HISTORY OF ERB'S PALSY/BRACHIAL PLEXUS . . .

Doctors, dating back to the 1700's, have described brachial plexus palsy as a paralysis of the arm. Dr. Wilhelm Heinrich Erb, a German neurologist, located the most common injury resulting in brachial plexus palsy, in the nerves present at the fifth and sixth cervical vertebrae (C-5 and C-6).

Erbs Palsy (Brachial Plexus and Shoulder Dystocia) is a condition that results from damage to the brachial plexus nerves. These are a series of nerves that travel from the spinal cord into the arm. The birth injury generally occurs when the delivering party exerts excessive force on the baby's head and neck during a vaginal birth. In 90 percent of Brachial Plexus Palsy cases, traumatic stretching of the infant's plexus during birth causes the palsy. One out of every one thousand births results in a brachial plexus injury. One out of every ten represents an injury serious enough to require some form of treatment. A brachial plexus injury (including Complete Brachial Plexus Palsy, Erbs Palsy and Klempkes Palsy) affects a bundle of five nerves known as the brachial plexus, which control muscles in the shoulder, arm, and hand. As a result of this injury, all or some of these muscles might suffer paralysis. Some sufferers have no muscle control and no feeling in their arms or hands. Some can move their arms, but have little control over the wrist and hand. Still others can use their hands well, but cannot use the shoulder or elbow.

TYPES OF ERB'S PALSY . . .

Complete Brachial Plexus Palsy occurs when injury affects all five nerves in the brachial plexus. It results in paralysis and demonstrable sensory loss in the entire arm, from the shoulder down. In addition, Horner's Syndrome, which causes eyelid droop, undilated pupil, and dormancy of sweat glands in the cheek of the affected side of the body, often accompanies the injury. Torticollis, a condition that causes a baby to face toward his good or uninjured side and prevents a baby from being able to face forward for any length of time, also accompanies Complete Brachial Plexus Palsy.

Erbs Palsy represents the paralysis of a group of muscles of the shoulder and upper arm. It involves the cervical roots of the fifth and sixth spinal nerves. The arm hangs limp, the hand may rotate inward and normal movements are lost. The elbow is extended but flexion of the wrist and fingers is preserved with the palm potentially facing up. Erb's Palsy sufferers commonly cannot lift their arm above the head and have difficulty gripping with the affected hand.

Klumpkes Palsy involves the seventh cervical vertebra and the first thoracic vertebra (C7 and T-1). Often suffers of Klumpkes Palsy experience weakness of the wrist and finger flexors and of the small muscles of the hand. Klumpkes Palsy is the most rare of the brachial plexus injuries, though the term is sometimes loosely applied to cases of Complete Brachial Plexus Palsy. It is extremely rare to have a true/isolated Klumpkes Palsy situation.

4 TYPES OF BRACHIAL PLEXUS INJURY..

There are four types of nerve injuries that can result in brachial plexus palsy. 1) An avulsion occurs when the injury results in the tearing of the nerve from the spine. This is the most serious type of brachial plexus injury. 2) With a rupture, the nerve tears, but does not tear away from the spine. 3) A neuronal exists when a nerve attempts to heal itself and scar tissue develops around the injury. This scar tissue exerts pressure on the injured nerve, thereby preventing signals from the nerve to the muscle. 4) praxis is a nerve injury in which the nerve does not tear. In cases of praxis, the injury heals on its own, with improvement showing within three months of the injury.

CAUSES...

Erb's Palsy is caused by an injury to one or more nerves that control and supply the muscles of the shoulder and upper extremities, otherwise known as the upper brachial plexus. It is usually seen in newborns and often occurs as a result of a excessive traction incident to delivery. During labor and birth, a baby's shoulder can get stuck on the mother's pelvic bone. This birthing emergency is called Shoulder Dystocia. Doctors may use many different procedures to dislodge the baby's shoulder so that the baby can safely pass through the birthing canal. In some cases, the doctor can reposition the mother, or the doctor can use his or her hands to maneuver and change the position of the baby. In particularly dangerous and difficult births, the doctor can break the baby's clavicle bone on purpose, break the mother's pelvic bone or perform an emergency C-section. A doctor can cut a deep episiotomy, perform the McRobert's maneuver, and exert suprapubic pressure. The doctor can also use gentle traction in a horizontal plane to avoid damaging the brachial plexus. In the event of shoulder dystocia, the doctor can support the head of the baby and apply a small amount of traction during the dislodging maneuvers. When the doctor uses excessive traction on the head while the baby's shoulder remains stuck, the brachial plexus nerves in the baby's neck may suffer injury. This injury results in one of the above mentioned types of brachial plexus palsy.

RISK FACTORS...

Some risk factors include fetal macrosomia (a condition in which the pre-birth weight of the baby is over 8 lbs. 14 oz.), maternal weight gain of 35 lbs. or more, maternal diabetes, maternal obesity, gestation that lasts beyond 40 weeks, short maternal stature, platypelliod (a contracted or flat pelvis). These risk factors may suggest an increased risk for shoulder dystocia and an increased risk for brachial plexus palsy. Also, a breech birth or other abnormal presentation of a fetus can increase the occurrence for shoulder dystocia, resulting in a brachial plexus injury. The use of labor-inducing drugs suggests an increased risk for shoulder dystocia.

When using an Epidural, a mother loses the pushing sensation, which can result in the baby descending in an awkward position. The use of tools, including forceps or a vacuum, to help the baby descend, may also increase the risk of shoulder dystocia.

TREATMENT ...

Most children with a brachial plexus palsy injury have damage to multiple nerves requiring more than one surgical procedure being performed. Injuries that involve nerves below the elbow have a lower rate of improvement because of the location of the nerves and the distance that they need to regenerate. A physical therapist may also work with children suffering from Brachial Plexus Palsy to help increase range of movement. Performing daily exercise to keep the muscle and joints limber and moving may also help Brachial Plexus Palsy, and may prevent the joints from freezing in place. The long-term goals for a child with brachial plexus palsy are to realize at least partial use of the affected arm or hand. An important goal is to have the ability to feed one's self or to use the affected arm or hand to help the other arm lift and carry things. By the age of two a child will make no further improvement or recovery with regard to Brachial Plexus Palsy.