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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]

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 and references

  1. Hemady N, Noble C; Newborn with abnormal arm posture. Am Fam Physician. 2006 Jun 173(11):2015-6.

  2. Weizsaecker K, Deaver JE, Cohen WR; Labour characteristics and neonatal Erb's palsy. BJOG. 2007 Aug114(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 Jan89(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 Aug87(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-Dec18(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 Jun119(7):2161-6.