Erb's Palsy

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Synonyms: Erb-Duchenne paralysis 

Erb's palsy is caused by damage to the brachial plexus during delivery of the neonate. This is mostly limited to the 5th and 6th cervical nerves.

  • It is rare. In the USA the incidence has been quoted as 1.6-2.9 per 1,000 live births.[1]
  • Upper plexus palsies are more common than lower plexus palsies.
  • 50% of cases are associated with shoulder dystocia.

Risk factors

Risk factors in Erbs palsy
Fetal factors
Maternal factors
Factors related to labour
  • Macrosomia
  • Maternal propulsive forces
  • Lateral traction exerted on head and neck during delivery in vertex presentation
  • Arm extended overhead in breach presentation
  • Excessive traction placed on shoulders during delivery

Raised maternal BMI at term and presence of gestational diabetes mellitus have also been reported as risk factors.[2] The same study reported high birth weight, long second stage of labour, Afro-Caribbean background and long deceleration phase of labour as other prominent risk factors.[2]

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The infant is unable to:

  • Abduct the arm from the shoulder.
  • Rotate the arm externally from the shoulder.
  • Supinate the forearm.

This results in the classic 'porter's tip' or 'waiter's tip' appearance.[1]

Clinical signs

  • Characteristic position - adduction and internal rotation of the arm with the forearm pronated.
  • Forearm extension is normal.
  • Biceps reflex is absent.
  • Moro reflex is absent on the affected side.
  • Sensory impairment on the outer aspect of the arm (unusual).
  • Power of the forearm is normal (if impaired, it suggests injury to the lower part of the plexus).
  • Hand grasp is normal unless the lower part of the plexus is also damaged.
  • MRI shows nerve root damage
  • Electromyogram (EMG) and nerve root studies are not helpful in determining the extent of the damage severity.[1] This has, however, been opposed.[3]

Other causes of abnormal posturing in newborns:

  • Intermittent immobilisation and positioning to prevent contractures.
  • Positioning such that arm is abducted to 90°, externally rotated at the shoulder, supination of forearm, extension at wrist with the palm turned toward the face.
  • Gentle massage.
  • Physiotherapy with active and passive movement exercises by the end of the first week.
  • Electrical stimulation may prove to be beneficial.[5]
  • Referral to a neurosurgeon if paralysis persists beyond three months or there is more proximal damage to the plexus.[1]
  • Surgery can involve direct neurorrhaphy after neuroma resection, neurolysis to remove any scar tissue, nerve grafting with transplant of another nerve or nerve transfer from a local functioning nerve; however, results are mixed and pain, along with functional disability, persist in significant numbers.[3]
  • Depends upon the degree of damage.
  • Effective hand grasp throughout is associated with a good prognosis.
  • Function may return within a few months.
  • Some may have been left with permanent damage.

Named after Wilhelm Heinrich Erb (1840-1921), a German neurologist who described a case in 1874, although an earlier case was described by Duchenne in 1872. However, Erb was also a pioneer in a description of the electrophysiological nature of tetany, characterisation of the physiological response to stimulation of the superior root of the brachial plexus, and describing the deep tendon reflex.[6]

Further reading & references

  1. Hemady N, Noble C; Newborn with abnormal arm posture. Am Fam Physician. 2006 Jun 1;73(11):2015-6.
  2. Weizsaecker K, Deaver JE, Cohen WR; Labour characteristics and neonatal Erb's palsy. BJOG. 2007 Aug;114(8):1003-9. Epub 2007 Jun 12.
  3. Kirjavainen M, Remes V, Peltonen J, et al; Long-term results of surgery for brachial plexus birth palsy. J Bone Joint Surg Am. 2007 Jan;89(1):18-26.
  4. Birch R, Ahad N, Kono H, et al; Repair of obstetric brachial plexus palsy: results in 100 children. J Bone Joint Surg Br. 2005 Aug;87(8):1089-95.
  5. Okafor UA, Akinbo SR, Sokunbi OG, et al; Comparison of electrical stimulation and conventional physiotherapy in functional rehabilitation in Erb's palsy. Nig Q J Hosp Med. 2008 Oct-Dec;18(4):202-5.
  6. Watt AJ, Niederbichler AD, Yang LJ, et al; Wilhelm Heinrich Erb, M.D. (1840 to 1921): a historical perspective on Erb's palsy. Plast Reconstr Surg. 2007 Jun;119(7):2161-6.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Gurvinder Rull
Current Version:
Peer Reviewer:
Dr Adrian Bonsall
Document ID:
2113 (v23)
Last Checked:
01/12/2014
Next Review:
30/11/2019

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