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Erb's Palsy & Brachial Plexus Injuries
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Perhaps the most common nerve injury in infants occurs at the time of birth. It is also called brachial palsy and involves a weakness or paralysis of one of the arms of the infant caused by damage to the brachial nerve plexus that runs along the armpit area. It happens when the infant's shoulders are stuck in the birth canal and the doctor doing the delivery pulls too hard on the head in one direction that pulls or breaks the delicate nerves in the armpit and shoulder area.
There are different forms of brachial plexus injuries in the infant, depending on the location of the injury. This can include brachial plexus injuries that only affect the upper part of the arm, Erb's palsy, which affects the upper arm and the way the lower arm is rotated, and Klumpke paralysis, which affects the infant's hand. Incidentally, there can be a droop of the infant eyelid on the opposite side of the body.
The symptoms are often seen soon after birth. The typical Moro reflex is lost on one side of the body in the arm and the arm is generally held flexed at the elbow, held tight against the body. There is a poor grip or grasp on one side of the body and a lack of movement in a spontaneous way on the upper or lower arm. The hand can be affected as well.
Causes of Erb's palsy and other brachial plexus palsies include difficulty in the delivery of the infant. If the infant's head is of normal size but the shoulders are large and out of proportion to the head, the shoulders can get stuck. Too much pulling on the head can contribute to Erb's palsy. A breech delivery can cause excessive tugging on the upper arms as they descend the birth canal and one or both sides of the body can be affected. There is an increased risk of Erb's palsy in situations involving a breech delivery (fortunately uncommon in today's medicine), having a bigger than average sized newborn infant and having shoulder distocia or stuck shoulders. The advent of cesarean sections has greatly reduced the number of infants that suffer from brachial plexus injuries and other nerve injuries. Fewer instruments are used today to deliver infants so that tugging and pulling are gentler than before.
Certain physical exams and tests can be done to confirm the diagnosis of Erb's palsy or other brachial plexus palsy. The physical exam can confirm the weakness of the muscles and the lack of Moro reflex on the side of the body affected by palsy. If the infant has only weakness or pseudoparalysis of the arm, the Moro reflex will be intact. (In pseudoparalysis, there is actually a fracture of the arm or clavicle that makes movement painful enough to decrease movement of the arm). Another test involves rolling the infant from side to side. The affected arm will be floppy if brachial plexus palsy is involved.
Treatment of brachial plexus palsy involves gentle massage of the affected arm and mild range of motion in order to revive the nerves. If strength to some degree has not returned by the age of three to six months, surgery can be done to connect the nerves and restore function to the arm. There can also be surgeries called tendon transfers that can help the function of the arm and make it work better. In pseudoparalysis, the infant really has a fracture and will begin moving the arm as soon as the fracture heals and the pain is diminished.
What's true is that most infants recover by the age of six months but those that do not recover by then often do not have a good outcome and will need multiple surgeries and will have a residual deficit of the affected arm.
Erb's palsy and other brachial nerve injuries can be prevented by predicting large babies in advance and expecting the potential for complicated deliveries so that there is no tugging on the affected body areas that cause brachial plexus injuries to occur in the first place.