Erb's Palsy: Symptoms, Causes, Diagnosis and Treatment

Written by Medicover Team and Medically Reviewed by Dr Ganisetty L V S Durga Parasuram , Pediatric Surgeon

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1. Causes 2. Find a Doctor 3. Diagnosis 4. Treatment 5. FAQs

Erb's Palsy, also known as Erb-Duchenne Palsy, is a condition caused by injury to the upper brachial plexus nerves (typically C5 and C6), which control movement and sensation in the shoulder, arm, and hand. It most commonly occurs during a difficult childbirth due to excessive stretching of the baby's neck and shoulder, although it can also result from trauma in older children and adults. Symptoms include weakness or paralysis of the affected arm, reduced grip strength, loss of sensation, and the characteristic "waiter's tip" arm position. Early diagnosis, physical therapy, and, in some cases, nerve surgery are essential to maximize recovery, improve arm function, and prevent long-term complications.

What are the Symptoms of Erb's Palsy?

Recognising the symptoms of Erb's Palsy early is important for timely intervention. Common symptoms include:

Weakness in one arm, which may become apparent when the baby has difficulty moving or lifting the arm.
Loss of feeling in the arm or hand can affect the child's ability to interact with their environment.
Partial or complete paralysis of the arm makes it challenging for the child to perform everyday activities.
The arm may hang limp or be bent at the elbow with the hand rotated inward, often referred to as the "waiter's tip" position.
Decreased grip strength on the affected side, which can be observed when comparing the baby's grasp in both hands.

These symptoms can vary in severity depending on the extent of the nerve damage. In some cases, muscle weakness may improve over time, while in others, long-term rehabilitation may be necessary. Early detection and intervention are key to improving outcomes and minimising long-term disability.

What are the Causes of Erb's Palsy?

Erb's Palsy, or brachial plexus injury, happens when the network of nerves that controls the muscles of the shoulder, arm, and hand are damaged. This condition is most often caused by injury during childbirth especially when the baby's shoulder gets stuck behind the mother's pelvis as the baby is being delivered (shoulder dystocia). Some common causes include:

Difficult or Assisted Delivery: Forceful pulling or excessive pressure on the baby's shoulder during delivery can stretch or tear the brachial plexus nerves.
Meconium: Increased birth weight babies have a higher risk for shoulder dystocia, which raises the likelihood of Erb's Palsy.
Breech Birth Position: Complications, including nerve damage, are more common amongst babies born in a breech position (feet or buttocks first).
Slow labour: When labour takes an extended amount of time, it can increase the risk of pulling or traction of the infant's head and neck.
Instrumental Delivery: Forceps and vacuums are some instruments that assist during the time of delivery; injury to the nerves might happen sometimes.

When to See a Doctor for Erb's Palsy?

Parents should seek prompt evaluation if a newborn is unable to move one arm normally or has persistent weakness after birth. A Pediatric Neurologist or Pediatric Surgeon can assess the severity and recommend appropriate treatment.

You should see a doctor if your child experiences:

Weakness or reduced movement of one arm
Persistent abnormal arm position after birth
Delayed improvement in arm function

Seek immediate medical attention if your child:

Has complete paralysis of the arm
Shows severe swelling or signs of fracture after birth
Develops worsening weakness or loss of sensation following trauma

These symptoms may indicate a severe brachial plexus injury requiring urgent specialist evaluation.

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How Is Erb's Palsy Diagnosed?

Erb's Palsy is most commonly diagnosed through a combination of physical examination and imaging studies. A health care provider, typically a pediatrician or neurologist, will:

Physical Examination: The doctor will examine the baby's movement and muscle strength in the affected arm, looking for signs of weakness or paralysis. The arm is also checked for reflexes and sensation.
History Review: The physician will inquire about the birth, including delivery complications such as shoulder dystocia, the delivery by forceps, or vacuum extraction that may be relevant to ascertain the aetiology of nerve injury.

Imaging Tests

To confirm the diagnosis and assess the extent of the nerve damage, doctors may use imaging tests such as:

X-rays: To check for bone fractures or dislocations, which can accompany nerve injuries.
MRI (Magnetic Resonance Imaging): To get detailed images of the nerves and surrounding tissues, helping to pinpoint the location and severity of the damage.
Ultrasound: To evaluate the brachial plexus and provide a non-invasive method of visualizing the affected area.

These imaging tests can provide valuable information for healthcare providers, aiding in the development of a tailored treatment plan. Accurate diagnosis through imaging is essential for determining the appropriate course of action, whether surgical intervention or conservative management.

What are the Treatment Options for Erb's Palsy?

The treatment approach for Erb's Palsy depends on the severity of the condition. Here are some common treatments:

Physical Therapy

Erb's Palsy is often initially treated with physical therapy. It consists of workouts that make the affected arm stronger and increase its range of motion. Parents learn how to do these at-home exercises to keep care consistent. Regular therapy contributes to recovery, helps prevent complications to the musculoskeletal system after discharge, and improves coordination and balance.

Occupational Therapy

Occupational therapy is directed at older children to help improve fine motor skills and work on the affected arm. And it involves you in tasks like dressing and feeding, which develop motor skills and independence. Therapists collaborate with families to design individual treatment plans customized to the needs of the child so that the child meets developmental milestones.

Surgery

In more serious cases, surgery can be required if there's no resolution with therapy. Additional surgical options may involve using nerve grafts to repair the brachial plexus, nerve transfers to reconnect the muscles and muscle or tendon transfers to help restore movement. Surgery is reserved when there is little benefit to non-surgical approaches and a thorough assessment of the risks and benefits.

Botox Injections

Muscle spasticity can sometimes be treated with Botox injections, which can enhance movement. The injections relax overactive muscles, improving the range of motion and reducing pain in the involved arm.

Splinting and Bracing

In addition, splinting or bracing may be employed alongside therapy to stabilize the affected arm, promote better alignment, and facilitate the strengthening of muscles. It helps to keep proper positioning when performing physical activities on these devices.

Spinal Surgery

Rarely is spinal surgery needed to relieve nerve pressure if nerve damage has affected the spinal cord. This may help improve communication between the brain and the affected muscles, which in turn may help recovery.

Therapeutic Ultrasound and Electrical Stimulation

Therapeutic ultrasound and electrical stimulation may also be applied to improve the function of the muscles and maximize the recovery of the injured muscle. These treatments activate muscle fibres and enhance circulation, contributing to the recovery of movement.

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What are the Preventive Measures for Erb's Palsy?

While not all cases of Erb's Palsy can be prevented, certain measures can reduce the risk:

Prenatal Care: Regular check-ups and monitoring of the baby's position during pregnancy help to detect potential risks, such as a large baby or breech position, which can increase the likelihood of Erb's Palsy.
Controlled Delivery: In cases where there are concerns about shoulder dystocia (when the baby's shoulder gets stuck during delivery), doctors may recommend specific manoeuvres or a C-section to avoid excessive pulling on the baby's neck and shoulders.
Appropriate Use of Forceps or Vacuum: Use of Forceps or Vacuum only If Required: If delivery assistance is needed, the appropriate and cautious usage of forceps or vacuum extraction can minimize the risk of damage to the nerves of the baby.
Management of Risk Factors: Complicated pregnancy conditions, such as gestational diabetes, which makes a baby larger than average size, ought to be closely managed throughout the pregnancy to decrease risk factors for complications at delivery.
Proper Training for Healthcare Providers: Ensuring that healthcare professionals are well-trained in recognizing and managing difficult deliveries can help avoid excessive pulling or twisting of the baby's head and neck.
Consideration of Family History: Families with a history of brachial plexus injuries during childbirth may benefit from closer monitoring and planning for delivery with healthcare providers to mitigate risks.

What is the Long-term Outlook for Children with Erb's Palsy?

The prognosis for Erb's Palsy varies. Many children recover fully with proper treatment, especially when the condition is mild. However, in more severe cases, some degree of weakness or loss of function may persist. The long-term outlook largely depends on the severity of the initial injury and the timeliness of intervention.

Support and Resources

It's crucial for parents to seek support and resources to manage the emotional and physical aspects of caring for a child with Erb's Palsy. Support groups, counseling, and educational resources can provide valuable assistance. Connecting with other families facing similar challenges can offer comfort and practical advice.

Access to resources such as specialized healthcare providers and therapists can further enhance the child's development and quality of life. By building a strong support network, families can navigate the complexities of Erb's Palsy with confidence.