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Erb's Palsy

Synonyms

Erb-Duchenne paralysis

Description

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

Epidemiology
  • Rare; in the United States the incidence has ben quoted as 1.6-2.9 per 1000 live births1
  • 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
Presentation

Infant is unable to

  1. abduct the arm from the shoulder
  2. rotate the arm externally from the shoulder
  3. supinate the forearm



This results in the classic "porter's tip" or "waiters tip" appearance1

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
Investigations
  • 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.2

Differential diagnosis3

Other causes of abnormal posturing in newborns

Management
  • Intermittent immobilisation and positioning to prevent contractures
  • Positioning such that arm is abducted to 90 degrees, 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
  • Referral to neurosurgeon if paralysis persists beyond 3 months or more proximal damage to plexus1
  • Surgery can involve direct neurorrhaphy after neuroma resection - however results are mixed and pain along with functional disability persist in significant numbers2
Prognosis
  • 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 be left with permanent damage
History

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 electrophysiologic nature of tetany, characterization the physiologic response to stimulation of the superior root of the brachial plexus, and describing the deep tendon reflex.4

Document References
  1. Hemady N, Noble C; Newborn with abnormal arm posture. Am Fam Physician. 2006 Jun 1;73(11):2015-6.
  2. 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. [abstract]
  3. 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. [abstract]
  4. 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. [abstract]
Acknowledgements EMIS is grateful to Dr Gurvinder Rull for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 2113
Document Version: 20
DocRef: bgp1379
Last Updated: 9 Oct 2007
Review Date: 8 Oct 2009


















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