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Erb’s palsy is also called Erb-Duchenne palsy; it is a paralysis of the arm caused by an injury to the brachial plexus, a collection of nerves that exit the neck, mix and match into a plexus, and go out to the arm. The main nerves involved in Erb’s palsy are C5 and C6. These comprise the ventral rami of the spinal nerves C5 to C8 as well as the thoracic nerve T1.
The injury (paralysis) comes from shoulder dystocia in a difficult birth. Shoulder dystocia usually comes when an infant is large, and the head is able to exit the birth canal but the shoulders get stuck. In order to get the shoulders out, the doctor can put too much traction on the infant’s head, stretching the neck and doing damage to the nerves of the brachial plexus. Depending on the type of damage, the paralysis can resolve spontaneously over a few months, might require physical therapy to get better or might require surgery. Some cases of shoulder dystocia happen during a breech delivery when everything but the head is out and pressure is put on the neck to get the head out. It can also affect an infant who suffers from a clavicle fracture at birth that is unrelated to dystocia.
A related injury can be seen at any age when there is a trauma to the head and shoulders that causes the nerves of the brachial plexus to stretch violently, resulting in a form of Erb’s palsy unrelated to shoulder dystocia or infancy. Gunshot wounds or violent traction on the arm can result in paralysis of the arm.
The paralysis in Erb’s palsy can be partial or complete and the damage to each nerve can be as simple as bruising to the nerve or as bad as avulsion of the nerve from the spinal cord. The damage is most likely to the nerve root C5 and one can refer to the union of C5 and C6 nerve roots as “Erb’s point”. This point is the furthest point from the force of traction and is, therefore, the first area affected. Erb’s palsy is a lower motor nerve syndrome so the muscles are weak and there is sensibility disturbance of the affected arm.
The nerves most commonly affected in Erb’s palsy are the musculocutaneous nerve, the suprascapular nerve, and the axillary nerve.
The signs and symptoms of Erb’s palsy include a lack of sensation in the affected arm and atrophy and paralysis of the deltoid muscle, the biceps, and the brachialis muscles. The limb often hangs to the side and is rotated medially with an extended forearm and pronated forearm. Flexion power in the elbow is lost and one can’t supinate the forearm. The arm cannot be raised from its side position. Of all muscles, the biceps muscle causes the greatest problems to the arm.
Whenever the injury occurs as an infant or neonate, it affects muscle development and the limb ends up with stunted growth with all aspects of the arm, including the shoulder and the fingers. The arm is much weaker than the one which is unaffected and nervous and circulatory development is diminished. Many develop contracture of the elbow and cannot raise their arm above the level of the shoulder without help.
The poor development of the circulatory system means that the arm has no ability to regulate its temperature, which is a difficult problem during the winter months as the arm can freeze if not protected against the cold. Healing is reduced in the affected limb and infections are possible if wounds are not protected against infection.
The nerve damage is often the most difficult problem of all. Some patients with Erb’s palsy have no sensation whatsoever of the affected limb while others have full sensory perception. The area most commonly affected by sensory loss is the area between the elbow and the shoulder; these are the first nerves damaged by the initial insult.
The appearance of the arm depends on what nerves are involved. Some situations will have the arm unable to straighten or rotate the arm and the arm will feel stiff and crooked. In other cases, the arm will be loose, and the patient will have little control over the arm. Physical therapy and massage can prevent these unusual appearances and can improve function.
In certain cases, the patient may feel a great deal of pain. There may be cramping pain that may be worse if they have slept on the shoulder. It doesn’t affect all patients with Erb’s palsy, but it can be extremely painful to those who have the problem. Patients can even faint or be sick from severe pain. It usually happens in the latter stages of growth but eventually fades with time.
Treatment of Erb’s palsy is sometimes unnecessary as the infant regains normal function on their own; others need intervention by a specialist. A pediatric surgeon is necessary for avulsion fracture repair. If the repair works well, the lesions will heal, and the function will normalize. Even so, physical therapy is required to strengthen the arm, prevent contractures and maximize sensation. If the child has not regained function after one year, he or she is unlikely to regain any further function without help. Some quickly develop arthritis in the affected extremity.
There are three common surgical treatments for Erb’s palsy including nerve transplants from the opposite limb, subscapularis releases, and latissimus dorsi tendon transfers. Nerve transplants are often done on patients who are younger than age 9 months because the procedure is more successful at that age. Subscapularis releases can be done at any time. A “Z” shaped cut is made into the muscle so that it is able to stretch more.
It can be done repeatedly until the desired effect is achieved. In a latissimus dorsi tendon transfer, the latissimus dorsi muscle is cut in half horizontally so that parts of the muscle is pulled around to attach to the outside of the biceps muscle. It provides some degree of external rotation to the arm if it works at all. There will be increased sensitivity of the biceps because the latissimus dorsi has twice the number of nerve endings as the biceps.