ERB’S PALSY

• Erb’s palsy is due to injury to the C5 nerve root and rarely the C6 nerve root is also injured. It occurs very early in life due to birth trauma or in young adults.

• Types :1. Neurapraxia• A stretch injury that "shocks," but does not tear the nerve is the

most common type. This is called a neurapraxia . Normally, these injuries heal on their own, usually within 3 months.

• Neurapraxia can happen in adults, as well as infants. For example, when it happens to football players who are injured during play, it is called "burners and stingers.“

2. Neuroma• A stretch injury that damages some of the nerve fibers may

result in scar tissue. This scar tissue may press on the remaining healthy nerve. Some, but not total, recovery usually occurs.

3. Rupture• A stretch injury that causes the nerve to be torn apart (ruptured)

will not heal on its own. A rupture happens when the nerve itself is torn.

4. Avulsion•An avulsion happens when the nerve is torn from the spinal cord. Nerve ruptures and avulsions are the most serious types of nerve injury. It may be possible to repair a rupture by "splicing" a donor nerve graft from another nerve of the child. It is not possible to repair an avulsion from the spinal cord. In some cases, it may be possible to restore some function in the arm by using a nerve from another muscle as a donor.

• Causes : • The nerves of the brachial plexus can be injured during a difficult

delivery from:• The infant's head and neck pulling toward the side as the

shoulders pass through the birth canal• Pulling on the infant's shoulders during a head-first delivery• Pressure on the baby's raised arms during a breech (feet-first)

delivery

Other situations where the brachial plexus can be damaged are: • A trauma to the side of the neck, for instance a motor vehicle

accident, fall or heavy blow• A stretch injury sustained while participating in a sport• An attempt to reduce a dislocated shoulder

• Risk Factors • These factors increase your chance of delivering a baby with

Erb’s palsy: • History of delivering larger babies• History of prolonged labor• Gestational diabetes

• Clinical Features : i. Characteristic position - adduction and internal rotation of the

arm with forearm pronated (a position sometimes described as ‘waiter’s tip’)

ii. Forearm extension normaliii. Sensory impairment on outer aspect of arm (unusual)iv. Power of the forearm is normal (if impaired, suggests injury to

lower part of plexus)v. Hand grasp normal unless lower part of plexus is also damaged

• Diagnosis : i. Ultrasound may be used to diagnose a shoulder dislocation (rare)

and diaphragmatic paralysis if suspectedii. MRI shows nerve root damageiii. EMG and nerve root studies are not helpful in determining the

extent of the damage severity, although this has been opposed.

• Special Tests : 1. Moro Reflex • Normal response : Bilateral symmetrical extension and abduction of

all extremities, with thumb and forefinger forming characteristic “C” are followed by adduction of extremities and return to relaxed flexion when newborn’s position changes suddenly or when newborn is placed on back on flat surface.

• Abnormal response : Asymmetrical response is seen with peripheral nerve injury (brachial plexus) or fracture of clavicle or long bone or arm or leg. No response occurs in cases of severe CNS injury.

2. Palmar Reflex : •Normal response : Newborn’s finger will curl around object and hold on momentarily when finger is placed in palm of newborn’s hand.•Abnormal response : Response is diminished in prematurity. Asymmetry occurs with peripheral nerve damage (brachial plexus) or fracture of humerus. No response occurs with severe neurologic deficit.

3. Bicep Reflex : •Tap the tendon of biceps, the response is flexion of the elbow.•Afferent and efferent pathway is by musculocutaneous nerve, centre is C5, C6.

• Differential Diagnosis : • Other causes of abnormal posturing in newborns: Klumpke's

paralysis• Clavicle fracture• Fractured humerus• Cerebral palsy

• Treatment :

1. Surgical treatment : • Nerve grafts, in which a damaged nerve is spliced with a healthy

nerve taken from another part of the body• Tendon transfers, in which healthy tendons from another part of

the body are relocated to the affected neck area to compensate for nerve damage.

2. Physiotherapy treatment : •Exercise therapy : I. Range of Motion Exercises (Passive)•The goal of these exercises is to alleviate stiffness of the joint due to disuse so that when function is restored to the child's arm, he will be able to use it normally. II. Functional Exercises•Functional exercises incorporate daily functional activities to encourage development of your child's arm. Progression in activities is made as the child gets older. III. Sensory Stimulation Exercises•Perform sensation exercises by rubbing objects with differing textures on your child's arm, such as a washcloth, a fleece blanket or a brush. To improve positional awareness of the arms in terms of the entire body, place your child's hand on different areas of the body, such as the mouth or the opposite hand.

IV. Shoulder strengthening exercises i. Shoulder shrugs : •To perform, have the patient stand straight and shrug her shoulders up as high as she can, hold it for a second and then return to the starting position to complete one repetition. Perform three sets of 10 repetitions each .ii. Dumbbell Raise : •Stand with a weight in both hands. Choose a weight light that you don't feel pain but heavy enough to create fatigue after one to three sets. The weights should hang next to your thighs with the ends facing forward and backward. Lift both hands at the same time, twisting your shoulder so the back of your hand faces forward as you lift. Try to lift your arm to a 45-degree angle but not past the point of pain.V. Hydrotherapy treatment to work on restoring movement and strength

• Electrotherapy: I. TENS (Transcutaneous Electrical Nerve Stimulation)II. FES (Functional Electrical Stimulation)III. Interferential StimulationIV. UltrasoundV. PSWD (Pulsed Short-Wave Diathermy)

• Prognosisi. Depends upon degree of damageii. Effective hand grasp throughout is associated with a good

prognosisiii. Function may return within a few monthsiv. Some may have been left with permanent damage