Brachial plexus palsy, also known as Erb's palsy, is a paralysis or weakness of the arm caused by an injury to one or more nerves that control and supply the muscles of the shoulder and upper extremities (upper brachial plexus). It is more commonly seen in newborns (neonates) and is often the result of a difficult delivery. When it occurs in adults, the cause typically is an injury that has caused stretching, tearing or other trauma to the brachial plexus network. The brachial plexus is the network of nerves that conducts signals from the spine to the shoulder, arm, and hand.
There are four types of brachial plexus injury, avulsion, the most severe type, in which the nerve is ripped from the spine, rupture, in which the nerve is torn but not at the point at which it is attached to the spine; neuroma, in which the nerve is torn and has tried to heal but scar tissue has grown around the site; and neuropraxia (stretch), the most common form of injury, in which the nerve has been damaged but not torn.
Brachial plexus palsy is a paralysis of the shoulder and upper part of the arm. It is most often seen in newborns. This disorder is characterized by an abnormal positioning (adduction) and internal turning of the shoulder with forearm rotation. This rotation causes the hand to be turned downward (pronation). On the affected side, there may also be paralysis of the diaphragm, a loss of feeling and a wasting of the muscles (atrophy). The wrist and hand are usually not affected by any loss of feeling or function.
The disorder is usually spotted at birth or shortly thereafter. One or more members of the delivery team will notice that the newborn does not move the upper or lower parts of the arm or hand on the affected side. The grip of newborn on the affected side will be noticeably weaker than the grip on the unaffected side. The startle reflex (Moro Reflex) will not be present on the affected side. Finally, the infant’s arm will be held awkwardly compared to normal carriage; on the affected side, the arm will not easily assume the normal position with the arm held against the body and bent at the elbow.
Other symptoms of those affected include a limited active range of motion of the entire arm or part of the arm, limpness, weakness of the affected muscles, lack of sensation in the arm or hand, and poor weight-bearing ability of the arm.
Brachial plexus palsy is an injury to the nerve roots and surrounding nerves of the upper brachial plexus. This type of nerve injury may be caused by abnormal stretching (traction) of the shoulder during a difficult delivery such as when the buttocks present first. Sometimes, the injury occurs in the course of an otherwise normal delivery when there is excessive sideways movement of the neck.
Newborns may present with varying kinds of paralysis. Brachial plexus injuries primarily affect the upper arm, while Erb’s paralysis affects both the upper arm and the rotation of the lower arm and hand. A related condition, known as Klumpke paralysis, affects the hand on the affected side and is caused by injury to the lower trunk nerves.
Among adults, these injuries may occur as a result of trauma from automobile accidents, sports injuries, or occasionally even puncture wounds, including animal bites.
Brachial plexus palsy is an uncommon disorder that affects males and females in equal numbers. It is most often seen in newborns, but injuries caused by abnormal stretching of the shoulder may cause brachial plexus palsy at any age. The incidence is estimated at 1 per 2,000 live births.
Treatment of brachial plexus palsy usually consists of physical therapy and splinting of the affected area. Improvement is usually rapid, but in some cases surgery may be necessary to repair the damaged nerves. Other treatment is symptomatic and supportive.
It is important to initiate evaluation and, if necessary, treatment as soon as possible. Infants whose injury occurs at birth may be seen by a physical or occupational therapist during the first few weeks of life.
In many cases, recovery is complete. The location and type of injury are important in determining the extent of recovery.
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Strombeck C, Forssberg H. Obstetric Brachial Pleus Palsy. In: NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:571-72.
Berkow R, ed. The Merck Manual-Home Edition.2nd ed. Whitehouse Station, NJ: Merck Research Laboratories; 2003:581-82.
Beers MH, Berkow R, eds. The Merck Manual, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:1490-91; 2132-33..
Hoeksma AF, ter Steeg AM, Nelissen RG, et al. Neurological recovery in obstetrical brachial plexus injuries: an historical cohort study. Dev Med Child Neurol. 2004;46:76-83.
Hoeller U, Rolofs K, Bajrovic A, et al. A patient questionnaire for radiation induced brachial plexopathy. Am J Clin Oncol. 2004;27:1-7.
Friedenberg SM, Hermann RC. The breathing hand: obstetric brachial plexopathy reinnervation from thoracic roots? J Neurol Neurosurg Psychiatry. 2004;75:158-60.
Kline DG, Kim DH. Axillary nerve repair in 99 patients with 101 stretch injuries. J Neurosurg. 2003;99:630-36.
Gei AF, Smith RA, Hankins GD. Brachial plexus paresis associated with fetal neck compression from forceps. Am J Perinatol. 2003;20:289-91.
Al-Qattan MM. Obstetric brachial plexus palsy associated with breech delivery. Ann Plast Surg. 2003;51:257-64; discussion 265.
Gherman RB, Ouzounian JG, Satin AJ, et al. A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies. Obstet Gynecol. 2003;102:544-48.
Blaauw G, Sloof AC. Transfer of pectoral nerves to musculocutaneous nerve in obstetric upper brachial plexus palsy. Neurosurgery. 2003;53:338-41; discussion 341-42.
Bellew M, Kay SP. Early parental experiences of obstetric brachial plexus palsy. J Hand Surg [Br]. 2003;28:339-46.
Kim DH, Cho YJ, Tiel RL, et al. Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Science Center. J Neurosurg. 2003;98:1005-16.
Bisinella GL, Birch R, Smith SJ. Neurophysiological prediction of outcome in obstetric lesions of the brachial plexus. J Hand Surg [Br]. 2003;28:148-52.
La Scala GC, Rice SB, Clarke HM. Complications of microsurgical reconstruction of obstetrical brachial plexus palsy. Plast Reconstr Surg. 2003;111:1383-88; discussion 1389-90.
Bahm J, Meinecke L, Brandenbusch V, et al. High spatial resolution electromyography and video-assisted movement analysis in children with obstetric brachial plexus palsy. Hand Clin. 2003;19:393-99.
Zaneteas PD. Brachial plexus injuries and the electrodiagnostic examination. Curr Sports Med Rep. 2003;2:7-14.
Marcus JR, Clarke HM. Management of obstetrical brachial plexus palsy evaluation, prognosis and primary surgical treatment. Clin Plast Surg. 2003;30:289-306.
Dunham EA. Obstetrical brachial plexus palsy. Orthop Nurs. 2003;22:106-16.
Argoff CE. A focused review on the use of botulinum toxin for neuropathic pain. Clin J Pain. 2002;18(6 Suppl):S177-81.
Sandmire HF, DeMott RK. Erb’s palsy without should dystocia. Int J Gynaecol Obstet. 2002;78:253-56.
Ruhmann O, Schmolke S, Gosse F, et al. Transposition of local muscles to restore elbow flexion in brachial plexus palsy. Injury. 2002;33:597-609.
Jennet RJ, Tarby TJ, Krauss RL. Erb’s palsy contrasted with Klumpke’s and total palsy: different mechanisms are involved. Am J Obstet Gynecol. 2002;186:1216-19; discussion 1219-20.
FROM THE INTERNET
NINDS Brachial Plexus Injuries Information Page. Reviewed 04-02-2003. 4pp.
NINDS Erb-Duchenne and Dejerine-Klumpke Palsies. Reviewed 07-27-2003. 4pp.
Roye BD. Brachial palsy in the neonate. Medical Encyclopedia. MedlinePlus. Update date: 7/27/2002. 3pp.
Vaca FE, Young O. Brachial Plexus Injury. emedicine. Last Updated: November 28, 2001. 11pp.