The Facts About Erb's Palsy: A Tragic Injury

I was born with a condition called Erb's palsy (or brachial plexus palsy) which is a nerve injury that occurs in the upper group of an arm's main nerves called the Erb's Point (or brachial plexus) and results in paralysis of the arm. But I'm not going to write about my story yet. Today, I'm just going to write an informative article about this rare condition to raise awareness and caution future parents.

Erb's palsy is almost always caused during birth, but this injury can also occur in later years by any kind of accident to which would cause severe damage to the shoulder and neck. Roughly one out of every thousand births result in a brachial plexus injury and every one out of ten of those injuries will be serious enough to require some kind of treatment. The injury happens due to a shoulder dystocia, which occurs in the birthing canal when a baby's shoulders get stuck. Excessive pulling on the shoulders to free the baby stretches the nerves and muscles to a traumatic degree.

The damage done to the brachial plexus nerves can range between bruising to tearing. There are four different types of injury that a baby can experience. An avulsion is when the nerve has been torn away from the spine and is the most severe. A rupture is when the nerve tears, but doesn't tear away from the spine. A neuronal is when a nerve attempts to heal itself and causes scar tissue to develop at the site of the injury which then exerts pressure on the injured nerve and prevents signals between the nerve and muscle. A praxis is when the nerve is bruised, but doesn't tear which, like every other bruise, will heal on its own with improvement showing within three months.

Depending on the injury, a baby may experience partial or complete paralysis in the affected arm. Most babies are only mildly injured and will therefore heal themselves soon after birth. However, with the unlucky few, the damage done to the Erb's Point can permanently impair development in the muscular, circulatory, and nervous systems. A lack of muscular development not only leads to a weaker arm, but also affects the arm's mobility which causes most patients to be unable to lift the injured arm above shoulder height without help. Many may develop an elbow contracture as well. A lack of circulatory development results in both the injured arm being unable to regulate temperatures and it takes longer for skin damage to heal which make cuts very susceptible to infection. The lack of nervous development, the most devastating and the most varying, generally affects between the shoulder and elbow because that's where the trauma to the nerves occurred. The nerves most affected by this palsy are the suprascapular, musculocutaneous, and axillary. Aside from the systems being dysfunctional there maybe also be stunted growth in the affected arm ranging from just arm length to everything from shoulder to fingertips.

An affected baby may alert medical staff by typically holding the injured arm at their side with the forearm turned in and the wrist bent. They will keep their arm in this position as much as they can. If their injury is severe then they may also have a droopy eyelid on the affected side. Once doctors suspect the condition they will properly diagnose the infant through neck x-rays, an MRI, and possibly nerve conduction tests if necessary. A pediatric neurologist will also evaluate the degree of injury to assess what can be done. Therapists will also design special splints or slings for the patient and teach parents special exercises to keep the arm functioning as much as possible.

As already stated, Erb's palsy usually heals by itself with the help of physiotherapy, but when this is a more serious injury then neonatal or pediatric neurosurgery is needed. There are three different types of surgery that can be done with the most common being a nerve transfer. This is generally performed on babies under nine months old because of the rapid rate that they develop which increases the effectiveness of the surgery. Performing this procedure on babies older than nine months poses more of a risk than a help because nerve damage can start to occur in the area where the nerves were taken from. Another surgery option is a subscapularis release where a "Z" is cut into the subscapularis muscle to provide stretch within the arm. This can be carried out repeatedly on the same arm as the muscle develops, but eventually this will compromise the muscle's integrity. The last option is a Latissimus Dorsi tendon transfer which involves cutting the Dorsi horizontally and pulling it around the bicep to provide external rotation, but this comes with increased sensitivity to the bicep as the Dorsi has about double the nerve endings per square inch than other muscles.

More than one surgery may be necessary depending on how the body reacts. Injuries that involve nerves below the elbow have a less successful rate of improvement because of their location. The distance makes it very difficult to heal. The main goals of therapy either by itself or after surgery is to ensure that the child is able to feed his or her self and be able to use the affected arm to help the other in lifting and carrying things. Unfortunately, by the age of two, if the child hasn't fully recovered then they never will as the body has developed too much to go back and repair the nerves.

Like most injuries, Erb's palsy can be easily prevented by taking pre-cautions. Pregnant mothers must maintain the usual good health and should pay attention to blood sugar levels in order to prevent rapid weight gain because larger babies are more likely to get stuck. If the baby is though to be too large to have a safe natural birth then obstetricians need to discuss alternative plans with the parents such as a Cesarean section or being induced earlier before the baby gets too big. Parents need to be anticipating this decision making well in advance to prevent a last minute crisis during delivery.

A Cesarean section should be heavily considered if any of the following risks occur: prior dystocia incidents with previous children, a larger baby, or the mother has a small or unusually shaped pelvis. Use of labour inducing drugs, prolonged labours, precipitous deliveries, breech position, and fetal malposition in the birth canal should also end in an emergency Cesarean. If, despite the parent's best efforts, a shoulder dystocia still occurs in a natural birth then there are several techniques and maneuvers that can be performed by medical staff to dislodge the baby's shoulder.

Needless to say, a child that grows up with Erb's palsy, such as myself, gathers a rather large amount of self-conscious feelings about their injured arm as they're unable to fully participate in a lot of activities. Also, explaining something so unheard of to curious students and teachers is cause enough for embarrassment. However, it is possible to lead a normal life and be happy, but I do admit that I sometimes feel like I'm missing out. That's for another day though as I plan on writing that article about my experience with Erb's palsy real soon.

I hope this article was helpful for you guys. The links below were great for getting information for this article and I recommend checking them out if you have further questions. Also, check out fellow CP PenPress' article, "How A Pregnancy Can Go Wrong: Erb's Palsy" for a traumatic personal experience with the condition.