ERB'S palsy

1. Brachial Plexus Injury
In Newborn
Dr Kanij Fatema
Associate Professor
Pediatric Neurology
BSMMU

2. • 13 days old girl came to
the OPD with decreased
movement of right arm
• There was history of
prolong labour and
normal vaginal delivery
• On examination, tone of
the right upper arm was
reduced
• Biceps jerk was absent
• Movement of the wrist
joint was present

3. • Video

4. Brachial Plexus
• Nerve roots from the fifth cervical through the first
thoracic nerves form the three primary trunks of the
brachial plexus
• Once formed, they divide promptly into anterior and
posterior divisions
• The posterior divisions join to form the posterior
cord, which gives rise to the upper and lower
subscapular, thoracodorsal, axillary, and radial nerves

5. • The anterior divisions of the fifth, sixth, and seventh
nerves form the lateral cord, and the anterior divisions
of the eighth cervical and first thoracic nerves form the
medial cord
• The lateral cord subsequently gives rise to the
musculocutaneous nerve and a branch to the
coracobrachialis.
• The medial cord gives rise to the ulnar, medial
antebrachial cutaneous, and medial brachial cutaneous
nerves
• Additional branches from the lateral and medial cords
unite to form the median nerve

7. Brachial Plexus Injury
• Birth-related brachial plexus injuries occur in 0.5-5
infants per 1000 live birth
• The incidence ranges globally from 0.2-4% of live births
• According to the World Health Organization,
prevalence is generally 1-2% worldwide, with the
higher numbers being in underdeveloped countries
• Also known as Obstetrical brachial plexus injuries

8. Etiology
• Excessive traction to the affected extremity during
breech delivery
• Traction to the head and neck during vertex delivery
• Shoulder dystocia
• Large birth weight (>4000 g)
• Can occur in the absence of fetal trauma
 One study showed that 50% of Erb’s palsy occur in normal-
sized infants without trauma at delivery

9. May be associated with
clavicle fracture in 10%
of cases and humerus
fracture in 10 % cases

10. Pathophysiology
• A first-degree injury, or neurapraxia, involves a temporary
conduction block with demyelination of the nerve . Complete
recovery occurs. Recovery may take up to 12 weeks
• A second-degree injury, or axonotmesis, results from a more
severe trauma or compression The endoneurial tubes remain
intact, and the recovery, therefore, is complete
• A third-degree injury ,the endoneurial tubes are not intact.
The pattern of recovery is mixed and incomplete
• A fourth-degree injury results in a large area of scar at the site
of nerve injury. No improvement in function is noted, and the
patient requires surgery to restore neural continuity
• A fifth-degree injury is a complete transection of the nerve.
Similar to a fourth-degree injury, surgery is required

11. Types
• Erbs Palsy (80–90 percent )
• Klumpkes Palsy
• Total plexus involvement
• Bilateral involvement (10 to 20%)
• Brachial neuritis (rare, may be associated
with DPT vaccinations)
• Recurrent inherited brachial plexus neuritis

12. Erb’s Palsy
• The most common form of brachial plexus
• 80–90 % of all cases
• Damage of the fifth and sixth cervical nerves or the
upper trunk of the brachial plexus result in paralysis
of the upper arm
• The deltoid ,biceps, brachialis, supinator, and
extensors of the wrist and finger muscles are
paralyzed

13. • The infant typically lies
with
 Humerus adducted
and internally rotated
 The elbow extended
 Forearm pronated
 Wrist flexed
• The biceps reflex is
absent

15. • The most common associated (not causative)
injuries include the following:
• Clavicular and humeral fractures
• Torticollis
• Cephalohematoma
• Facial nerve palsy
• Diaphragmatic paralysis

16. Workup
• Lab studies generally
are not necessary for
the diagnosis of brachial
plexus palsy
• X ray arm( to exclude
fracture)
• X ray chest ( to exclude
paralysis of
hemidiaphragm)
• MRI of the plexus
( before surgery to
determine the extent of
injury)
• NCS and EMG
(controversial)

17. Treatment
• Counseling
• Gentle handling (as the injury is painful and there
is chance of extension of injury)
• Immobilization not recommended
• Passive range of motion ( to prevent contracture
of the shoulder) : start after 10 to 14 days
• Surgery
• Botulinum toxin might be recommended to
reduce contracture

18. Occupational therapy
• Throughout the first six months , OT is the mainstay
of treatment
• As the child gets older, bimanual activities (eg,
swimming, basketball, wheelbarrow walking,
climbing) should be encouraged
Exercises are intended to:
• Maintain joint mobility
• Prevent contractures
• Provide sensory input for sensory stimulation

19. • Therapy alone is usually sufficient for mild brachial
plexus injuries
• Therapy also is a prerequisite for successful surgery,
if surgery is necessary
• If contracture develops :Static and dynamic splinting
of the arm is useful to reduce contractures to
prevent further deformity
• Commonly prescribed splints include resting hand
and wrist splints, elbow extension splints, dynamic
elbow flexion and supinator splints

21. Surgery
• Surgery for newborn brachial nerve lesions is
becoming more popular, especially when electrical
physiologic and neuroimaging data indicate primary
injury to the plexus and no nerve root evulsion
• Primary nerve reconstruction, followed by
appropriate tendon transfers
• Surgical intervention may benefit 20–25 percent of
all patients

22. Outcome
• Although quick recovery may be observed, complete
recovery may take many months
• Good return of hand and arm function by 6 months
is a good prognostic sign
• In a study (Waters, 1999), 80 to 90 percent of 66
patients with brachial plexus injuries experienced a
spontaneous return of function

23. Klumpke’s paralysis
• Injury to the lower trunk of the plexus, involving the
C8 and T1
• This condition is rare(less than 1 %)
• Weakness of the forearm extensors, flexors of the
wrist and fingers, and intrinsic muscles of the hand
occurs
• Horner’s syndrome is often present as a result of
involvement of the sympathetic fibers accompanying
T1

24. • The elbow is typically
flexed
• The forearm is supinated
• The wrist is extended
• A clawlike deformity of
the hand with
hyperextension of the
wrist and fingers
• The triceps reflex may be
diminished, and the grasp
reflex is usually absent

25. Total brachial plexus involvement
• 10 % of brachial palsy of newborn
• The arm hangs limply from the shoulder
• No muscle movement
• Tendon areflexia
• Decreased sensation over the arm and hand
• The outlook for recovery after complete brachial
plexus injury is poorer than the others

26. Recurrent inherited brachial plexus neuritis
• Hereditary neuralgic amyotrophy
• Carried on chromosome 17q25.3
• Autosomal dominant disorder
• The long thoracic nerve is involved
• Lumbar plexus involvement may be noted
• The condition is believed to be an immune complex
disease that causes damage to blood vessel walls

27. Clinical features
• Pain
• Brachial plexus-innervated muscle weakness
• Tendon reflexes are reduced
• Scapular winging present
• Autonomic nerves are affected
• Short stature, hypotelorism, small face and
palpebral fissures, prominent epicanthal folds,
and syndactyly are part of the syndrome

28. • In most cases recovery occurs spontaneously
• NCV and EMG to detect axonal loss
• No specific treatment

29. In a nut shell

31. Take Home Message
• Brachial plexus injury in newborn is not uncommon
• Most of the newborns recover
• Occupational therapy is the cornerstone of therapy

32. Occupational therapy
• Video

33. Thank You