Erb's palsy is the result of damage to the set of nerves (brachial plexus) that controls the muscles and movement of the arms, hands and fingers. The severity of an Erb's palsy depends on the degree of damage to the nerves. Brachial plexus injury (Erb's palsy) is usually a birth injury caused by physical trauma to the newborn during the delivery.
Most injuries to the brachial plexus occur at birth as a result of forcible traction of the baby in the presence of an obstetrical complication. Brachial plexus injuries are more often than not the result of traumatic stretching (lateral traction) of the plexus during the birth of the child. Failure of the medical provider assisting a delivery to take the necessary precautions and perform each obstetrical procedure correctly usually underlies the appearance of an Erb's palsy. In most instances, Erb's palsy is usually a preventable injury. Obstetrical situations that create conditions that can cause Erb's palsy include:
Large infant for gestational age (over 8 & 1/2 pounds)
Gestational diabetes' infant
Excessive weight gain during pregnancy
Prior obstetrical history of delivering large infants
Pregnancy beyond 40 weeks
Abnormal bony pelvis
The three types of brachial plexus injuries are classified as: (1) 'Stretch injury' which may spontaneously recover in 1-2 years of age with substantial recovery of function; (2) 'Rupture injury' when nerves are torn in one or more places within the brachial plexus and surgery is required to repair such an injury; and (3) 'Avulsion injury' which is the most severe type of Erb's palsy caused by nerves of the brachial plexus tear completely off from their spinal cord origin resulting in a total flaccid arm. Surgery is required to repair an avulsion type injury. A later complications also resulting in Erb's palsy results from the formation of a (4) neuroma which is a form of scar tissue that forms around the site of nerve injury when the nerve attempts to repair itself. Surgery is required to repair the formation of a neuroma.
Erb's palsy most commonly involves the C5 and C6 nerve roots. Brachial plexus injuries range from mild neuropraxia with early recovery to complete disruption with no potential for recovery. Nerve lesions can be pre- ganglionic or post-ganglionic. Pre-ganglionic lesions are associated with a worse prognosis. Pre-ganglionic lesions are more common in breech deliveries. Birth injuries usually produce lesions of the axillary nerve, musculocutaneous nerve and suprascapular nerve. Muscles most often paralyzed include the supraspinatous and infraspinatous. In most severely affected children, the deltoids, biceps, brachialis and subscapular muscles are also involved. Electromyogram (EMG) helps to distinguish reversible vs. irreversible nerve injury and helps to map out the anatomy of the injury. Evidence of biceps function on EMG before 6 months of age are associated with near normal function.
The extent of nerve damage correlates with degree of the resulting Erb's palsy. Every child is affected to a different degree depending on the extent of injury and location of the brachial plexus. Some children would have no muscle control or sensation in the arm or hand while another would be able to move the arm but not the hand and/or fingers.
A variation of Erb's palsy which affects the lower nerves of the brachial plexus is known as 'Klumpke's Palsy' in which injury to the lower roots (C8 and T1 and/or C7) produces weakness intrinsic to the hands and fingers. Klumpke's palsy is usually a pre-ganglionic lesion with sensory deficit along the medial aspect of the arm, forearm and hand. Sometimes, Horner's syndrome can be associated with this type of palsy.
Management of Erb's palsy will depend on the amount of clinical and electromyographic retained function. Exercise and physical therapy can aid in the recovery of an Erb's palsy. Surgical intervention is required when spontaneous and /or assisted recovery is ineffective. Nerve grafting, tendon transfers, release of subcapsularis and release of contractures are some of the treatments. Untreated brachial plexus injuries lead to muscle contractures, arms deformities and risk of subluxation. Surgical therapy is most effective between 5 and 12 months of age.
Failure of the medical provider assisting a delivery to take the necessary precautions and perform each obstetrical procedure correctly ( negligence) usually underlies the appearance of an Erb's palsy. The most common factors associated with causing an Erb's palsy are:
Obstetrician's lack of experience
Failure to diagnose a large for gestation infant
failure to perform an indicated cesarean section
Failure to diagnose an abnormal labor
Use of instrumentation or Pitocin to accelerate the delivery of a large infant
Failure to manage shoulder dystocia appropriately
If your child suffered an Erb's Palsy, the injury may have been diagnosable, avoidable or preventable, or plainly resulted from a medical provider's mistake in handling an obstetrical condition, you and your child are entitled to receive compensation. If your child's condition was the result of medical negligence, Dr. Borten and the medical malpractice attorneys at Gorovitz & Borten can help you assert your rights and get the compensation you deserve.
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