Erb’s Palsy

Erb’s Palsy: What is it?

Erb’s palsy, sometimes referred to as brachial plexus birth palsy or Erb-Duchenne palsy, it is a condition that affects the shoulder and arm and results in skeletal muscle weakness or loss.

Wilhelm Erb is, one of the first doctors to recognize the illness, is honored in the name of the condition.

The most prevalent brachial plexus condition, Erb’s palsy, is caused by accidental trauma or nerve injury experienced during childbirth.

All of the arm muscles are supplied by the brachial plexus, a network of nerves that extends around the neck. These nerves supply the shoulders, arms, hands, and fingers with movement and sensation. Lightness is a sign of weakness.

Anatomy:

The divisions, branches, roots, cords, and trunks make up the five sections of the brachial plexus. In the plexus’s length, there are numerous “pre-terminal” or “collateral” branches in addition to five “terminal” branches.

Roots (C5-T1)

The first nerve fibers that arise from the spinal cord are called the roots (C5-T1). The C5, C6, C7, C8, and T1 are the five roots.

Trunks

Three trunks are formed when the roots come together: the upper (C5-C6), middle (C7), and lower (C8-T1) trunks.

Sections

Anterior and posterior sections exist in every trunk. The lateral cord is formed by the combination of the anterior divisions and posterior divisions, whereas the posterior cord is formed initially. The anterior division of the middle trunk directly joins the lateral cord.

The cords

Three cords make up the brachial plexus;

The anterior divisions (C5-C7) of the upper and middle trunk comprise the lateral cord.

The front portion of the lower trunk is where the medial cord originates (C8-T1).

All three trunks’ posterior divisions are formed by the posterior cord (C5-T1)

Branches

Major branches that supply the upper limb originate from the cords;

The Musculocutaneous nerve and the lateral root of the Median nerve are examples of lateral cord branches.

The ulnar and median nerves’ medial roots are among the branches of the medial cord.

The radial nerve and the axillary nerve are examples of posterior cord branches.

Terminal Branches

The nerve known as the musculocutaneous nerve stimulates the anterior arm muscles.

The median nerve supplies sensory innervation to the lateral palm and fingers as well as innervation to the muscles of the hand and forearm.

The medial palm and fingers receive sensory innervation from the ulnar nerve, which also innervates the forearm and hand muscles.

The teres minor and deltoid are supplied by the axillary nerve.

The dorsal hand and posterior arm receive sensory innervation from the radial nerve, which also regulates the muscles in the forearm and posterior compartment of the arm.

Etiology:

An injury to the C5 and C6 cervical spinal nerves is the cause of Erb palsy.
The ventral rami of the cervical spinal nerves C5–C8 and the thoracic nerve T1 make up the brachial plexus, which includes the C5–C6 nerves.
The cervicoaxillary canal in the neck, the ribcage, and the axilla are where these nerves exit the network that starts in the spine.
Strain of the neck during delivery is the most common cause of brachial plexus injury.
The two of the most significant risk factors are shoulder dystocia and macrosomia.
Usually, it happens to babies who are macrosomic and had to be extracted from the birth canal.
This action stretches the brachial plexus, potentially causing damage to it.
On the other hand, average weight babies and shoulder dystocia are not always associated with brachial plexus injury.
Additional risk factors for brachial plexus injury include vacuum and forceps delivery, multipara mothers, ultrashort second stage of labor, obesity in mothers, and diabetes in mothers.
After a cesarean section, erb palsy can also happen.

The pathophysiological understanding:

The upper trunk of the brachial plexus is formed by the ventral rami of the cervical spinal nerves C5 and C6.
The anterior and posterior divisions of each trunk are separated to form the cords.
The axillary, suprascapular, and musculocutaneous nerves are the branches that supply the muscles in the upper limb.
Small or large brachial plexus injuries are possible.
There are three classifications for the severity: neurometric, axonometric, and neuropraxic.
The least severe injury is a neuropraxic one. It is curable and heals without difficulty.
Axon and myelin sheath disruption occurs in axonometric lesions.
The healing process for axonometric lesions varies based on their severity and can take several months when proper treatment, such as physical therapy, is given.
The neurometric condition has the worst prognosis; permanent harm to the axon, myelin sheath, and supporting structures via the nerve is caused by avulsion of the roots from the spinal cord.
A neuroma forms at the proximal end of the nerve in an attempt to regenerate.

What signs and symptoms are present with Erb’s palsy?

The level of nerve damage determines the symptoms of Erb’s palsy.

Typical indications and symptoms consist of;

Paralysis or weakness in the afflicted arm.
Elbow, arm, and shoulder are weak or paralyzed.
Insufficient control over muscles, resulting in trouble extending the arm.
You are unable to bend your elbow or remove your arm from your body.
Restricted wrist, elbow, or shoulder range of motion.
Feeling a tingling or painful sensation in your hand or arm.

Erb’s palsy signs;

Specifically, it paralyzes the muscles in the biceps, deltoid, brachialis, and brachioradialis.
Supinators, infraspinatus, and supraspinatus muscles of the rotator cuff partially inhibit the ability to perform
Loss of abduction, flexion, lateral rotation of the arm, supination of the forearm, biceps, and supinator jerks
It causes abnormalities in the upper limbs, causing the arm to hang loosely, adduct, and rotate medially.
Fingers curled and wrist flexed.
The deformity is also referred to as “waiter’s hand deformity” or “policeman’s deformity.”

How is Erb’s palsy diagnosed?

In order to assess nerve function and gauge the extent of the injury, medical professionals diagnose Erb’s palsy through a combination of physical examinations, imaging tests (such as MRIs or X-rays), and nerve investigations (such as nerve conduction studies or electromyography).

Electromyography (EMG). The results of this test indicate how well the muscles and nerves work.

The presence of pseudomeningoceles (abnormal collection of cerebrospinal fluid) suggests avulsion damage to the affected spinal roots, and magnetic resonance imaging (MRI) of the shoulder may reveal shoulder dislocation.

Shoulder dislocation may be seen on a computed tomography (CT) scan; the presence of pseudomeningoceles suggests that the affected spinal roots have suffered an avulsion.

Physical Inspection:

A thorough history and physical examination are conducted, with particular attention paid to the neurological examination, in order to confirm the diagnosis.

History: to become knowledgeable about problems related to pregnancy, such as obesity in mothers, gestational diabetes, prenatal macrosomia, prolonged labor in the second stage, shoulder dystocia, and the use of forceps during delivery.

Usually, a physical examination shows that the affected arm moves very little or not at all.

Neurologic examination: Assess reflexes, strength, and feeling in the muscles; the affected arm lacks the Moro reaction.

What results in adult cases of Erb’s palsy (brachial plexus injuries)?

For both adults and teenagers, brachial plexus injuries are most frequently caused by traffic accidents, particularly those involving motorcycles.
In addition, bullet or knife wounds, workplace accidents, contact sports incidents (like football), complications during surgery, or tumors can cause these injuries.
Men are subject to these kinds of injuries more often than women.

What is the treatment for Erb’s palsy?

Medicines:

Pain control: In order to treat pain caused on by tense muscles or irritated nerves, a doctor may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) or other medications.

Management of Physiotherapy:

The goals:

Reduce the pain and suffering
Increase the degree of mobility
Reduce spasms and tightness in the muscles
Avoid deformities and contractures
Improve the power and strength of your muscles
Improve the daily activities

Pain Reduction:

Heat therapy: Applying heat such as with warm baths or moist heat packs can help blood flow, relax muscles, and relieve stiffness and pain.

Cold therapy: Applying ice packs or cold packs can numb pain, reduce inflammation, and relax the symptoms of acute pain.

Electrical stimulation: Electrical muscle stimulation (EMS) or transcutaneous electrical nerve stimulation (TENS) can help relax muscles and minimize feelings of pain.

Ultrasound (Therapeutic machine) therapy: When high-frequency sound waves are applied to the skin, deep tissue heat is produced. This helps reduce pain, inflammation, and spasms in the muscles.

Reduce spasms and tightness in the muscles:

Flexibility can be increased and muscle tightness can be decreased with mild stretching exercises that target the tense muscles.

Controlled, repetitive motions that progressively expand range of motion and relax muscle tension are the basis of dynamic stretching.

Static stretching extends muscles and releases tension by maintaining a stretch posture for a while.

Muscle spasms can be decreased blood flow can be increased, and muscles can relax when heat is applied to the affected area.

TENS may interfere with pain signals, but EMS may stimulate relaxation by contracting muscles.

Improve movement:

Joint mobilization: Mild motions performed on the joints can help them move more freely, become less stiff, and relax pain got on by joint dysfunction.

Soft tissue mobilization: To alleviate pain, promote circulation, and minimize muscle tension, therapists apply manual methods including myofascial release, massage, and stretching.

Slow passive movement is necessary to preserve muscle properties.

Exercises for range of motion: The goal of physiotherapy is to either maintain or improve the range of motion in the afflicted shoulder and arm joints.

Avoid deformity and contracture:

In order to avoid deformities and contractures, proper positioning is important. In order to maintain the child’s ideal alignment and joint integrity, physiotherapists instruct parents and other caregivers on how to properly position the child’s body during rest and activity.

To avoid contractures, certain stretches focus on tight muscles and connective tissues. Stretching should be done gently and on a regular basis to prevent pain or injury.

It may be advised to wear orthotic devices, such as braces or splints, to support correct alignment, avoid contractures, and support proper positioning during rest or activity periods.

Surgical Treatment:

If, by the time your child is six months old, their palsy does not improve, your doctor may recommend surgery, such as;

Nerve restoration

Nerve grafts, transfers, decompressions, and neurolysis are among these surgical procedures.

Muscle restoration

To take the place of the damaged tissue, a muscle or tendon transfer from another area of the body is used.

It is important to recognize that nerve regeneration and healing in any form takes time; results do not appear right away.

Prevention:

Diabetes in the prenatal parent, either gestational or prenatal.
A mother who is overweight or obese at the time of birth, or both.
A history of shoulder dystocia during pregnancy.
Carrying multiple children during pregnancy.
Breech birth position: the baby enters the delivery canal without its head first.

Summary:

Erb’s palsy is a disorder that results in arm weakness or paralysis; it typically affects newborns whose shoulders are injured during childbirth. The brachial plexus, a network of nerves close to the neck that regulates movement and sensation in the shoulder, arm, and hand, is the source of the injury.

The most common cause of Erb’s palsy is shoulder dystocia, a difficult delivery where the baby’s shoulder gets stuck in the birth canal. This can happen if the baby is large, breech (feet-first), or in a face presentation.

Some babies regain full function, and most recover in a matter of months. It’s important to get involved early.

FAQ:

Is Erb’s palsy completely curable?

The condition known as Erb’s palsy resolves in a few months in mild cases with timely and suitable therapy. But extreme cases may never fully recover, even with treatments and surgery. The best line of security against your child receiving ineffective treatment is early detection of Erb’s palsy.

Why is the condition known as Erb’s palsy happening?

An injury received either during birth or later in life can cause muscular weakness in the arm or shoulder, which is known as Erb’s palsy. In babies who experienced shoulder injuries during delivery, it is most common.

How does Erb’s palsy express itself?

One of the signs of the condition Erb’s palsy is loss of motion and arm weakness. Both newborns and adults may experience it. The brachial plexus is usually injured by a traumatic force applied downward on the upper arm and shoulder during newborn delivery, or by a physical injury sustained during that process.

Does Erb’s palsy hurt?

The brachial plexus may stretch or be shocked, but it does not tear, making it the least severe type of Erb’s palsy. It can still cause burning pain, and your child may feel extremely uncomfortable for three months or so, even though it usually heals completely.

What makes Klumpke’s palsy different from Erb’s palsy?

Where the musculocutaneous nerve damage takes place divides klumpke’s palsy from Erb’s palsy. Erb’s palsy is a result of injury to the upper brachial plexus.
An injury to the lower brachial plexus causes Klumpke’s palsy.

What part does physiotherapy play in treating Erb’s palsy?

By doing this, the joint will not become permanently stiff and will become more independent when it comes to daily tasks like getting dressed, eating, and playing with friends and family. For the best chance of recovery, physiotherapy treatment should start as soon as possible.

What Are Erb’s Palsy’s Typical Symptoms?

The most typical signs of Erb’s palsy are loss of sensation or motor function in the hand, shoulder, or arm. A more severe case could result in partial or complete paralysis of the limb. In the initial days or months following the birth of your child, symptoms might not always be obvious.

What Is Erb’s Palsy’s Prognosis?

A lot of mild cases of Erb’s palsy will go away on their own in without any kind of treatment. These cases typically resolve in a few weeks or months. But Erb’s palsy doesn’t always get better on its own. In severe cases of Erb’s palsy, surgery may be necessary to restore normal function to the hand or arm.

Regarding Erb’s palsy, which nerves are involved?

When the cervical nerves 5 and 6 are severed from the upper trunk of the brachial plexus, erb palsy results.

What is the weakness of Erb’s palsy?

Brachial plexus palsy, which may happen during childbirth, is the result of severe brachial plexus injury that causes weakness or paralysis in certain arm regions. Erb’s palsy is the type of brachial plexus palsy that occurs most frequently. Childbirth can result in brachial plexus palsy.

Erb’s palsy: is it preventable?

It varies. There are risk factors for Erb’s palsy in certain cases, and they might not be preventable. On the other hand, poor delivery care is the root cause of many cases. Some medical personnel may deliver a patient with excessive force, which could harm the brachial plexus. Medical negligence might be to blame in these cases.

References:

“Brachial Plexus Harm: The signs and Causes” by Mayo Clinic (2024, March 27). The Mayo Clinic. You can find out more about the signs, causes, and treatments of brachial plexus injuries by clicking this link.

Causes, Diagnoses, and Treatments for ERB’s Palsy | Health Baptist. (n.d.). Baptist Medical Center. The website of Baptist Health offers information on conditions, treatments, and erbs palsy.

B. I. J. Center (2023, November 26). Causes, Signs, Treatments, and Prognosis of Erb’s Palsy. Birth-related injuries. Erbs palsy: https://www.childbirthinjuries.com/

C. C. M., Professional (n.d.-h). Erb’s Palsy. Cleveland Medical Center. 21986-erbs-palsy can be found under https://my.clevelandclinic.org/health/diseases.

2024, April 15; Dalwani, D. Exercises, Treatment, and Symptoms of Erb’s Palsy. Treatment and exercise in physical therapy. [Pathological-therapy.us/erbs-palsy]

Madhani, N. B., Ali, C. D. M., and Basit, H. (2023, April 8). https://www.ncbi.nlm.nih.gov/books/NBK513260/#:~:text=Erb%20palsy%2C%20or%20Erb%2DDuchenne%20paralysis%2C%20is%20a%20paralysis,C6%20of%20the%20brachial%20plexus. Erb Palsy. StatPearls – NCBI Bookshelf.

Image brachial plexus, OrthoInfo – AAOS – Brachial Plexus Injuries (n.d.). Brachial plexus injuries: https://orthoinfo.aaos.org/en/diseases-conditions/