Erb's Palsy and Klumpke's Palsy

Different types of brachial plexus injuries may be classified as either Erb's Palsy or Klumpke's Palsy. Erb's palsy is one of the most common and serious of all shoulder dystocia injuries, a type of trauma which results from a newborn's shoulder becoming stuck behind the mother's cervix during delivery. It results in damage to the nerves connecting the arm and shoulder from the use of excessive force or torque by the obstetrician, to release the stuck shoulder of the newborn.

More specifically, when a baby's shoulder becomes stuck behind the mother's pubic bone the baby's head delivers but the shoulders do not follow. This condition is known as a shoulder dystocia. At this point the physician must perform a particular delivery maneuver avoiding the placement of pressure on the shoulder. If this procedure is done improperly, an Erb's Palsy can occur where the nerve tissue between the arm and shoulder is stretched, partially torn or completely ruptured. Such an injury can result in a partial or complete paralysis of the arm.

A properly trained obstetrician will identify shoulder dystocia risks and take steps to avoid injury during delivery. Increased risk factors include:

1. High birth-weight babies ( >8lbs 14oz)
2. Maternal Diabetes
3. Heavy Mothers
4. Short Maternal Stature
5. A Contracted or Flat Pelvis
6. Pregnancy Beyond 40 weeks
7. Protracted Second Stage of labor

If any of these high risk factors exist, a delivery involving a shoulder dystocia can be prevented by scheduling a caesarean section. Where a shoulder dystocia does occur during birth, one of sixteen different maneuvers taught to obstetricians to free the trapped shoulder can be utilized.

Klumpke's palsy is a lower plexus injury, frequently resulting in paralysis of the hand and wrist, which results from a similar situation to that of Erb's palsy.

Types of Erb's Palsy

There are different types of brachial plexus injuries. Children with Erb's palsy are all affected in different ways. The variations are that some children will not have any muscle control or feeling in the arm or hand while some children can move their arms but have little control over the wrist and hand with other children able to use their hands well but can't use their shoulder or elbow muscles. Depending on the type of nerve damage in Erb's palsy children the symptoms can range from mild to severe.

With Erb's palsy there are four different types of nerve injuries, including:

1. An avulsion meaning the nerve is torn from the spine
2. A rupture meaning the nerve is torn but not where it attaches to the spine
3. A neuroma meaning the nerve has tried to heal but scar tissue has grown around the injury placing pressure on the injured nerve praxis. While the nerve has been damaged, it has not been torn and improvement should be seen within 3 months
4. Neuropraxia is the mildest form of a nerve injury. Neuropraxia, the most common form of Erb's palsy is localized to the specific place where the injury occurs. It is a physiologic block of nerve conduction within an axon without any anatomical interruption. Many infants born with brachial plexus palsy have neuropraxia and sometimes recover within 4-6 weeks

Symptoms of Erb's Palsy

Symptoms of Erb's Palsy are usually very obvious. A baby suffering from Erb's Palsy will be seen with the affected arm laying by their side and an extended elbow devoid of movement.

The injuries that are associated to Erb's palsy are the neck, clavicle, shoulder, and arm. Some precautions or problems that should be evaluated for signs of brachial plexus injuries are shoulder or elbow dislocation, a frozen shoulder, soft tissue or joint contractures. Lifting a child with Erb's Palsy from under the armpits should always be avoided.

Examples of different symptoms of Erb's palsy can include:

1. No muscle control and no feeling in the arm or hand
2. The ability to move but with little control
3. The use of hands but not of the shoulder or elbow
4. The entire arm may be paralyzed with the hand and fingers hanging limp
5. Facial paralysis on the affected side
6. Not able to sit up without assistance
7. The inability to crawl without the use of therapeutic devices

Treatment for Erb's Palsy

Treatment for Erb's Palsy that does not spontaneously recover generally consists of exercise and physical therapy. In 80% of the babies born with Erb's palsy recovery will occur without a surgical intervention. Often times, though, a child with brachial plexus palsy can benefit from surgical procedures to increase their arm functions.

Surgery is found to be most effective in Erb's Palsy children that are between the ages of 5 and 12 months; beyond this age group, surgery will not be as effective. Whether or not surgery is performed is dependent upon the individual child's condition. Where surgery occurs, it is performed by a pediatric neurosurgeon. The Erb's Palsy surgical procedure requires special anesthesia, an operating microscope, monitoring equipment, and specialists to be able to expose and identify each of the nerves of the brachial plexus and surrounding structures. Most children with Erb's Palsy have damage to multiple nerves so more than one procedure must be performed. Erb's palsy may also be helped by performing daily exercises to both keep muscles limber and to prevent the joints from freezing.