Erb's palsy
Encyclopedia
Erb's palsy is a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the upper trunk C5-C6 is severed. These form part of the brachial plexus
, comprising the ventral rami of spinal nerves C5-C8, and T1. These injuries arise most commonly, but not exclusively, from shoulder dystocia
during a difficult birth. Depending on the nature of the damage, the paralysis can either resolve on its own over a period of months, necessitate rehabilitative therapy, or require surgery.
, an abnormal or difficult childbirth or labor. For example, it can occur if the infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal. The condition can also be caused by excessive pulling on the shoulders during a vertex presentation (head first delivery), or by pressure on the raised arms during a breech
(feet first) delivery. Erb's palsy can also affect neonates affected by a clavicle
fracture unrelated to dystocia.
A similar injury may be observed at any age including adults, following a traumatic fall "onto the side of the head and shoulder, whereby the nerves of the plexus are violently stretched: the upper trunk of the plexus sustains the greatest injury, and the subsequent paralysis may be confined to the muscles supplied by the fifth nerve - the deltoid, biceps, brachialis and brachioradialis, with sometimes the supraspinatus, infraspinatus and supinator". "The brachial plexus may also be injured by direct violence or gunshot wounds, by violent traction on the arm, or by efforts at reducing a dislocation of the shoulder joint; the amount of paralysis will depend upon the amount of injury to the constituent nerves"
syndrome associated with sensibility disturbance and vegetative phenomena.
The most commonly involved nerves are the suprascapular nerve
, musculocutaneous nerve
, and the axillary nerve
.
The signs of Erb's Palsy include loss of sensation in the arm and paralysis and atrophy of the deltoid, biceps, and brachialis muscles. "The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm". The resulting biceps damage is the main cause of this classic physical position commonly called "waiter's tip."
If the injury occurs at age early enough to affect development (e.g. as a neonate or infant), it often leaves patients with stunted growth in the affected arm with everything from the shoulder through to the fingertips smaller than the unaffected arm. This also leaves the patients with impaired muscular, nervous and circulatory development. The lack of muscular development leads to the arm being much weaker than the unaffected one, and less articulate, with many patients unable to lift the arm above shoulder height unaided, as well as leaving many with an elbow contracture.
The lack of development to the circulatory system can leave the arm with almost no ability to regulate its temperature, which often proves problematic during winter months when it would need to be closely monitored to ensure that the temperature of the arm was not dropping too far below that of the rest of the body. However the damage to the circulatory system also leaves the arm with another problem. It reduces the healing ability of the skin, so that skin damage takes far longer than usual to heal, and infections in the arm can be quite common if cuts are not sterilized as soon as possible. This will often cause many problems for children since they often injure themselves in the course of their childhoods.
The nervous damage is often the most problematic of the side effects to Erb's Palsy, but it is also the most varying. There have been cases of patients who have lost complete sensory perception within the arm after procedures whereas they had full sensory perception before. The most common area for a loss of sensory perception (except where the arm faces a total loss) is that between the shoulder and the elbow since the nerves which provide information from that area to the brain are also those first damaged in the initial causative trauma.
Neonatal / pediatric neurosurgery is often required for avulsion fracture
repair. Lesions may heal over time and function return. Physiotherapeutic care is often required to regain muscle usage.
Although range of motion is recovered in many children under one year in age, individuals who have not yet healed after this point will rarely gain full function in their arm and may develop arthritis
.
The three most common treatments for Erb's Palsy are: Nerve transplants (usually from the opposite leg), Sub Scapularis releases and Latissimus Dorsi Tendon Transfers.
Nerve transplants are usually performed on babies under the age of 9 months since the fast development of younger babies increases the effectiveness of the procedure. They are not usually carried out on patients older than this because when the procedure is done on older infants, more harm than good is done and can result in nerve damage in the area where the nerves were taken from. Scarring can vary from faint scars along the lines of the neck to full "T" shapes across the whole shoulder depending on the training of the surgeon and the nature of the transplant.
Subscapularis releases, however, are not time limited. Since it is merely cutting a "Z" shape into the subscapularis muscle to provide stretch within the arm, it can be carried out at almost any age and can be carried out repeatedly on the same arm; however, this will compromise the integrity of the muscle.
Latissimus Dorsi Tendon Transfers involve cutting the Latissimus Dorsi in half horizontally in order to 'pull' part of the muscle around and attach it to the outside of the biceps. This procedure provides external rotation with varying degrees of success. A side effect may be increased sensitivity of the part of the biceps where the muscle will now lie, since the Latissimus Dorsi has roughly twice the number of nerve endings per square inch of other muscles.
is credited with the first medical description of an obstetric brachial plexus
palsy. In his 1768 treatise on midwifery, he reported a case of transient bilateral arm paralysis in a newborn after difficult labour.
In 1861, Guillaume Benjamin Amand Duchenne coined the term "obstetric palsy of the brachial plexus" after analyzing 4 infants with paralysis of identical muscles in the arm and shoulder, after publishing his initial findings in 1855. In 1874, Wilhelm Heinrich Erb
concluded in his thesis on adult brachial plexus injuries that associated palsies of the deltoid
, biceps
and subscapularis are derived from a radicular lesion at the level of C5 and C6 rather than isolated peripheral nerve lesions.
, and Canadian journalist Barbara Frum
. Martin Sheen
was injured during birth and developed the condition in his left arm. His difference in arm length and range of motion can be seen in his movies, especially Apocalypse Now
. Another sufferer is British singer-songwriter and artist Matt Parsons
. Despite her condition, professional wrestler Traci Brooks has achieved a successful career. Another is former Iowa Hawkeyes standout defensive lineman Adrian Clayborn
. Additionally, gangster rapper and Academy Award winner DJ Paul
of Three Six Mafia also has a deformed arm from the condition, which he often hides by wearing a cast during public appearances.
Brachial plexus
The brachial plexus is a network of nerve fibers, running from the spine, formed by the ventral rami of the lower four cervical and first thoracic nerve roots...
, comprising the ventral rami of spinal nerves C5-C8, and T1. These injuries arise most commonly, but not exclusively, from shoulder dystocia
Shoulder dystocia
Shoulder dystocia is a specific case of dystocia whereby after the delivery of the head, the anterior shoulder of the infant cannot pass below the pubic symphysis, or requires significant manipulation to pass below the pubic symphysis. It is diagnosed when the shoulders fail to deliver shortly...
during a difficult birth. Depending on the nature of the damage, the paralysis can either resolve on its own over a period of months, necessitate rehabilitative therapy, or require surgery.
Cause
The most common cause of Erb's palsy is dystociaDystocia
Dystocia is an abnormal or difficult childbirth or labour. Approximately one fifth of human labours have dystocia.Dystocia may arise due to incoordinate uterine activity, abnormal fetal lie or presentation, absolute or relative cephalopelvic disproportion, or a massive fetal tumor such as a...
, an abnormal or difficult childbirth or labor. For example, it can occur if the infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal. The condition can also be caused by excessive pulling on the shoulders during a vertex presentation (head first delivery), or by pressure on the raised arms during a breech
Breech birth
A breech birth is the birth of a baby from a breech presentation. In the breech presentation the baby enters the birth canal with the buttocks or feet first as opposed to the normal head first presentation....
(feet first) delivery. Erb's palsy can also affect neonates affected by a clavicle
Clavicle
In human anatomy, the clavicle or collar bone is a long bone of short length that serves as a strut between the scapula and the sternum. It is the only long bone in body that lies horizontally...
fracture unrelated to dystocia.
A similar injury may be observed at any age including adults, following a traumatic fall "onto the side of the head and shoulder, whereby the nerves of the plexus are violently stretched: the upper trunk of the plexus sustains the greatest injury, and the subsequent paralysis may be confined to the muscles supplied by the fifth nerve - the deltoid, biceps, brachialis and brachioradialis, with sometimes the supraspinatus, infraspinatus and supinator". "The brachial plexus may also be injured by direct violence or gunshot wounds, by violent traction on the arm, or by efforts at reducing a dislocation of the shoulder joint; the amount of paralysis will depend upon the amount of injury to the constituent nerves"
Presentation
The paralysis can be partial or complete; the damage to each nerve can range from bruising to tearing. The most commonly involved root is C5 (aka Erb's point: the union of C5 & C6 roots) as this is mechanically, the furthest point from the force of traction, therefore, the first/most affected. Erb-Duchenne palsy presents as a lower motor neuronLower motor neuron
Lower motor neurons are the motor neurons connecting the brainstem and spinal cord to muscle fibers, bringing the nerve impulses from the upper motor neurons out to the muscles...
syndrome associated with sensibility disturbance and vegetative phenomena.
The most commonly involved nerves are the suprascapular nerve
Suprascapular nerve
The suprascapular nerve arises from the upper trunk . It innervates the supraspinatus muscles and infraspinatus muscles....
, musculocutaneous nerve
Musculocutaneous nerve
The musculocutaneous nerve arises from the lateral cord of the brachial plexus, opposite the lower border of the Pectoralis major, its fibers being derived from C5, C6 and C7.-Path:...
, and the axillary nerve
Axillary nerve
The axillary nerve or the circumflex nerve is a nerve of the human body, that comes off the of the brachial plexus at the level of the axilla and carries nerve fibers from C5 and C6...
.
The signs of Erb's Palsy include loss of sensation in the arm and paralysis and atrophy of the deltoid, biceps, and brachialis muscles. "The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm". The resulting biceps damage is the main cause of this classic physical position commonly called "waiter's tip."
If the injury occurs at age early enough to affect development (e.g. as a neonate or infant), it often leaves patients with stunted growth in the affected arm with everything from the shoulder through to the fingertips smaller than the unaffected arm. This also leaves the patients with impaired muscular, nervous and circulatory development. The lack of muscular development leads to the arm being much weaker than the unaffected one, and less articulate, with many patients unable to lift the arm above shoulder height unaided, as well as leaving many with an elbow contracture.
The lack of development to the circulatory system can leave the arm with almost no ability to regulate its temperature, which often proves problematic during winter months when it would need to be closely monitored to ensure that the temperature of the arm was not dropping too far below that of the rest of the body. However the damage to the circulatory system also leaves the arm with another problem. It reduces the healing ability of the skin, so that skin damage takes far longer than usual to heal, and infections in the arm can be quite common if cuts are not sterilized as soon as possible. This will often cause many problems for children since they often injure themselves in the course of their childhoods.
The nervous damage is often the most problematic of the side effects to Erb's Palsy, but it is also the most varying. There have been cases of patients who have lost complete sensory perception within the arm after procedures whereas they had full sensory perception before. The most common area for a loss of sensory perception (except where the arm faces a total loss) is that between the shoulder and the elbow since the nerves which provide information from that area to the brain are also those first damaged in the initial causative trauma.
Treatment
Some babies recover on their own; however, some may require specialist intervention.Neonatal / pediatric neurosurgery is often required for avulsion fracture
Avulsion fracture
An avulsion fracture is a bone fracture which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma. This can occur at the ligament due to the application forces external to the body or at the tendon due to a muscular contraction that is stronger than...
repair. Lesions may heal over time and function return. Physiotherapeutic care is often required to regain muscle usage.
Although range of motion is recovered in many children under one year in age, individuals who have not yet healed after this point will rarely gain full function in their arm and may develop arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
.
The three most common treatments for Erb's Palsy are: Nerve transplants (usually from the opposite leg), Sub Scapularis releases and Latissimus Dorsi Tendon Transfers.
Nerve transplants are usually performed on babies under the age of 9 months since the fast development of younger babies increases the effectiveness of the procedure. They are not usually carried out on patients older than this because when the procedure is done on older infants, more harm than good is done and can result in nerve damage in the area where the nerves were taken from. Scarring can vary from faint scars along the lines of the neck to full "T" shapes across the whole shoulder depending on the training of the surgeon and the nature of the transplant.
Subscapularis releases, however, are not time limited. Since it is merely cutting a "Z" shape into the subscapularis muscle to provide stretch within the arm, it can be carried out at almost any age and can be carried out repeatedly on the same arm; however, this will compromise the integrity of the muscle.
Latissimus Dorsi Tendon Transfers involve cutting the Latissimus Dorsi in half horizontally in order to 'pull' part of the muscle around and attach it to the outside of the biceps. This procedure provides external rotation with varying degrees of success. A side effect may be increased sensitivity of the part of the biceps where the muscle will now lie, since the Latissimus Dorsi has roughly twice the number of nerve endings per square inch of other muscles.
Discovery
The renowned British obstetrician William SmellieWilliam Smellie (obstetrician)
William Smellie was a Scottish obstetrician.He practiced medicine before getting a licence, but enrolled later at the University of Glasgow and received his M.D. degree in 1745. After training in obstetrics in London and Paris, he opened a practice in London and began teaching...
is credited with the first medical description of an obstetric brachial plexus
Brachial plexus
The brachial plexus is a network of nerve fibers, running from the spine, formed by the ventral rami of the lower four cervical and first thoracic nerve roots...
palsy. In his 1768 treatise on midwifery, he reported a case of transient bilateral arm paralysis in a newborn after difficult labour.
In 1861, Guillaume Benjamin Amand Duchenne coined the term "obstetric palsy of the brachial plexus" after analyzing 4 infants with paralysis of identical muscles in the arm and shoulder, after publishing his initial findings in 1855. In 1874, Wilhelm Heinrich Erb
Wilhelm Heinrich Erb
Wilhelm Heinrich Erb was a German neurologist who was a native of Winnweiler, Rhineland-Palatinate.- Academic career :...
concluded in his thesis on adult brachial plexus injuries that associated palsies of the deltoid
Deltoid muscle
In human anatomy, the deltoid muscle is the muscle forming the rounded contour of the shoulder. Anatomically, it appears to be made up of three distinct sets of fibers though electromyography suggests that it consists of at least seven groups that can be independently coordinated by the central...
, biceps
Biceps
Biceps may refer to:*Biceps brachii muscle, a muscle located on the inside of the upper arm*Biceps femoris muscle, one of the hamstring muscles of the back of each thigh*Biceps , a point in a metrical pattern...
and subscapularis are derived from a radicular lesion at the level of C5 and C6 rather than isolated peripheral nerve lesions.
Notable people with Erb's palsy
Notable individuals afflicted by Erb's palsy were Kaiser Wilhelm II of Germany, Joseph StalinJoseph Stalin
Joseph Vissarionovich Stalin was the Premier of the Soviet Union from 6 May 1941 to 5 March 1953. He was among the Bolshevik revolutionaries who brought about the October Revolution and had held the position of first General Secretary of the Communist Party of the Soviet Union's Central Committee...
, and Canadian journalist Barbara Frum
Barbara Frum
Barbara Frum, OC was a Canadian radio and television journalist, acclaimed for her interviews for the Canadian Broadcasting Corporation.-Personal life:...
. Martin Sheen
Martin Sheen
Ramón Gerardo Antonio Estévez , better known by his stage name Martin Sheen, is an American film actor best known for his performances in the films Badlands and Apocalypse Now , and in the television series The West Wing from 1999 to 2006.He is considered one of the best actors never to be...
was injured during birth and developed the condition in his left arm. His difference in arm length and range of motion can be seen in his movies, especially Apocalypse Now
Apocalypse Now
Apocalypse Now is a 1979 American war film set during the Vietnam War, produced and directed by Francis Ford Coppola. The central character is US Army special operations officer Captain Benjamin L. Willard , of MACV-SOG, an assassin sent to kill the renegade and presumed insane Special Forces...
. Another sufferer is British singer-songwriter and artist Matt Parsons
Matt Parsons
Matt Parsons is an Australian retired professional rugby league player of the 1990s and 2000s. He played at prop for the South Sydney Rabbitohs, then the Newcastle Knights, with whom he won the 2001 NRL Premiership...
. Despite her condition, professional wrestler Traci Brooks has achieved a successful career. Another is former Iowa Hawkeyes standout defensive lineman Adrian Clayborn
Adrian Clayborn
Adrian Clayborn , a native of St. Louis, Missouri, is an American football defensive end for the Tampa Bay Buccaneers.-Personal life:...
. Additionally, gangster rapper and Academy Award winner DJ Paul
DJ Paul
Paul Beauregard, better known by his stage name DJ Paul, is an American rapper and record producer from Memphis, Tennessee. He is one half of the current Memphis-based rap group Three 6 Mafia. He is also the half brother of former Three 6 Mafia member Lord Infamous. He won an Academy Award for Best...
of Three Six Mafia also has a deformed arm from the condition, which he often hides by wearing a cast during public appearances.