6. Watt AJ, Niederbichler AD, Yang LJ, et al; Wilhelm Heinrich Erb, M.D. (1840 to 1921): a historical perspective on Erb's palsy. Plast Reconstr Surg. 2007 Jun;119(7):2161-6.
Original Author: Dr Gurvinder Rull Current Version:
Last Checked: 22/01/2010 Document ID: 2113  Version: 22 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.